Babies often get misshapen heads from laying on one side or even from being squished while still inside mom. The misshapen head is referred to as plagiocephaly, scaphocephaly, or brachycephaly — depending on the overall shape (see photo under “Diagnosis” below).
These head shapes, especially plagiocephaly, are very common. If I knew I’d one day have a blog, I would have taken pictures showing the head shape of my child who had positional plagiocephaly. My baby is now a teen with a normal head shape, so it’s too late for photos.
Below is a picture of a baby with positional plagiocephaly. Note the flat left back of the head. In this picture you can’t see the ears, but we look to see if the ear and forehead are pushed forward to help assess the severity of the plagiocephaly.
Below I’ll summarize the guidelines for the diagnosis of as well as treatment options for plagiocephaly with repositioning, physical therapy and helmets from the Joint Section on Pediatric Neurosurgery of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons.
Most of the time we can make the diagnosis in the office without any special tests or x-rays. If there is a concern that one of the sutures (growth plates between the bones of the skull) is closed, a skull x-ray or an ultrasound of the area in question can assess if the suture is open or closed. If the diagnosis is still in question after those studies, a CT of the head may be needed. The picture below shows how the skull shape changes if one or more of the sutures is closed (represented by a missing line).
Photo source:By Xxjamesxx, via Wikimedia Commons Wikimedia
The first treatment used to treat plagiocephaly is repositioning. Repositioning helps with all infants with positional plagiocephaly to some extent.
Repositioning is just what it sounds like: change the position of your baby so the side down alternates when sleeping or laying.
Put fun items to look at on alternating sides when baby is laying on the back when awake.
When feeding, hold baby in alternate arms so when they turn to face you they are looking different directions each feed. (This happens naturally when breastfeeding.)
Use supervised tummy time several times each day and hold baby upright as much as possible to get baby off the back of his head when not sleeping.
The American Academy of Pediatrics has issued a warning against the use of positioning pillows due to risk of suffocation.
Stretching and massage
A stiff neck often is associated with positional plagiocephaly because it limits head movement to one side. The stiff neck is called torticollis.
Torticollis makes it difficult for baby to turn his head to one side, but gentle stretching can help. I show parents how to hold one shoulder down while gently moving the head to stretch the neck – with each ear to the shoulder and then the chin to each shoulder.
It’s important to do a gentle but firm stretch, no jerking or forced movements.
Massaging the neck muscles first can help.
Think of what you do when you have a sore neck and want to stretch it. Working with a Physical Therapist has been shown to be more effective than repositioning alone and as effective as positioning devices (which are not recommended due to safety concerns).
Babies with persistent moderate to severe plagiocephaly after repositioning and physical therapy may benefit from a helmet to mold the head to a round shape.
The helmet corrects more rapidly than positioning alone, so is also used if there is significant plagiocephaly in older infants.
I reserve this option for the more severe cases that don’t respond to repositioning and physical therapy since it is expensive and often not covered by insurance.
I don’t know if these recommendations will make it easier for insurance to pay for a helmet when indicated.
Prevention is key!
We have significantly decreased the risk of SIDS by placing babies on their backs to sleep, but have seen a rise in flat heads due to their positioning. Prevention of the flatness involves several positioning strategies.
Supervised tummy time
Start supervised tummy time early on – the longer you wait to start, the more Baby might resist it. I see so many parents who are hesitant to put Baby on his or her stomach. Concerns range from the umbilical cord stump still being on and bothering the baby (it won’t) to spitting up will worsen (test it out, for many babies it’s actually better) to “I thought babies should never be on their stomachs” (only when sleeping or not supervised).
Tummy time is an important time for baby to develop muscle strength. It needs to be supervised, but it can be a fun time to interact with Baby. Lay face to face and talk to Baby, encouraging him or her to look up. Grab a brightly colored object and move it around for Baby to watch. Enjoy your play time.
Back to sleep
It’s important for babies to sleep on their back, but they tend to have their head facing one direction or another. They should alternate which side they face, but many babies have a stiff neck and favor looking to one side. Think of when you wake with a stiff neck – probably from positioning overnight. Many babies are in the same position for quite awhile at the end of pregnancy – of course they’re stiff!
Massage & Stretch
If Baby’s neck is stiff, you can massage his or her neck and shoulder muscles gently. Slowly move the head right and left (chin to each shoulder) and side to side (ear to shoulder). Don’t quickly force the head movement, but think of what you do if you have a stiff and sore neck.
The more frequently you stretch it out, the better it feels, right? I recommend stretching Baby’s neck with each diaper change (before the change or after you wash your hands!) until it isn’t stiff for several days and Baby moves his or her head easily without your help.
See this American Academy of Pediatrics article on how to prevent flat heads in babies.
When we have newborns we don’t want them exposed to germs. We avoid large crowds, especially during the sick season. We won’t let anyone who hasn’t washed their hands hold our precious baby. We might even wash our hands until they crack and bleed.
But what happens when Mom or Dad gets sick? What about older siblings? How can we prevent Baby from getting sick if there are germs in the house?
In most circumstances it is not possible for the primary caretaker to be completely isolated from a baby, but there are things you can do to help prevent Baby from getting sick.
Wash hands frequently, especially after touching your face, blowing your nose, eating, using common items (phone, money, etc) and toileting.
Wash Baby’s hands after diaper changes too. Make this a habit even when you’re not sick… you never know when you’re shedding those first germs!
Wipe down surfaces
Viruses that cause the common cold, flu, and vomiting and diarrhea can live on surfaces longer than many expect.
Clean the surfaces of commonly touched things such as doorknobs; handles to drawers, cabinets, and the refrigerator; phones; and money frequently when there is illness in the area.
Avoid touching your face
Avoid touching your eyes, nose and mouth – these are the “doors” germs use to get in and out of your body.
Pay attention to how often you do this. Most people touch their face many times a day. This contributes to getting sick.
Kiss the top of the head
Resist kissing Baby on the face, hands, and feet.
I know they’re cute and you love to give kisses, but putting germs around their eyes, nose, and mouth allows the germs to get in. They put their hands and feet in their mouth, so those need to stay clean too.
Cover your cough
I often recommend that people cover coughs and sneezes with their elbow to avoid getting germs on their hands and reduce the risk of spreading those germs.
When you’re responsible for a baby, the baby’s head is often in your elbow, so I don’t recommend this trick for caretakers of babies. Cover the cough or sneeze with your hands and then wash them with soap and water or use a hand sanitizer if soap and water aren’t available.
If you’re vaccinated against influenza, whooping cough, and other vaccine preventable diseases, you’re less likely to bring those germs home. Encourage everyone around your baby to be vaccinated.
If you get your recommended Tdap and seasonal flu vaccine while pregnant, Baby benefits from passive immunity.
Social media has allowed the sharing of misinformation about many things, especially medically related things. When the specifics of something are unknown to a person, pretty much anything that’s said can sound reasonable, so people believe what they hear. This happens with many things, such as vaccine risks, chelation, and vitamin K. I want to tackle 7 Vitamin K Myths.
Refusing Vitamin K
I am especially frustrated when parents refuse to give their newborns vitamin K after birth. Since 1961, the American Academy of Pediatrics has recommended giving every newborn a single shot of vitamin K given at birth.This is a life saving treatment to prevent bleeding.
Vitamin K works to help our blood clot. Insufficient levels can lead to bleeding in the brain or other vital organs. Vitamin K deficiency bleeding or VKDB, can occur any time in the first 6 months of life. There are three types of VKDB, based on the age of the baby when the bleeding problems start: early, classical and late. Unfortunately there are usually no warning signs that a baby will have significant bleeding, so when the bleeding happens, it’s too late to do anything about it. Why parents don’t want to give this preventative life saving treatment is usually based on incorrect information.
This is a matter of a fairly low risk of bleeding if you don’t give vitamin K: 250-1700 per 100,000 within the first week, and 4-7 per 100,000 between 2 and 12 weeks. You might notice that the number is variable – it’s hard to study since the large majority of babies have gotten vitamin K over the years and the risk is low even without vitamin K. However, when there is bleeding it has significant consequences: lifelong disability or death. And we also know that there’s very low risk from the vitamin K and it works very well to prevent bleeding. So why take the chance of not giving it?
Conspiracy Theories, Misunderstandings, and Science
This is not a governmental conspiracy to somehow kill children. It’s a world wide attempt to help children survive and thrive.
All newborns should be given 1 mg of vitamin K intramuscularly [IM] after birth [after the first hour during which the infant should be in skin-to-skin contact with the mother and breastfeeding should be initiated]. (Strong recommendation, moderate quality evidence)
Science is hard to understand
Most people look at scientific information and can’t make heads or tails of what it means.
That coupled with the fact that things we read that make us react emotionally (such as fear that something will harm our child) makes us remember and associate with the information that created the emotion, whether it is right or wrong. This can lead parents to make dangerous decisions for their children while trying to do the right thing.
I’m going to attempt to de-bunk the most common concerns I’ve heard because the best way to combat misinformation is to help explain the facts as we know them.
1. If every baby’s born with too little vitamin K, that’s the way we’re supposed to be.
Babies are born with very little vitamin K in their body. If they don’t get it with a shot, they need to either eat it or make it. Breast milk has very little vitamin K and babies won’t be eating leafy greens for quite awhile. Formula does have it, but it takes several days for vitamin K to rise to protective levels with formula and the highest risk of bleeding is during that first week of life. (Of course if you’re using this argument because you want babies to be all natural, you probably won’t be giving formula at this point.)
Bacteria help us make vitamin K, but babies aren’t colonized at birth with these gut bacteria.
Just because they’re born that way doesn’t mean they’re supposed to stay that way. Inside the mother the baby is in a very different situation. They don’t breathe air. A fetus doesn’t eat. They don’t have gut bacteria. Their heart has a bypass tract to avoid pumping blood to the lungs. This all works well in utero, but must change once they leave the womb. Change takes time, and during this time they are at risk. Why not minimize the risk if we know a safe way to do it?
2. The package insert has a big warning at the top that it can kill.
There are many reasons why we should not use the package insert of a medicine or vaccine to make healthcare decisions. These have been discussed before so I won’t go into all the details but please see these great blogs on how to read and use package inserts:
Reactions to IV (intravenous) vitamin K are much more common than IM (intramuscular) injections. The difference is anything given by IV goes directly into the bloodstream and back to the heart. But we don’t give vitamin K by IV to newborns.
IM injections go into the muscle, allowing very slow absorption of the medicine. This not only decreases reactions to the injected vitamin, but also helps the level of vitamin K stay elevated for a prolonged time after a single injection.
Many years ago there was a small study that suggested vitamin K led to childhood cancers. This issue has been extensively studied since then and no link has been found.
Vitamin K does not cause cancer.
Rates of cancer have not increased in the years since vitamin K has been given to the large majority of newborns worldwide. This is reported in the Vitamin K Ad Hoc Task Force of the American Academy of Pediatrics report Controversies Concerning Vitamin K and the Newborn.
4. Bleeding from vitamin K deficiency is rare or mild.
In the US bleeding from vitamin K deficiency is rare because most babies get the vitamin K shot soon after birth. In countries where vitamin K is not used routinely, bleeding is not rare at all. Some communities of the US where vitamin K is being refused by parents are seeing an increase in newborn bleeding.
Early VKDB occurs within 24 hours of birth and is almost exclusively seen in infants of mothers taking drugs which inhibit vitamin K. These drugs include anticonvulsants, anti-tuberculosis drugs, some antibiotics (cephalosporins) and blood thinners to prevent clots. Early VKDB is typically severe bleeding in the brain or gut.
Classic VKDB typically occurs during the first week of life. The incidence of classic VKDB ranges from 0.25-1.7 cases per 100 births.
Late onset VKDB occurs between 2 and 12 weeks usually, but is possible up to 6 months after birth. Late VKDB has fallen from 4.4-7.2 cases per 100,000 births to 1.4-6.4 cases per 100,000 births in reports from Asia and Europe after routine prophylaxis was started.
One out of five babies with VKDB dies.
Of the infants who have late VKDB, about half have bleeding into their brains, which can lead to permanent brain damage if they survive. Others bleed in their stomach or intestines, or other vital organs. Many need blood transfusions or surgeries to help correct the problems from the bleeding.
5. It’s just as good to use oral vitamin K.
Early onset VKDB is prevented well with the oral vitamin K in countries that have oral vitamin K available, but late onset VKDB is an issue.
Children with liver or gall bladder problems will not absorb oral vitamin K well. These problems might be undiagnosed early in life, putting these kids at risk for VKDB if they are on an oral vitamin K regimen.
Getting the oral form isn’t easy
There is no liquid form of vitamin K that is proven to be effective for babies in the US.
That is a huge issue.
Some families will order vitamin K online, but it’s not guaranteed to be safe or even what it claims to be. This is an unregulated industry. It is possible to use the vitamin K solution that is typically given intramuscularly by mouth, but this requires a prescription and the taste is questionable, so baby might not take the full dose.
It would be an off-label use so physicians might not feel comfortable writing a prescription. The other issue that might worry physicians is with compliance in remembering to give the oral vitamin K as directed, since most studies include babies with late onset bleeding who had missed doses.
Vitamin K in food
Most of us get vitamin K from gut bacteria and eating leafy green vegetables.
Newborns don’t have the gut bacteria established yet so they won’t make any vitamin K themselves. They may get vitamin K through their diet, but breastmilk is very low in vitamin K. Unless baby is getting formula, they will not get enough vitamin K without a supplement.
It is possible for mothers who breastfeed to increase their vitamin K intake to increase the amount in breast milk, but not to sufficient levels to protect the baby without additional vitamin K.
What do other countries do?
Many countries that have used an oral vitamin K protocol, such as Denmark and Holland, have changed to an intramuscular regimen because the oral vitamin K that was previously used became no longer available.
Australia and Germany: 3 oral doses of 1 mg vitamin K are less effective than a single IM vitamin K dose. (In 1994 Australia changed to a single IM dose and their rate went to zero after the change.)
Netherlands: A 1mg oral dose after birth followed by a daily oral dose of 25 mcg vitamin K1 may be as effective as parenteral vitamin K prophylaxis.
Sweden: (a later study) 2 mg of mixed micellar VK given orally at birth, 4 days, and 1 month has a failure rate of one case of early and four cases of late VKDB out of 458,184 babies. Of the failures, 4 had an undiagnosed liver issue, one baby’s parents forgot the last dose.
Oral Vitamin K vs injectable (IM) Vitamin K
When vitamin K is given IM, the chance of late VKDB is near zero.
Oral vitamin K simply doesn’t prevent both early and late bleeding as well. This is especially true if there is an unknown malabsorption disorder, regardless of which dosing regimen is used.
6. My baby’s birth was not traumatic, so he doesn’t need the vitamin K.
Birth trauma can certainly lead to bleeding, but the absence of trauma does not exclude it.
Late vitamin K deficient bleeding (VKDB) cannot be explained by any birth traumas since they can occur months later.
7. We’re delaying cord clamping to help prevent anemia and bleeding. Isn’t that enough?
Delayed cord clamping can have benefits, but decreasing the risk of bleeding is not one of them.
There is very little vitamin K in the placenta or newborn. Delaying the cord clamping cannot allow more vitamin K into the baby.
Still not convinced?
Read stories about babies whose parents chose to not give vitamin K: