PLAGIOCEPHALY

Drs. Mikael Petrosyan and Gary Rogers from Children's National discuss plagiocephaly, the diagnosis, work up and treatment.  They also discuss a new product that Dr. Rogers has developed 

Transcript

Intro: 0:07

This is SURGUCATION, surgical education for parents. We are here to inform, inspire connect and heal. Plagiocephaly SURGUCATION episode 11, Dr. Gary Rogers, Chief of Plastics and Reconstructive Surgery. Children's National Hospital.

Dr. Petrosyan 0:31

Hi, my name is Mikael Petrosyan. I'm your host. Welcome to SURGUCATION, today, we have a privilege of having Dr. Gary Rogers as our guest. He's a Chief of Pediatric Plastics and Reconstructive Surgery. Today, we're going to talk about plagiocephaly, flathead and I know a lot of parents and they're concerned, and there are various treatments. And today I've invited him to talk about it and explain to us what is plagiocephaly and what parents need to know. Welcome to SURGUCATION.

What is Plagiocephaly?

Dr. Rogers 0:57

Thanks, Mike. Thanks for having me. So plagiocephaly actually plagiocephaly itself is actually flattening up one side. So it's from the skewed oblique head. So plagiocephaly is kind of a generic term. People throw out there. So people say flathead syndrome, there's all kinds of stuff, ascribed to this, but plagiocephaly separately itself is actually where the flattening is up. One side, not across the back flattening across the back. It's called brachycephaly. So brachycephaly brachy means short in Greek and wide. And so we end up having a h ead that is broader and a little bit shorter front to back. And then there's every variation in between. So really this depends on how the infant is laying during the first few months of life. If they're laying way over t o the side here, they tend to have flattening that is up t o side or plagiocephaly. If they lay more in the middle and ends up being brachycephaly and then every variation.

Dr. Petrosyan 1:44

So essentially the same sort of a combination of different versions of

What is the Pathogenesis of Plagiocephaly?

Dr. Petrosyan 1:49

slack

Speaker 2 1:49

Pathogenesis and if you let , if you take all comers, and lay them all on their back, so I've had four kids, none of my kids got flat. We did nothi ng different. I didn't move them around or reposition them or do tummy time with them . We did nothing. None of my kids are flat. My brothers, all their kids are flat. And so the question is why and 25% of kids who land on their back get flat. So it's not that their heads are soft or that there's something inherently bad about back sleeping is that these kids have some underlying predisposing risk factor for getting flat. If you want to look at those, the three big ones are torticollis, which is probably 95% of that. That's a muscle imbalance of the sternocleidomastoid muscles. One side being tight, one side being twisted, sort of, and that gets to the classic posture is like, is this where the head's tilted to one side and the chin rotated to the other, but it can be any variation. It can, it can be from minimal amount of a neck imbalance all the way up to fibrotic muscles that never get better. And we ended up doing surgery to release those and everything in between. So, but that tendency to go to one side, that imbalance drives the kids, these prone kids to keep their head in one position. So parents will often tell you, they go in and try to move the head over. It goes right back to the same side and just keep doing that . So why repositioning for kids that are prone to it? Well, that's why repositioning is difficult. So if you're a parent, you take, you go in every hour and turn your child's head to the side. And they have torticollis five minutes later their head is right back in the same spot. So repositioning in kids that have torticollis in my experience is not very effective. Um , and that's one of the problems with the current AAP recommendations. It's repositioning tummy time, early therapy that therapy will help torticollis, and if you can move the neck.

Dr. Petrosyan 3:25

we're talking about physical

The Role of Physical Therapy

Dr. Petrosyan 3:26

therapy,

Dr. Rogers 3:26

physical therapy. So if you can turn the head and move the head and stretch the neck out, the idea is that you might release those muscles earlier and get the child to start moving well and not have that. Side-by-side the big problem we run into with physical therapy is that often it needs to be identified by the pediatrician. And so a lot of pediatricians don't pick that up until the kids are three or four months of age by then, the head shape is already determined. There's studies that show that up to four months is when you flatten. Then after four months, the flattening stops because now kids are moving, they have independent motion.

Dr. Petrosyan 3:55

So is there something that parents did to cause this obviously there's nothing, but, so this is a reassuring for parents that we don't know why it happens. Some kids are pretty exposed and there's actually

The Role of Torticollis

Dr. Petrosyan 4:06

a treatment for this

Dr. Rogers 4:06

Yes. In torticollis, a torticollis, a predisposing. If you look at the risk factors for play yourself in torticollis, they're almost identical. I've written papers on this. So oligohydramnios , multiple births, larger children, firstborns males, all of these risk factors end up really big . All these are really packaging issues in utero, right? So it's a packaging problem. So with torticollis , imagine getting crammed into maternal pelvis like this two or three weeks. So say it's one week may have a little bit of tightness, say it's five weeks. You may have more tightening. You see you're crammed in with a twin or triplet. Okay? Now you're in there the whole time. And if your head is put in this position, this muscle may tighten. This muscle is now stretched and is looser. You come out and lo and behold, you have this, this, this neck issue. So , um, those risk factors, so it's nothing a parent does, but it may have to do with the maternal pelvis. It may have to do with other issues, but it's essentially a packaging problem in utero t hat ends up turning into a F lathead problem after the fact. And that's because when you come out of the pelvis and you lay a child on a flat mattress, which is recommended, right, nice flat f or mattress, their head will eventually take on the shape. If they're not redistributing the point of contact, t heir head will take on the shape of whatever they're laying on. It's new Newton's law, right. Is equal and opposite forces. So as they lay there and the head keeps growing, it can't grow through the bed. It grows along the beds, analogous to how a pumpkin flattens in a field.

Dr. Petrosyan 5:35

I see. So you can put a , if you put a pumpkin and the glass or a bowl

Dr. Rogers 5:39

In a bowl round , right. And that was, that was the end . So there's a lot of little , uh, going back to thousands of years ago and, you know, Indian Pakistan, little millet seed, somebody realized if you put your child on a , on a hard floor or on a surface that they will get flat . So people have built, these little doughnuts have been used for centuries. Uh, and the idea was to create some kind of concavity so that the, the head would not be less than gets a flat surface, but maybe a more concave surface. And those things are, there's tons of those pillows on I go to Amazon, you'll find hundreds and hundreds of those things on the, on the market.

Dr. Petrosyan 6:12

There are, there is treatment for plagiocephaly or Flathead . What about the helmets? I've seen a lot of helmets that are in market and kids wear them and parents like them. Uh , what is the, what is the correct age for the helmets? Is there a certain age that parents need to inquire for helmets? And , uh, is there , um, what is the success rate of helmets?

Treatments of Plagiocephaly?

Dr. Rogers 6:33

So Helmet success rates have varied in studies or studies that of Europe.

Dr. Petrosyan 6:37

obviously has to do with compliance. I'm assuming.

Dr. Rogers 6:40

with the compliance, with how well the helmets made. So if a helmet does the idea of the helmet is to hold the areas that have overgrown. So, so go back to the pumpkin analogy. We now have a flat spot and have areas that overgrew conceptually and areas that undergrou, you hold the areas that have overgrown and you expand the area, allow the area that's flat to expand out. And so the helmet was devised in 1979 by a guy named Sterling Claren and his idea, the whole conception of it was exactly that is if the bed can flatten the back out and allow this to overgrow, then we hold this and let the back roll back out again. And they do work effect . I think if they're designed properly and they're used consistently, they work extremely well.

Dr. Petrosyan 7:21

Is there any other products in the market that I'm similar to helmet and that parents can use early? I know you had some product that you have been working on. Why don't you

The new products

Dr. Petrosyan 7:30

tell us about it?

Dr. Rogers 7:30

We do. So, you know, when, when I, when I was a young attending at Boston Children's seeing litanies of patients coming in with , with handfuls of pillows and things that they tried to use. Uh, we started working on a different concept to see if we could create a surface that would not only just be an isolated, single size surface, but something that would expand over time. And it also had the shape on thing with the pillows and little military things as they don't have the shape of an occiput. So the head is going to grow into the form of whatever you put it against. So what you don't want to do is put it into a form that doesn't look like a normal occiput. So we created a custom made implant, custom made a block that was effectively foam. That was cut out with a little skid on it. And that became the first version of what we now have called the perfect noggins . So this was the, this was a custom made device. We studied it. We wrote a paper on it showing that versus repositioning a therapy. And there was no , no question that worked better than doing standard repositioning physical therapy for , for head , uh , a cemetery. Um, the problem with that device was it, this had to be custom contoured every week. And so that became arduous for parents. And we ended up having to come up with a different design, which is a layer design we have now, which is the perfect noggin. So we, we created this, I have one here just showing it this device, which you know , has multiple layers. And these are the , so the shape of this is a nice, is a nice soft foam, but it's from just like a helmet would be, and this has a contoured surface. That's effectively built off the back of a normal infant occiput. So I study this, we do shape analysis here, and this is built on that kind of idea. And I went through and redesigned this entire thing, but this has multiple layers that goes from 11 inch head circumference all the way up to 17 and a half inch heads our conference . So you can literally accommodate a child from birth until four months of age. Now, four to five months of age, they start rolling, getting head control. They're not going to get flat. So if you can get through the first four months of life without flattening, you're never going to get flat in a normal, healthy term child.

Dr. Petrosyan 9:24

Wonderful. And this is basically, you can use this on the bedsheets , and it's not, it's not something cause I know , American academy of pediatrics does not recommend any additional things in the bed, soft, soft things, toys or pillows. This is nothing but not soft, actually Pretty hard.

Dr. Rogers 9:43

And the foam surfaces are soft enough, but this is not like a , like a fabric or something where you're going to go face down. In fact, we have airation holes in it. Uh it's from , so it is effectively like a mattress topper rather than a reap , a reposition or something that people get confused about. repositioner something that holds an infant in place. So there , there, there are things that like wedges where people are up on the side and they did have deaths where they would put two or three week old kids on these wedges and then they would roll out and go face down. So most of the deaths you read about are bolsters soft bolsters and repositioning devices. This is neither child and move on. This thing can move freely. There 's no nothing restraining them. And this is not a soft surface at all. As you, these are the kinds of things that the American academy pediatrics recommends against.

Dr. Petrosyan 10:26

So yeah, these are, so these are sold in Amazon and we do not recommend purchasing this because these are not recommended. These are dangerous to be having bed very soft. Totally non-recommended we do not recommend

Dr. Rogers 10:38

Does this look like the back of your occiput? I mean, I'm not arguing that that looks nothing like it. And the idea, this is actually a very popular one. This is baby move . This, this, this, this pillow does two things. If you're successful in getting your child to lay in this head like this.

Dr. Petrosyan 10:53

It restricts their breathing actually.

Dr. Rogers 10:53

are six to breathing , you're going to flex your neck because the occiput is about an inch and a half off the back of the neck. So what happens is this, if you look at any of the pictures, kids are positioned just like that . Even in their own stuff, you can see this child's chin is right to the chest. That's not a safe position for her . Yeah .

Dr. Petrosyan 11:09

We don't endorse any of this products. Nor recommend having them or purchasing them.

Dr. Rogers 11:12

So these are soft. This is a soft bolster. This is actually that the AAP would go blaze . There was a other products on them. I was going to go through some of these because I think they're useful to talk about and why they're different. Uh, you know, these all lay in the bed there , again, these are , this is a true pillow, kind of a soft pillow. This is a mattress St . The same issue. That's not what your occiput is shaped like, correct. Chin, you contrast that with this, which is that's , that's what your shape, that's a shape of an intranet. And then you have things like this, another same idea. These

Dr. Petrosyan 11:43

Are , I've seen this in car seats as well.

Dr. Rogers 11:45

Um , so you know, you put that in the problem with this again, is if you're in a car seat and you're laying on a flat surface and the infant occiput jets out like this, you'll end up, you see

Discussing other products

Dr. Rogers 11:55

the kids flex like this or their heads that are in. So when I was a parent, you know , we had , oh , I'm pairing . But when I had four kids early on, we'd be putting our hand back there trying to keep their head stuck against a car seats that wouldn't be laying like this and not breathing. So these are not, I, my personal opinion is these are not useful. There's really no data suggest any of these actually work either. Uh , and , and they're not particularly safe. So that's, what's different about the product. This is from , this is level they're neck and head are in neutral alignment. They can move freely in this device. And it just fits in. This actually fits in the bed on the mattress that you have normally, or a bassinet. And you just plop it down and put them in it. And guess what? No repositioning, no worrying about a head getting flat. They will not get flat in this device.

Dr. Petrosyan 12:38

I think what's attractive. This advice is that you can use it early on. It's not, you don't have to wait until to get to the helmet age so you can use it early on. And hopefully you don't, you wouldn't need the helmet later on in life. Oh , that's the purpose of having them

Dr. Rogers 12:51

Probably wouldn't. And I know exactly, right? So I think if you can, you , again, you can't get the , the reason you get flat is because you're laying against a flat surface. You can't get flat in a bowl. So if you grow the pumpkin and a bowl, the pumpkin will just continue to look around. And so the idea here is to get them past that four month window, where they can flatten and have them with an eye shape, if you can keep a child in this, which most people can, if you swaddle them, or even if you don't swaddle them , uh , their headship will come out nice and round at four months. That's for sure. Awesome. Actually study this. And we have peer review papers to show that it works.

Dr. Petrosyan 13:21

Is this a product currently available? And parents can purchase this.

Where to find the perfect nogging

Dr. Rogers 13:25

Yeah, this is online. You can go to Amazon, A mazon. It's also on the website. We have a www.theperfectnoggin.com which is , uh , you know, either one is a good source for this and , uh , people can buy it. And it has instructions that come with it. It tells that we I'm accessible to parents. So I'd keep my email open. And

Dr. Petrosyan 13:44

I know you have also a blog about the noggin stop that you ride since sometimes thenoggindoctor.com. We'll leave . We'll leave that in the comments section of the video, as well as the podcast. Um, but the lesson learned from for parents is that plagiocephaly a Flathead is, is a treatable condition. Yes. Nothing to worry about. Uh, it's not something they did or repositioned. Some kids are predisposed to develop this condition,

Dr. Rogers 14:11

correct.

Dr. Petrosyan 14:11

There's a treatment for it. Yes. Well, we know we have an early treatment. Dr. Rogers came up with and as well as the late treatment , which if you missed it early on treatment, there's always helmets that most parents use. It's good to have access to that as well.

Dr. Rogers 14:27

Yeah. And helmets or helmets are a choice. I tell parents when they come to the office, that is something, no one has to have a helmet to be able to say, do I need a helmet? My advice is, do you want a helmet? It's not, it's not a necessity. And so most people would think that is as you get bigger. So a cemetery on the back of the head that stops it for months as you grow and widen. And then of course, you start looking at people, not from the top down from the back. It looks better with time. There's no doubt that plagiocephaly looks better with time. The question is how thick is your skin as a parent to sit and watch that while it, while that , uh , improves. And that's, that's the problem. There's been studies where they've looked at kids five or six months, five or six years of age who had played the cephalic early on and over half the parents still notice the flattening. So the idea that it all works out is not true. That 56% of parents said my kid is still flat. And the flattening still there is a social problem. A minority of parents said it was, but the fact is over half Of themselves.

Dr. Petrosyan 15:21

and go away . Basically, it what you are saying.

Dr. Rogers 15:22

I have plenty of pictures on the website a nd the noggin d octor, this k nown i t w as actually studies with looking at CT scans to come through emergency rooms, o r people have looked at the objective measures, right? Just a CT h as done for trauma, that kind of stuff. 13, 18 year old kids, those are fully grown. Their head is fully grown. Over 12% of them have clinically measurable a nd, a nd clinically significant plagiocephaly. So the idea that this is something that the pediatricians often think is that it goes away on its own. Certainly it looks better. I mean, this looks worse than that. that looks better, But the idea that it somehow goes away all on its own is not, not factual.

Dr. Petrosyan 15:59

Well, thank you very much. Uh, Dr. Rogers for being here and helping us understand plagiocephaly those of you who are interested can go to theperfectnoggin .com website also , on Amazon, the product is available and there's an email for Dr. Rogers. W e can, u h, he's very accessible and he can answer all the questions that those parents who have kids with plagiocephaly can inquire.

Dr. Rogers 16:22

Thanks, Michael .

Dr. Petrosyan 16:23

All right . Have a great day. Thank you .