Safe Sleeping May Cause Flat Heads for Babies

From the WebMD Archives

Sept. 20, 2000 -- Since the early 1990s, the "Back to Sleep" campaign -- which recommends that all healthy infants sleep on their backs to decrease the risk of sudden infant death syndrome (SIDS) -- has been a roaring success, cutting the SIDS rate by about 40%.

That's great news, but one of the seldom discussed side effects of this campaign -- launched by the American Academy of Pediatrics (AAP) -- is a marked increase in cases of positional plagiocephaly, a condition usually resolved by time and Mother Nature. It occurs when babies sleep exclusively on their backs and have consistent pressure on their soft, forming skulls. As a result, they develop flat spots on their heads.

In fact, one study in the journal Pediatrics found that cases of positional plagiocephaly have increased sixfold since the "Back to Sleep" campaign began. Until researchers were able to pinpoint the reason for this increase, many doctors mistook this fairly harmless condition as something more serious called craniosynostosis -- a premature fusion of the skull that can impair brain growth.

According to many experts, positional plagiocephaly usually disappears within several months after the baby has begun to sit up. Still, across the country, many parents are opting to put their kids in helmets that coax their heads into a more symmetrical shape. Helmets cost about $3,000 and some insurance companies may pick up the tab. Children must wear them for about 23 hours a day for an average of four and a half months.

For babies with less severe flattening, the AAP recommends placing them on their stomachs when they are awake and supervised, a strategy some activists are calling "Stomach to Play and Back to Sleep." Other recommendations include putting children to sleep on their backs but in varying places in the room, so their attention will be drawn in different directions. Also, time in car seats and other infant carriers should be limited, because they can also increase the risk of flat spots.

Joseph Shin, MD, an assistant professor of surgery and director of the Yale Craniofacial Center in New Haven, Conn., sees one to two cases of plagiocephaly each week.

"We agree with the AAP that 'Back to Sleep' is beneficial for the prevention of SIDS, but clearly we have seen an increase in positional plagiocephaly," Shin tells WebMD. "Whether the baby needs a helmet or not depends a little bit on how severe the problem is and how old the child is."

Generally, he says, children between three and 15 months of age with positional plagiocephaly -- not craniosynostosis -- benefit from helmets. "Over time, with weekly reshapings, the helmet will mold the child's head into a normal shape, [but] a lot of cases can improve without treatment," Shin says.

"Anytime [parents] see an abnormal shape in the head in the front or back, or the head has an asymmetrical look, they should consult with a pediatrician," he suggests. "Oftentimes, the pediatrician can reassure that it's a mild condition and rule out more serious conditions like craniosynostosis," he says.

Shin also points out that plagiocephaly often occurs with a condition called muscular torticollis, or a shortness of the neck muscle.

"The biggest problem I have seen is the tendency of children to pick a side due to shortened neck muscle, which can result in mild to moderate deformity if untreated," says Ann Marie Flannery, MD, a pediatric neurosurgeon and professor at the Medical College of Georgia in Augusta.

"The alert mother or father should notice if their child has a side tendency and do what they can to get them to change sides. If this is instituted when the baby is six weeks to two months, chances are that they will not have a flat head when they get older," she tells WebMD.

For example, if your child shows signs of torticollis, put their toys to the side they don't usually face, or try things to encourage them to look to the other side, she suggests.

"We have gotten away from using helmets because it is hard to get one that fits well," Flannery says. "There is some use for helmets in more serious cases, but they require a serious commitment, are extremely expensive, and we have no proof that they are better than repositioning."