The Infant Skull, Brain and Development - Flattening and Misshaping Plagiocephaly

TheInfantSkull,BrainandDevelopment
FlatteningandMisshaping
(Plagiocephaly)
Newtown Community Chiropractic
Level 1, 241 King Street
Newtown, 2042
p: 02-9519-4729
info@newtowncommunitychiropractic.com.au
The Infant Skull, Brain and Development - Flattening and Misshaping (Plagiocephaly)
|
P a g e 2 o f 6

THE NORMAL CRANIAL BONES
Pregnancy, the birth process, and early infancy, can have long-term effects on your childs health.
The sutures and fontanelles allow the bones of the cranium to overlap one another during the birth
process as they compress when entering the birth canal.
This process is called molding and the cranial bones should resume their normal shape within one
week of the birth.
The cranium will take on a rounded appearance in which the skull itself will be much larger in relation
to the facial structure.
The delicate nervous system in infancy is protected not by bone but by cartilage. The cranium itself at
this stage of development functions as membranous tissue in a constant state of flux.
It is constantly expanding and realigning to adapt to the extremely rapid growth of the brain during the
first 3 years of life.
22
Shape of Skull
Note the shape of the head and determine the extent of cranial molding.
Temporary asymmetry is usual after birth and the shape should return to
normal within 10 days.
Cesarean section infants usually have a more symmetrical cranial
presentation due to lack of cranial molding while passing down the birth
canal. This is not necessarily a good thing and cranial compression and
molding techniques are usually called for.
Look for:
Symmetry
Asymmetry may occur if the infant sleeps
or nurses consistently on one side.
In premature infants at birth the head is relatively long
on the occipital-frontal diameter and narrow in the bi-
temporal diameter.
Bulging
Elongation
Crowning
Widening / flattening of cranial bones
Relative position of the mastoid tips to each other.
Relative position of the mastoid body
Is it tightly fitted to the occiput or does it lean or project outward?
Does one mastoid appear larger than the other?
Does one mastoid tip angulate more that the other?
4
The sutures and fontanelles allow the bones of the cranium
to overlap one another during the birth process as they
compress when entering the birth canal.
This process is called molding and the cranial bones should
resume their normal shape within one week of the birth.
The cranium will take on a rounded appearance in which the
skull itself will be much larger in relation to the facial structure.
The delicate nervous system in infancy is protected not by
bone but by cartilage. The cranium itself at this stage of
development functions as membranous tissue in a constant
state of flux.
It is constantly expanding and realigning to adapt to the
extremely rapid growth of the brain during the first 3 years of
life.
Z/I9/Z009
Zb
! Troumo
!Microfroumo: repefifive (foIIs on buff), "Iow
force "
ExompIes:
!Disruption
destruction of a normally formed structure
!Mocrofroumo: Iorge forces (i.e., MVC)
! Vifomin deficiency i.e., Vif D & FoIic Acid defiency
! 0esfofionoI diobefes ossociofed wifh ferofogenicify
! Degenerofive Process: consider L8P in chiIdren
!Infecfion & MeopIosms: Iyfic desfrucfion of bone
Deformofions occur offer embryogenesis, ond resuIf from
nondisrupfive mechonicoI forces, such os infrouferine or
posfnofoI posifioning, fhof couse obnormoI formofions or
disforfions of normoI body porfs.
!"#$%&$&'(!"#)$)"%)%*
! Deformation - altered structure and function
of an otherwise normal structure
" PosifionoI pIogiocephoIy, oIso coIIed deformofionoI pIogiocephoIy or
pIogiocephoIy wifhouf synosfosis, is on ocquired phenomenon.
" Hos become more common since fhe I990s "8ock-fo-SIeep" inifiofive
fo prevenf SIDS).
" In I99Z, 707 of infonfs were prone sIeeping ond pIogiocephoIy
rofes were I in 300 Iive birfhs.
" In I997, b yeors offer fhe "8ock-fo-SIeep" compoign wos
inifiofed, prone infonf sIeeping posifion decreosed fo I0.b7,
concurrenfIy fhe pIogiocephoIy rofe rose b-foId, fo I in o0 Iive
birfhs.IZ,
HummeI ef.oI. Advonces in MeonofoI Core, Z00b
+)&*%"#$),(-$.&$/*0(1".(2#033/$.0()%($4/(54)'6
#The causes of asymmetry is multi-factorial
$ physiological,
$ osseous,
$ neurological and neurological and
$ genetic
#Analysis Based on Precept of Structure Function
VIimmeren ef.oI. Eur Spine J Z004
Localized Asymmetry in Infancy
# PIogiocephoIIy
#TorficoIIis - see cIinicoI presenfofion
#ScoIisios - discussed shorfIy
EfioIogy
! TypicoIIy posifionoI,
! Moy oIso be seen wifh forficoIIis, ! Moy oIso be seen wifh forficoIIis,
! More common in infonfs of muIfipIe
gesfofion,
! Associofed wifh hydrocephoIus ond
shunf pIocemenf,
! If due fo croniosynosfosis ony or oII
sufures moy be invoIved.
EfioIogy
! Common in some roces, such os,
Americon Indions, MoIoyons, 8urmese, !
TypicoIIy posifionoI in whife infonfs,
! PoreIy pofhoIogicoI! however, if due fo
croniosynosfosis fhe Iombdoid or coronoI
sufure moy be fused.
HummeI ef.oI. Advonces in MeonofoI Core,
Z00b
DoIichocephoIy
!o foII norrow heod.
common in chiIdren sIeeping on fheir
sides or in exfreme coses - synosfosis of
fhe sogifyoI sufure ,suspecf if no
improvemenf over fime.
!View fhe infonf's possive posifion in fhe supine, prone, ond supporfed
siffing posifions.
!EvoIuofe for fhe direcfion fhof fhe heod is preferenfioIIy furning.
Mofe fiIf of heod fo I side.
!Heod fiIf moy be mosf evidenf when observing fhe infonf from fhe
bock.
!Infonfs 3 fo 4 monfhs connof deveIopmenfoIIy moinfoin fheir heod in
midIine, however fhey shouId be obIe fo move fheir heod from side fo
Protocol for Evaluating Cranial Asymmetry
Sfep I: Inspecfion/Observofion
midIine, however, fhey shouId be obIe fo move fheir heod from side fo
side eosiIy.
!View fhe infonf's heod from obove.
!Mofe fhe posifion of fhe eors ond fhe shope of fhe
foreheod.
! In deformofionoI osymmefric pIogiocephoIy, fhe bock ond
fronf of fhe heod shiff forword fo I side, ond fhe eor posifion
on fhe some side is shiffed in fhe some direcfion.
!EvoIuofe fhe degree of occipifoI !offening.
Z/I9/Z009
Zb
! Troumo
force "
ExompIes:
!Disruption
!"#$%&$&'(!"#)$)"%)%*
fo prevenf SIDS).
birfhs.IZ,
+)&*%"#$),(-$.&$/*0(1".(2#033/$.0()%($4/(54)'6
$ physiological,
$ osseous,
$ genetic
# PIogiocephoIIy
EfioIogy
gesfofion,
shunf pIocemenf,
EfioIogy
Z00b
DoIichocephoIy
siffing posifions.
bock.
side eosiIy.
foreheod.
Shape of Skull
Temporary asymmetry is usual after birth and the shape should return to normal within 10 days.
Cesarean section infants usually have a more symmetrical cranial presentation due to lack of cranial
molding while passing down the birth canal. This is not necessarily a good thing and cranial
compression and molding techniques are usually called for.
Plagiocephaly the flattening or misshaping of the bones of the skull - is usually caused either by the
position of the baby in third trimester (with the head crammed against the pelvis) or through birth
trauma (forceps, suction or manual stress). It may be accompanied by torticollis (the head held to the
side).
Suspect plagiocephaly if:
There is any flattening or misshaping of the bones of the head or a bald spot
The head is held to one side or rotated to one side or the baby prefers to turn the head to one
side
The shape of the face is asymmetrical
When looking at the head from above, one ear appears further forward than the other
Having completed post-graduate studies in paediatrics, we have specific techniques for helping babies
fire up their brain. There are many things we can do, and specific advice we can give parents, to
increase brain function.
Every pregnant woman should be checked, to make sure she can have her ideal birth.
Every baby should be checked, to make sure it gets the best start to life.
Who do you know who has not been checked?
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P a g e 3 o f 6

ENCOURAGING BRAIN DEVELOPMENTAL
Pregnancy, the birth process, and early infancy, can have long-term effects on
your childs health.
Early brain development is key to your childs lifelong health and success. It is
an important pathway to lifelong learning, behavioural competence, positive
social relationships and health.
Your baby starts perceiving its environment in-utero:
Touch develops in the 8th week, then next taste and smell
Balance develops just after the first trimester - this makes it crucial for
the pregnant woman to keep moving, so that the developing brain is
exposed to constant movement input
Early vision then develops, with baby opening its eyes in-utero
Hearing develops near the end of the second trimester
For healthy development, the babys brain needs mum to be as healthy as
possible. The 5 things you need to do to be as healthy as possible in the
pregnancy:
1. Live a healthier nutritional lifestyle - provide your body with the right
nutrient building-blocks
2. Exercise more- movement is vital for your health and for your babys
growth
3. Be adjusted regularly, by a wellness family chiropractor
4. Choose a wellness pregnancy provider - a doula or a midwife
5. Be inspired and learn. Pregnancy and birth are not like anything youve
done before
At birth, your babys brain is small, compared to the rest of its body and
compared to how developed the brain will become. In fact, in your babys first
month of life, its brain increases its number of connections 30-fold! This huge
growth in brain-power is driven by your babys experience of the world,
through movement and stimulation.
When the brain is not functioning at its optimum, we see:
a wired unsettled baby (crying; digestive, sleeping & feeding issues;
overly sensitive)
coordination issues
learning difficulties
emotional issues
Having completed post-graduate studies in paediatrics, we have specific
techniques for helping babies fire up their brain. There are many things we
can do, and specific advise we can give parents, to increase brain function.
Every pregnant woman should be checked, to make sure she can have her
ideal birth.
Every baby should be checked, to make sure it gets the best start to life.
|
P a g e 4 o f 6

DEVELOPMENTAL DELAY & PLAGIOCEPHALY
The birth process, and early infancy, can have long-term effects on your
childs health.
The most basic part of your babys brain - the brainstem - is responsible for
your babys function during pregnancy and immediately after birth. This part of
the brain controls your babys development, breathing, heart and digestion.
The brainstem can often be stressed by birth, even a vaginal birth, with the
tension and trauma of pulling on the babys head.
Plagiocephaly is the misshaping or deformation of the head, present from
birth. It may be the result of either the babys head being stuck in the wrong
position in-utero, often for a long period of time in third trimester or as a result
of the birth process. Birth may cause the babys head to be constantly pushed
with every contraction against a part of mums pelvis or pubic bones, or
trauma is associated with forceps, suction and caesarian births. Either cause,
from constraint in utero or birth trauma, affects the shape of the babys
cranials (skull bones). Contrary to popular belief, the research shows that this
deformation does not work itself out and is not just aesthetic. Plagiocephaly
affects brain function and development and may result in decreased cognition
and coordination. Plagiocephaly is a significant public health issue, because
of the common misconceptions that it is an aesthetic misshaping that will
clear up by itself, whereas in reality the research shows that it actually affects
brain function.
Both brainstem tension from birth and plagiocephaly may cause the baby to
be unsettled. Research also shows that brainstem stress and plagiocephaly
can cause developmental delay, affecting cognition and coordination.
A wired or unsettled baby may have:
unexplained crying that may be high-pitched or not calm easily
digestive issues
sleep difficulties
feeding issues
overly sensitive
Developmental delay may be noted by kids finding it hard to sit still, focus, cut
with scissors or use glue.
Growing brains need three things:
6. Oxygen: physical activity and healthy breathing are crucial
7. Fuel: healthy nutrients are the building blocks
8. Activation: the brain needs to have healthy input from the senses and
a good level of firing.
As chiropractors, we check all of these things early on: how your baby is
breathing, that its nutrient requirements are met, and that the brain is
receiving the correct inputs from the senses and processing those, being
activated well.
Having completed post-graduate studies in paediatrics, we have specific
techniques for helping babies with brainstem tension, plagiocephaly or
developmental delay. There are many things we can do, and specific advise
we can give parents, to increase brain function.
References:
1. Yeargin-Allsopp, Murphy, Oakely & Sikes 1992
2. Drillien, Pickering & Drummond 1988, Glascoe & Shapiro 1999
3. Child Care in Practice. Vol 11:4 2005:415-432
About 17% of
children have
developmental
delay.1
Many are not
detected before
school entrance.2
Children with
immature physical
development
performed less
well on measures
of educational
achievement... 3
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P a g e 5 o f 6

PLAGIOCEPHALY (FLAT HEAD)
INCREASED INCIDENCE OF THIS SIGNIFICANT
PUBLIC HEALTH ISSUE
Medical professionals have begun to notice an alarming rise in the incidence
of a skull deformity in infants called flat head syndrome. Plagiocephaly, the
medical term for this flattening of the skull, can occur as a result of consistent
pressure on a particular spot. It is a condition that can be permanent if not
cared for early on.
The increase in plagiocephaly is frequently blamed on the fact that babies are
now placed on their backs to sleep, in an attempt to prevent sudden infant
death syndrome (SIDS). If a babys head is always in the same position, the
pressure can deform the skull. There has been a dramatic increase in
plagiocephaly since the Back to Sleep campaign was launched to prevent
SIDS the rate of plagiocephaly rose 5 times in the first 5 years of the
campaign.
1
However, back-sleeping is not the only factor. Extended periods of time spent
in a baby seat can also contribute to this condition, as can long periods in
strollers, swings, and other devices that put babies in a back-lying position.
Thomas R. Littlefield, M.S., is affiliated with an Arizona clinic that treats
plagiocephaly. In an article in the Journal of Prosthetics and Orthotics, he
notes that 28 percent of infants who attend the clinic spend 1.5 to 4 hours
daily in car seats or swings, and nearly 15 percent are in them for more than
four hours per day. Another 5 percent of infants are allowed to sleep in these
devices. Littlefield observes that cranial distortion resulting from overuse of
car seats and swings is more severe and complex than in children who
develop plagiocephaly from back-lying on a mattress. Consequently, he
recommends reducing the time spent in car seats and swings, if possible.
Concern over plagiocephaly also led the American Academy of Pediatrics to
suggest in 2003 that infants should spend minimal time in car seats (when
not a passenger in a vehicle) or other seating that maintains supine
positioning.

22
Shape of Skull
Look for:
Symmetry
temporal diameter.
Bulging
Elongation
Crowning
22
Shape of Skull
Look for:
Symmetry
temporal diameter.
Bulging
Elongation
Crowning
Z/I9/Z009
Zb
! Troumo
force "
ExompIes:
!Disruption
!"#$%&$&'(!"#)$)"%)%*
fo prevenf SIDS).
birfhs.IZ,
+)&*%"#$),(-$.&$/*0(1".(2#033/$.0()%($4/(54)'6
$ physiological,
$ osseous,
$ genetic
# PIogiocephoIIy
EfioIogy
gesfofion,
shunf pIocemenf,
EfioIogy
Z00b
DoIichocephoIy
siffing posifions.
bock.
side eosiIy.
foreheod.
Z/I9/Z009
Zb
! Troumo
force "
ExompIes:
!Disruption
!"#$%&$&'(!"#)$)"%)%*
fo prevenf SIDS).
birfhs.IZ,
+)&*%"#$),(-$.&$/*0(1".(2#033/$.0()%($4/(54)'6
$ physiological,
$ osseous,
$ genetic
# PIogiocephoIIy
EfioIogy
gesfofion,
shunf pIocemenf,
EfioIogy
Z00b
DoIichocephoIy
siffing posifions.
bock.
side eosiIy.
foreheod.
When infants must be in a back-lying position, moving their heads occasionally can help reduce pressure and avoid
developing a flat spot. The simplest and most effective prevention, however, is to decrease the cumulative time an
infant spends on her back.
Plagiocephaly the flattening of the skull bones is not just aesthetic. Even though some parents may be advised
that it is only an aesthetic concern that is mostly covered up when the baby grows a full head of hair, recent
research shows that it also affects the brain and, in turn, the babys functioning and health.
Suspect plagiocephaly if:
There is any flattening or misshaping of the bones of the head or a bald spot
The head is held to one side or rotated to one side or the baby prefers to turn the head to one side
The shape of the face is asymmetrical
When looking at the head from above, one ear appears further forward than the other
1. Hummel et al. Advances in Neonatal Care. 2005
|
P a g e 6 o f 6

PLAGIOCEPHALY: WHAT TO DO
Plagiocephaly, the flattening or misshaping of the cranials (bones of the skull) is not just an aesthetic
problem. This misconception, that it is purely aesthetic and not a concern, is a significant public health
issue.
Recent research shows that plagiocephaly is associated with early neurodevelopmental
disadvantage (developmental delay)
1
. As another research states, such developmental delays may
not be significant enough to be noticed until school, as it comprises developmental difficulties
presenting as subtle problems of cerebral dysfunction during the school-age years.
2
The research shows that the possible dysfunctions associated with plagiocephaly may include motor
dysfunction
3
(movement), hearing changes
4
, decreased mental and psychomotor

abilities
5
, general
nervous system changes
6
, vision
7
and middle ear infections
8
.
The conclusion of recent research is that plagiocephaly compromises the brains function, affecting
cognition and coordination of the body, resulting in a host of decreased performance throughout the
body.
42
Gently place both palmer surfaces of your
hands with little fingers touching on the occipital
bone with the fingertips contacting below the
inferior nuchal line and the rest of the occiput
resting in the palm. Thumbs to sphenoid.
Feel for strength and frequency of the
pulse.
It should feel equal in all fingertips.
Next place the pad of you index finger on the
frontal bone, your middle fingers on the
sphenoid, ring fingers on the temporals, little
fingers on the occiput and the thumbs on the
parietals.
Feel for equality and strength of the CRI.
Cranial Diagnostics: Palpation
Palpation of CSF Pulsations
Cranial Bone Manual Ranges
of Motion
NOTE: This is the less definitive than primary, secondary and
visual analysis in evaluating the childs skull due to the
increased mobility found in children, especially under age 3.
Chiropractic Care
The aim of care for a baby with plagiocephaly is not purely physical aesthetics. The
objective is to improve neurological function, which will result in greater control of the brain
over the bodys functions. Restoring full neck movement increases the amount of visual
and auditory input to the brain, resulting in higher stimulation and functioning of the brain.
Chiropractic care includes information, advise and empowering the parents to take active
care. Visit to visit, chiropractic involves decreasing the tension in the body, so that
movement is freer and there is less stress on the system, as well as balancing the
movement in the cranial bones (the bones of the skull) so that the brain has more room to
develop symmetrically and reach its potential. Maintaining motion in the cranial bones
means that as the brain grows, the skull grows in symmetry.

As chiropractors, we check all of the warning signs early on: how your baby is breathing, that its
nutrient requirements are met, and that the brain is receiving the correct inputs from the senses and
processing those, being activated well. We check for movement and position of the babys skull bones,
for tension in the brainstem and for developmental milestones and primitive reflexes, to see that your
babys development is age-appropriate.
Home-care
When settling, pat the baby on the bottom, while holding bub vertically up on the shoulder
Minimise light and sound input
Wrap the baby to comfort in sleep
Settle bub by holding your child in your hands while youre gently bouncing on a gym ball
Use gentle deep pressure squeezing on the babys arms and legs, to calm the baby
Encourage a lot of tummy time (specific exercises are given by the chiropractor)
References
1. Case-Control Study of Neurodevelopment in Deformational Plagiocephaly. Speltz et al. Pediatrics 2010 Feb
2. Long-term developmental outcomes in patients with deformational plagiocephaly. Miller et al. Pediatrics 2000
Feb
3. Are infants with torticollis at risk of a delay in early motor milestones compared with a control group of
healthy infants? Ohman et al. Dev Med Child Neurol. 2009 Jul
4. Auditory ERPs reveal brain dysfunction in infants with plagiocephaly. Balan et al. J Craniofac Surg 2002 Jul.
5. Neurodevelopmental delays in children with deformational plagiocephaly. Plast Reconstr Surg 2006 Jan.
6. Neurologic findings in infants with deformational plagiocephaly. Fowler et al. J Child Neurol 2008 Jul.
7. Visual field defects in deformational posterior plagiocephaly. Siatkoski et al. J AAPOS 2005 Jun
8. Incidence of otitis media in children with deformational plagiocephaly. Puzycki et al. J Craniofac Surg 2009
Sep.

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