Family Matters

Babies With Flat Heads on the Rise: Is ‘Back to Sleep’ to Blame?

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Nearly 20 years ago, the chief activity in a baby’s life — sleeping — got a radical makeover. The American Academy of Pediatrics (AAP) launched its “Back to Sleep” campaign in 1992, urging parents and caregivers to put sleepy infants on their backs rather than on their stomachs, as had been the norm.

Researchers had learned that back-sleeping cuts the risk of sudden infant death syndrome, or SIDS; the rate of SIDS has been halved since the campaign’s inception. But back-sleeping appeared to simultaneously increase the likelihood that babies might wind up with a flat head, a condition known as plagiocephaly, which means “oblique head” in Greek. Instead of a sweet, round orb, an infant might find himself — as mine did — with a lopsided noggin.

While the AAP believes that back-sleeping has increased the prevalence of flat heads, says neurosurgeon Joseph Piatt, who was chairman of the AAP’s section on neurological surgery when its policy statement on plagiocephaly was drafted, the cosmetic inconvenience seems a small price to pay. As Piatt puts it: “The AAP perspective on this is that babies with funny-shaped heads are better than dead babies, from a public-health standpoint.” (More on A possible explanation for SIDS?)

Now a new study published online Monday in the Archives of Pediatrics & Adolescent Medicine confirms the increase, but casts doubt on whether it’s actually related to the Back to Sleep protocol. Rather, the authors, from the Texas Department of State Health Services, contend that the rise in cases is due to increased awareness on the part of practitioners.

“We feel there is little evidence for an actual increase in plagiocephaly from 1999 to 2007,” says Peter Langlois, senior epidemiologist of the Birth Defects Epidemiology and Surveillance branch of the Texas Department of State Health Services. “We think it’s because we are getting better at picking up more and more cases.”

Piatt, a professor of neurological surgery and pediatrics at Thomas Jefferson University in Philadelphia, finds that hard to believe. When he began civilian practice in 1989, he was not aware of plagiocephaly as a condition and did not learn about it in his medical training. Now, he figures that babies with flat heads account for one of every four new outpatient visits at A I duPont Hospital for Children in Wilmington, Del., where he is a neurosurgeon.

In the study, reported cases of plagiocephaly jumped from 3 cases per 10,000 live births to 28.8 cases per 10,000 live births between 1999 to 2007, according to data from the Texas Birth Defects Registry. Researchers from the Texas Department of State Health Services identified a total of 6,295 cases, which works out to an average annual increase of more than 21% per year. (More on Time.comWhy Parents Should Stop Using Crib Bumpers Now)

Incidences of plagiocephaly were reflected in all demographic groups, regardless of maternal age, race or ethnicity, infant sex, gestational age or multiple births. “A small part of this might have been due to delayed compliance with the American Academy of Pediatrics recommendation for supine infant sleeping and a slight increase in preterm births. It was definitely not due to changes in birth defect coding practice, trends in multiple births or trends in clinical conditions,” wrote the authors.

Part of the increase, suspects Langlois, can be traced to more premature births; preemie babies’ skulls are more malleable. It’s likely also a reflection of the availability of commercial treatments for plagiocephaly. Parents are advised to reposition an affected baby’s head and engage in supervised “tummy time,” but there are also orthotic helmets that help remold still-soft baby craniums. When helmets are prescribed by doctors, it’s reported to the birth defects registry; if repositioning is all that’s recommended, there may be no record of an infant’s plagiocephaly diagnosis.

“What used to be a mild case of repositioning in 1999 might get a prescription for a helmet in 2007 because there’s more awareness of treatment options and possible insurance reimbursement options,” says Langlois. More on Time.comStudy: Most Babies Sleep Through the Night (But Not Mine))

The AAP is noncommittal about the efficacy of orthotic helmets. They are considered an “option,” says Piatt, who thinks the helmets have a short-term effect. “Babies who get helmets look better in six months,” says Piatt. “They have rounder heads than comparable babies who don’t get helmets. But I don’t know whether that translates into better-looking heads at 5 years of age. There hasn’t been any meaningful study of that question.”

When my son developed a seriously asymmetrical head by the time he was 6 months old, our pediatrician discouraged us from considering a helmet. We pursued the treatment anyway on the grounds that it couldn’t hurt (plus, they were fun to decorate); when Aviv finished treatment at 14 months, his head was noticeably rounder though far from perfect. Even our pediatrician agreed it had seemed to help. Unknown was how Aviv’s head would have evolved without the helmet.

Now 8, Aviv is sitting next to me as I write this. I just got up and surveyed the back of his head. The left side is really round; the right side is really not. “Has anyone ever noticed that you have a flat head?” I ask.

“I do?” he says, bemused. If for no other reason than that, I would say the helmet was worth it.