Hats off to Helmets

At first, I didn’t notice the flat spot on the back of her head. Most infant heads look a little misshapen, at least in the beginning. My daughter was born with a head tilt from being squashed in the womb alongside her twin sister. It never occurred to me at the time that this would cause the back, right side of her head to flatten. When a health care provider pointed it out around her three-month checkup, I gasped. How could I have missed it? I should have been more diligent about propping up her drooping head or changing her sleep positions. Now, I feared, her head would be permanently deformed.

Studies show that twins are several times more likely to have some form of cranial deformation as infants compared with singletons. This is due in large part to overcrowding in the womb—the baby in the lower position tends to be at greater risk. In addition to bearing the weight of her twin sibling above, her head can get lodged in the mother’s pelvis, restricting her head movement. This affects the baby’s developing neck muscles, which can lead to congenital muscular torticollis, otherwise known as a head tilt. Torticollis, in turn, increases the baby’s chances of developing a flat spot. In fact, one study showed that up to 90 percent of infants born with torticollis also had plagiocephaly, the technical term used to describe an asymmetrical head shape.

Twins also have a higher risk of being born premature. The softer skulls of preemies are more susceptible to deformation. If a premature baby is placed on a respirator, this can restrict her head mobility, causing the back of her head to flatten.

The “Back to Sleep Campaign,” initiated by the American Academy of Pediatrics in 1992, has played a role as well, affecting not just multiples, but all infants. Although the campaign has been credited with a 40 percent drop in the incidence of sudden infant death syndrome the United States, it has also had the unforeseen consequence of increasing the number of babies with flat heads. About 20 to 25 percent of infants who sleep on their backs develop cranial flattening.

For several months, once a week, my daughter received physical therapy to correct her head tilt. We did stretching exercises to loosen the tight neck muscles on one side and strengthening exercises to build up the muscles on the other side. We placed her on her belly (which she hated) multiple times a day, dangled toys in front her nose, and moved the toys from side to side, forcing her to turn her head in the direction she normally avoided. There were many tears and cries of frustration.

Bit by bit, her head tilt began to disappear. But her flat head did not. My husband and I were confronted with a dilemma: Should we have her fitted with a cranial helmet that would essentially re-mold her skull? Or should we let her hair grow in and hope that it becomes less noticeable over time? Our pediatrician assured us that our daughter’s head shape would have no bearing on her brain development. Nor would it affect her vision or hearing, or anything else for that matter. It was purely a cosmetic issue.

Still, the flat spot on her head was pretty obvious, especially in the bath. For weeks, my husband and I agonized over whether to contact a plastic surgeon. Were we being shallow? Did it really matter? A helmet might fix her head shape, but what about any long-term side effects? Or if we didn’t correct it now, would our daughter later resent us when, as a teenager, she becomes stricken by the desire to shave her head? It was a possibility we could not ignore.

We made the appointment. At 6 months, my daughter came home from the orthotic and prosthetic clinic wearing her very own cranial helmet. It was pale blue with yellow and white daisies (we chose the pattern). She looked like a cheerful, little gladiator. The first day she wore it, my husband and I didn’t know what to expect. Would it bother her? Would she be able to fall asleep? But, much to our surprise, the helmet didn’t faze her in the least. And it worked beautifully. After wearing the helmet for a total of eight weeks, 23 hours a day (we took it off once a day to clean it), her flat spot filled in, her head was nice and round.

The helmet had another effect that we didn’t anticipate. Shortly after my daughter stopped wearing her helmet, she developed a keen interest in headwear. It started with headbands. Then, she moved on to hats—all kinds of hats, sun hats, winter hats, hard hats. She began experimenting. Sometimes she would walk around the house with her white blankie draped over her head like Lawrence of Arabia heading off into the desert. Then she got more daring. Once, she found a pink gift bag on the floor, turned it upside down, and put it on her head. She mounted her rocking horse and “rode off” without a care in the world. Another time, I found her playing quietly in a corner in the living room with a green bucket on her head, looking completely unmoved.

It got to the point where our daughter could not leave the house without the appropriate headwear. There were many scenes—trying to explain to a 2-year old why she can’t wear her favorite blue fluffy winter hat on a hot summer day became almost a ritual. Now, she has to have something on her head all day long (currently, it’s her pink bike helmet), and even at night when she goes to bed. I should also mention that her baby doll wears a hat at all times and there are many tears when baby’s hat falls off.

Now I’m not saying that all children who wear cranial helmets as babies develop a fondness for headwear. But it’s hard for me to find any other explanation for my daughter’s fixation. Regardless, I figure it’s a small price to pay for a nice round head. And in some ways, it’s been a bit of a blessing. When my daughter wears a hat, she feels safe and happy. I watch her casually stroll down the street or strut across the playground with her hat on, however bizarre it might look that day, and I see a confident little girl, completely unconcerned with what other people think. It’s wonderful to watch. And then, I think for a moment, gee, if only I had worn a helmet as a baby.

Further Reading

Cranial deformations and cranial helmets:
http://www.childrenshospital.org/az/Site1453/mainpageS1453P4.html
http://bostonbrace.com/Content/Overview_of_Plagiocephaly.asp
http://bostonbrace.com/Content/Boston_Band_for_Plagiocephaly.asp

Congenital muscular torticollis:
http://www.webmd.com/parenting/baby/tc/congenital-torticollis-topic-overview

“Back to Sleep” Campaign and Tummy Time:
http://www.nichd.nih.gov/sids/
http://www.nichd.nih.gov/health/topics/Tummy_Time.cfm
http://www.healthychildcare.org/sids.html

Scientific articles:

Rogers GF. 2011. Deformational plagiocephaly, brachycephaly, and scaphocephaly. Part I: terminology, diagnosis, and etiopathogenesis. The Journal of Craniofacial Surgery. Volume 22, Number 1. Pages 9-16. http://www.ncbi.nlm.nih.gov/pubmed/21187783

Rogers GF. 2011. Deformational plagiocephaly, brachycephaly, and scaphocephaly. Part II: prevention and treatment. The Journal of Craniofacial Surgery. Volume 22, Number 1. Pages 17-23. http://www.ncbi.nlm.nih.gov/pubmed/21187782

Freed SS and Coulter-O’Berry C. 2004. Identification and Treatment of Congenital Muscular Torticollis in Infants. Journal of Prosthetics and Orthotics. Volumer 16, Number 4S. Pages 18-23. 2004. http://www.oandp.org/jpo/library/2004_04S_018.asp

Littlefield TR et al. 2002. Multiple-birth infants at higher risk for development of deformational plagiocephaly: II. is one twin at greater risk? Pediatrics. Volume 109, Number 1. Pages 9-25. http://www.ncbi.nlm.nih.gov/pubmed/11773537

Peitsch WK. 2002. Incidence of Cranial Asymmetry in Healthy Newborns. Pediatrics. Volume 110. Number 6. Page e72. http://www.pediatricsdigest.mobi/content/110/6/e72.full

Tags: children's hospital, cranial helmets, Featured Posts, head deformities, plagiocephaly, twins

Category: Columns, Parenting Advice, TwinLife Baby, TwinLife Parent