Generality
Plagiocephaly is a cranial abnormality typical of infants, characterized by a unilateral flattening of the occipito-parietal region of the cranial vault.
The causes of plagiocephaly are numerous; the most common is the prolonged one-sided support of the head on the bed (or on the cradle), during the night or during the day.
The diagnosis is quite immediate and is usually based on objective examination only.
With few exceptions, plagiocephaly heals without any special medical treatment, but only with simple tricks (change the position of the baby when he is awake, put him to sleep on a slightly inclined shelf, etc.).
Recalls of anatomy of the human skull
Equipped with bones and cartilages, the skull is the skeletal structure of the head that constitutes the face and protects the brain, the cerebellum, the brainstem and the sensory organs.
Contrary to what many people believe, its organization is very complex, perhaps among the most complicated of the human body. In fact, it has between 22 and 28 bones, which are even and uneven, have an irregular shape and are flat (flat bones).
To simplify the study and understanding of the skull, the anatomists have thought of dividing it into two compartments, called neurocranium and splancnocranium .
neurocranium
The neurocranium is the upper cranial region, containing the brain and some of the main sensory organs. Its most important bones - strictly flat - are the frontal, temporal, parietal and occipital bones; these, taken together, form the so-called cranial vault .
splanchnocranium
The splanchocranium, or facial massif, is the antero-inferior region of the skull, composed of even and uneven bones. Represents the skeletal structure of the face, therefore it contains bony elements such as the mandible, upper jaw, cheekbones, nasal bone etc.
Figure: human skull. The main bones of the cranial vault and the anatomical subdivision of the neurocranium / splancnocranium are reported (NB: the red line ideally separates the neurocranium from the splancnocranium).
SKULL DEVELOPMENT
At birth and during the first months of life, the cranial bones of newborns - especially those of the cranial vault - are easily molded, as they are still soft, tender and not fused together.
With growth, they merge in some strategic points ( cranial sutures ) and their consistency changes: they become "stronger", less malleable and more resistant to shocks and constant pressure.
This process, which involves the progressive strengthening of the cranial bones, is part of the numerous mechanisms of ossification, concerning the human body.
What is plagiocephaly?
Plagiocephaly is a morphological abnormality of the skull, typical of small children, characterized by a unilateral flattening of the occipito-parietal compartment of the cranial vault.
The unilateral nature of the deformation causes the head to have an asymmetry, such as to make it very similar to a rhomboid-type parallelogram.
If it is not high grade or sustained by particularly serious causes, plagiocephaly is a condition that is generally resolved without special treatment.
Figure: human skull. starting from the left, the photos propose a child with a normal head (normocephaly), a case of mild plagiocephaly, a case of moderate plagiocephaly and a case of severe plagiocephaly. . From the site: www.cranialtech.com
ORIGIN OF THE NAME
The word plagiocephaly derives from the union of two terms of Greek origin: "plagios" (πλάγιος ‚), which means" oblique ", and" chefale "(κεφαλή), which means" head ".
Thus, the literal meaning of plagiocephaly is "oblique head".
PLAGIOCEFALIA AND FLAT HEAD IN THE NEWBORN
Together with brachycephaly, plagiocephaly represents one of the two causes of a more general condition, known as flat head in the newborn or flat head syndrome .
WHY ‰ HIT THE SMALL CHILDREN?
Plagiocephaly affects infants and very young children because the bones of the cranial vault are still soft and more easily modified (hence malleable).
Causes
Plagiocephaly has several causes.
Currently, the one considered the most common is the prolonged supine positioning of the child, during the night and during daily naps. In fact, the supine position can involve the partial support of the back side of the head on the bed or on the cradle, in which the child sleeps. All this determines a non-negligible pressure to the damages of the interested cranial region; in the long run, due to the high malleability of the infant's cranial bones, this abnormal pressure can change the shape of the skull.
Plagiocephaly resulting from prolonged supine positioning is called postural plagiocephaly .
Warning: reading the above, novice parents may find it wrong to put their child to sleep with their backs against the bed. However, it is important to point out that this is not the case at all: the supine position is correct and, unlike the one on the side or on the stomach, it is not among the factors favoring the so-called sudden infant death ( SIDS ).
OTHER POSSIBLE CAUSES
Among the other various causes of plagiocephaly, include:
- Some problems of uterus and intrauterine life .
According to some research, the scarcity of amniotic fluid - a condition that takes the name of oligohydramnios - would be responsible for morphological alterations of the head, including plagiocephaly and brachycephaly.
In particular, it would be decisive when the fetus, during labor, passes through the cervical canal of the uterus.
- Premature birth .
When crossing the cervical canal, children who are born prematurely have a greater tendency to undergo a morphological modification of the skull, as the malleability and softness of the cranial bones are even higher than those given to term.
In this regard, readers are reminded that the last weeks of pregnancy are crucial for strengthening the cranial bones and making them resistant enough not to undergo alterations while crossing the cervical canal.
- Neck muscles too weak .
Children who are too weak on one side of the neck have a tendency to bend the head to one side only, causing them to take a wrong position. All this would favor the flattening of only one side of the head.
- Craniosynostosis .
Craniosynostosis is the term by which doctors indicate an abnormality of the skull due to the premature fusion of one or more cranial sutures.
The form of craniosynostosis responsible for plagiocephaly is that which involves the lambdoid suture, located between the parietal bones and the occipital bone, in the back of the head.
As will be seen in the chapter dedicated to therapy, the craniosynostosis of the lambdoid suture always requires surgical treatment and this distinguishes the plagiocephaly due to this cause (ie the premature fusion of the aforementioned suture) from that due to one of the previous causes.
Epidemiology
Plagiocephaly is today much more common than in the past, due to a substantial increase in cases of postural plagiocephaly.
It has an almost equal incidence in all the races present in the world and affects both sexes equally.
According to some statistics, they would suffer from postural plagiocephaly:
- 16% of children of 6 weeks
- 20% of children of 4 months
- 7% of 12 month old children
- 3% of children aged 24 months
Symptoms and Complications
The clinical sign that characterizes every case of plagiocephaly is the unilateral flattening of the back of the head.
At this typical manifestation, other anomalous can sometimes be added, such as:
- One ear more advanced than the other (NB: this can be seen by observing the child from above).
- One eye smaller than the other.
- One cheek more swollen than the other.
WHAT DOES THE APPIACTION SEAT DEPEND ON?
The precise location of the flattening depends on the causes.
For example, in the case of postural plagiocephaly, the anomaly lies on the side of the head that the child has the habit of resting more often on the couch; while, in the presence of a weak musculature of the neck, the flattening of the head results on the opposite side to that where the muscles are weak (and towards which the infant tends to bend the head).
COMPLICATIONS
In general, plagiocephaly is a drawback only from an aesthetic point of view; a drawback, among other things, almost always temporary.
It is very rare that it involves complications: when present, these are often associated with the presence of craniosynostosis, a really uncommon condition, which affects one newborn every 1, 800-3, 000.
Diagnosis
In general, an objective examination is sufficient to diagnose plagiocephaly and its peculiarities.
In medicine, by physical examination we mean the evaluation by the doctor of the symptoms and signs present and / or reported by the patient.
The use of more specific diagnostic tests - in this case instrumental tests such as X-rays or CT scans - takes place only in the presence of doubts concerning the causes: where there is suspicion of a craniosynostosis, the attending physician has the duty to investigate the situation thoroughly, to understand how to act from a therapeutic point of view.
Treatment
The treatment adopted varies according to the severity of the plagiocephaly.
In case of slight flattening, the anomaly generally heals without particular care; in these cases it is sufficient to put into practice (by parents) some simple tricks, whose common purpose is to reduce the pressure on the occipital area of the skull.
In the case of more pronounced flattening, the aforementioned measures are still useful, however they may not be sufficient to achieve recovery. In fact, in these situations, it is probable that the remodeling of the head is only partial, therefore the morphological anomaly can leave signs of its passage.
Finally, cases of plagiocephaly sustained by weakness of the neck muscles and craniosynostosis deserve a mention apart: each of these requires specific medical treatment, the failure to apply of which tends to have permanent repercussions.
SIMPLE REMEDIES TO REDUCE THE PRESSURE ON THE HEAD
The devices, which reduce the pressure on the back of the head, are:
- When the child is awake,
- Make him assume such positions that he does not place the back of his head on the shelf where he is. A valid solution is to lay it on your stomach (ie prone), taking care to keep it always awake and stay with it for as long as it remains in that position. These precautions are explained by the link, already recalled above, between the prone position during sleep and the sudden death of the infant.
- When the baby sleeps,
- Always avoid placing it with the head facing only one side only. In other words, varying its position often, so that there is no particular area of the head subjected to greater pressures than others.
If this recommendation is difficult to implement, it is good to put the baby to sleep on a slightly inclined or flat shelf.
- When the child plays,
- Often change the position of toys that attract more attention. This can be a way to make his head spin even when he is lying on the crib or bed.
- When you are traveling with your child or take it for a walk,
- Provide for the use of seats and strollers that do not cause excessive pressure on the back of the head.
Also in this case, it is essential to prevent the child from keeping his head always turned towards the usual side.
A particularly valid remedy is to use baby slings or rucksacks, which allow the parent to hold the newborn in front of him, without the latter resting his head on some shelf.
To observe the first results of these important measures, parents may have to wait 6 to 8 weeks.
WHEN THE NECK MUSCLES ARE WEAK
When plagiocephaly is associated with weak neck muscles, physicians recommend physiotherapy to parents.
In fact, there are particular physiotherapy exercises that guarantee a reinforcement of the neck and the possibility of turning the head on both sides.
By allowing the patient to tilt the head both to the right and to the left, the pressure on an exclusive area of the head is considerably reduced; furthermore, at this point, it is possible to implement the precautions reported above.
Early use of physiotherapy increases the chances of complete recovery.
IN THE PRESENCE OF CRANIOSINOSTOSIS
The plagiocephaly due to craniosynostosis requires an ad hoc surgical intervention, aimed at the separation of the cranial sutures fused early between them.
To know the characteristics of the operation, the reader can rely on what is reported in the article here.
USE OF HELMETS: ARE THEY EFFECTIVE?
In some countries of the world, doctors use cranial orthoses, similar to helmets, with the aim of protecting the head from pressure and favoring the correction of morphological anomalies such as plagiocephaly or brachycephaly.
Especially in recent years, the use of these corrective tools has raised some doubts. In fact, several experts believe that cranial orthoses produce limited improvements, especially when compared to the aforementioned devices.
Furthermore, they are not recommended for two other reasons: they are expensive (and not all families could afford them) and very uncomfortable for the child.
Prognosis
With the appropriate precautions, the forms of mild plagiocephaly heal completely between the first and second year of life.
