When my son was an infant, we followed modern medical wisdom and always put him to sleep facing upward. Within a few weeks, he developed a noticeably flat plane on one side of the back of his soft, bald little head.
"Deformational plagiocephaly" is the technical term, and it's a widespread condition that has risen sharply since public health campaigns to put babies to sleep on their backs began in the 1990s. It affects at least one-fifth of American babies and possibly closer to half. My own overwrought, sleep-deprived diagnosis sounded more like, "Oh, no, my baby's head is going flat!"
We brought him to specialists who raised the prospect that he might need to wear a helmet virtually non-stop for a few months, to protect his flat spot from pressure and help it round back out.
A helmet? All day and night? But there was no actual danger from his moderate head-flattening, no known risk except perhaps of future ridicule. In the end, we tried a custom-carved foam "head cup" and special "positioner" pillows to help vary which side he slept on. And we consoled ourselves that he just wouldn't be able to become a skinhead when he grew up, which was surely just as well.
It's the kind of parental decision you can second-guess yourself about forever. (There's no sign of any flatness nine years later beneath his full head of hair, but what happens if he goes bald?) So I found welcome reassurance in a study just out in the journal BMJ on "Helmet therapy in infants with positional skull deformation."
The paper is small but it's the first randomized, controlled study — the gold standard in medical research — of helmets for plagiocephaly in babies. And it found that, at least in 84 babies without other risk factors, the helmets don't help. The babies tended to improve with or without helmets. From the press release:
There was no meaningful difference in skull shape at the age of two years between children treated with therapy helmet and those who received no active treatment. Both groups showed similar improvements although only a quarter made a full recovery to a normal head shape, according to the team of researchers based in The Netherlands.
The results are especially underwhelming when you consider that the helmets, made of firm foam in a hard plastic shell, can cost as much as several thousand dollars, even in Great Britain, where the national health system doesn't tend to pay for them.
The findings can also seem a bit daunting when you consider that once the flat-headedness developed in babies, only about a quarter of them fully "normalized," helmet or not.
Dr. Carolyn Rogers-Vizena, a craniofacial surgeon in the department of plastic and oral surgery at Boston Children's Hospital, emphasizes this point: By no means should concerns about head flatness dissuade parents from putting babies to sleep on their backs, which is known to protect against Sudden Infant Death Syndrome. Back-sleeping alone should not be blamed, she added; babies who develop flat heads usually have other risk factors that lessen mobility, including neck tightness, prematurity or developmental delays.
Also, the study offers useful new knowledge but it's only one small study, she said, "it's certainly not the be-all and end-all."
Because the study is the first of its kind and has not yet been reproduced by other researchers, "it won't yet dramatically change my practice," Dr. Rogers-Vizena said. "But it gives me something new to tell parents when we’re counseling them, and hopefully bigger, higher-powered studies will come out so we can get a sense of who’s an appropriate candidate for a helmet and who’s not."
The study excluded many babies who would be typical patients for Dr. Rogers-Vizena, those with more severe cases or the neck tightness known as torticollis.
Still, it could offer some solace to parents agonizing over the helmet decision, as I did.
"There's a huge amount of parental anxiety around deformational plagiocephaly," Dr. Rogers-Vizena said, "and I think there's often a lot of guilt, because parents feel, 'I did this — I didn't pick him up enough or he was in the wrong position in utero.' And hopefully this will alleviate some of that anxiety and say, 'You don't have to be super-aggressive'" about getting plagiocephaly treated, and "parents shouldn't feel like they're being negligent by not helmeting."
(Note: Helmet makers are questioning the study's findings, The New York Times reports, saying that a helmet's benefits all depend on the right fit.)
Ideally, of course, you head off head problems before they happen. In an editorial that accompanies the paper, Brent R. Collett of the Seattle Children's Research Institute writes in part that the findings highlight the importance of preventing plagiocephaly — whether through public messages about "tummy time" or other means.
A striking 2011 French paper found that prevention is highly possible if new parents are actively educated to help their babies move more freely. Only 13 percent of babies in the study whose parents got preventive education developed plagiocephaly, compared to 31 percent in a control group. (Also striking, from the abstract: "For each supplementary hour of immobility during the third and fourth months of life, the risk of Deformational Plagiocephaly at four months doubled.")
The French study used a brochure headlined "For baby's sake, let's do things differently from day one" and "Give baby room to move!" It included statements like "I only use my baby's car seat when traveling" and "If baby always turns his/her head to the same side, I attract baby's attention on the other side" whether "by talking to or looking at baby at every contact" or "with a toy or brightly colored material close by."
Here's more on prevention from the orthotics company Boston Brace's page on plagiocephaly:
Repositioning: An infant’s skull is incredibly flexible in its growing stages prior to cranial maturity. This makes it vulnerable to risks of flattening while placed against any surface for long periods of time.
To avoid this, some medical experts recommend a technique called “repositioning,” which simply means alternating the infant’s position to evenly distribute the gravitational pressures on a growing skull.
Suggested means of repositioning include encouraging infants to respond to toys and stimuli equally on both right and left sides. If flattening becomes apparent on a certain area of the infant’s head, parents should encourage a position in which the flattened portion of their child’s head is not in contact with any surface. Also recommended is to have an infant spend time on their stomach, which must be supervised for safety reasons.
Dr. Rogers-Vizena says there are also many products on the market to help prevent or alleviate plagiocephaly, from donut-shaped pillows to other head supporters and even hats, but there hasn't been enough research for her to be able to recommend any of them.
Readers, any anecdotal evidence to share?