Can Wearing Head Band Cause Babies to Have Cone Head

Ochsner J. 2001 Oct; iii(4): 191–199.

Misshapen Heads in Babies: Position or Pathology?

Abstract

A newborn's skull is highly malleable and chop-chop expanding. Every bit a result, any restrictive or constrictive forces applied to a infant's caput tin can result in dramatic distortions. These changes can be mild, reversible deformations or severe, irreversible malformations that tin result in brain injury. This paper reviews the beefcake and physiology of normal and aberrant brain and skull growth, the etiology of cranial deformation, the types of craniosynostosis virtually usually seen in infants, and the importance of early diagnosis and treatment.

At birth, the shape of a newborn'southward skull is highly variable due to its inherent plasticity, intrauterine constraint, and the tortuous journey through the birth canal. Variations from the typical oval shape that ordinarily event from the vaginal delivery procedure will generally return to normal in a relatively short catamenia of fourth dimension. If this does not occur, the possibility of a rapidly progressive, irreversible, and, in rare circumstances, life threatening cranial malformation needs to be considered.

Historical Perspective: "Intentional Cranial Deformation"

Man's fascination with misshapen heads dates back to prehistoric times. Archaeologists have constitute creative renderings of the imposing heads of Neanderthals who lived 45 000 years ago. Hippocrates described in detail a people referred to every bit the "Macrocephales." Even in mod times, the television serial "Saturday Night Alive" entertained viewers with their comic series "The Coneheads."

Of particular historical interest is the do of intentional cranial deformation, "the process of dynamic distortion of the normal vectors of infantile neurocranial growth through the agency of externally applied forces"(one). Taking advantage of the rapid caput growth and malleable skull unique to the newborn flow, individuals have applied constrictive devices (wooden boards, stones placed in a crib, ties, transmission molding) over the by centuries to intentionally and permanently deform a child'due south skull. In 1805, the Lewis and Clark expedition encountered the Chinook tribe at the mouth of the Columbia River. Infants of the tribal leaders were noted to take their heads constrained by wooden sticks and rope (Figure 1). These devices were placed soon later nascency and kept in place for months to years to create a permanent cranial deformity that was interpreted every bit a mark of stardom. Similarly, it was the practise in the House of Este in the 1400s to place restrictive ties known as "bandeau" at birth on the heads of the royal newborns. A portrait of a princess who underwent this process hangs in the Louvre Museum (Figure 2).

Chinook tribal leader with babe in wooden constraint

Princess of the House of Este (circa 1400) in "bandeau."

The rationale for this dramatic intervention was to create form and tribal distinction. In other societies, similar practices were felt to heighten intellectual and sexual abilities and to provide intimidation in battle through the imitation of beasts. The digging of skulls that underwent this blazon of intentional deformation has led to a improve understanding of growth and development of the human skull.

Normal Development of the Human Skull

The study of human head growth must brainstorm with a bones understanding of the normal skull, brain, and cranial sutures. The skull is formed from embryonic mesoderm, which differentiates into the mesenchymal neurocranium and viscerocranium. The average occipital-frontal circumference (OFC) is 35 cm in the term newborn, 45 cm at 1 year, and 55 cm in an adult. These measurements illustrate the extremely rapid growth in the starting time years; in fact, a newborn'due south head circumference is larger than the chest circumference at nascence. The OFC increases past ii cm per calendar month for the first iii months of life, 1 cm per calendar month for the 2d iii months of life, and 0.5 cm per calendar month from vi–12 months. The volume of the cranial vault is 65% of adult size at birth and 95% of the adult size at historic period 10 years. In contrast, facial size is 40% of adult size at nascency and 65% at ten years.

Appreciation of normal brain growth guides our understanding and direction of many forms of skull anomalies. The rapid growth in neuronal cell number during the 10^th through eighteen^th weeks of gestation achieves near developed prison cell numbers; this is followed past dramatic increases in dendritic growth and arborization then myelinization. At 15 months of age the brain is roughly 65% adult size while the cerebellum has achieved adult proportion. The bulk of myelinization is complete past 2 years of age.

The cranial sutures are unique structures composed of dense connective tissue membranes that function equally gristly, or "syndesmotic," joints, which let growth. The most important sutures are the sagittal, coronal, lambdoidal, and metopic sutures (the standard method of viewing and illustrating skull shapes is the vertex view — Figure iii); importantly, these growth plates do non usually calcify and close until adolescence.

Vertex view of normal skull

Abnormal Development: Malformation vs. Deformation

There are two very singled-out processes of morphogenesis through which the human skull is misshapen: malformation and deformation. Malformation refers to an intrinsically altered developmental procedure that interferes with prison cell migration and differentiation through genetically programmed biochemical processes or through extrinsic chemic interference (teratogens). In essence, this process represents an error in the normal development of a part. Examples would include congenital center disease due to chromosome 22q11 deletion or a fissure lip secondary to fetal alcohol exposure. In contradistinction, a deformation is an amending of a torso office that is developing normally until a mechanical forcefulness is applied. This blazon of birth defect occurs afterward a office is fully formed and is and then physically contradistinct due to extrinsic pressures. Examples would be dislocated hips in a newborn, due to compression in the breech position during gestation, or a calcaneovalgus foot deformity due to in utero positioning. The most mutual abnormal cranial shapes are shown in Figure 4.

Cranial Deformations

In full general, cranial deformations are common, mild, and typically reversible, while cranial malformations are relatively rare, progressive, and often irreversible anomalies which, if not aggressively treated in a timely manner, can consequence in astringent cosmetic and functional damage. Deformations, which occur in ane out of 3 newborns, result from three major mechanisms—peripartal molding, supine sleep position, and torticollis (Table 1) (2).

Table 1.

Etiology of Cranial Deformations

Molding

One out of three infants will have some degree of deformational molding. Fetal caput constraint is more common in primigravidas, large for gestational age babies, and when there is cephalopelvic asymmetry, oligohydramnios, multiple births, or prolonged courses of labor. Caput succedaneum (Figure five) is due to edema of the skin and subcutaneous tissues of the scalp resulting in a "conehead" appearance, which normally resolves in less than half dozen days. A cephalohematoma is a traumatic subperiosteal hemorrhage that does non cross a suture line. This deformity is initially soft and, with fourth dimension, becomes business firm equally it calcifies; information technology by and large requires upwardly to iv months to resolve entirely.

Babies born breech (Figure 6) typically accept craniofacial and limb deformations resulting from their in utero position. These babies characteristically have a long, narrow head, ("dolichocephaly" or "type ane"), with a prominent occipital shelf, redundant skin over the neck, overlapping lambdoidal sutures, and an indentation below their ears (from shoulder compression). These babies are too more probable to have a head-tilt, or torticollis, after nascency due to fetal constraint. Developmental dysplasia of the hips and calcaneovalgus foot deformity are likewise more commonly seen in this population and may or may non be reversible without intervention.

Supine Sleep Position

In 1992, the American Academy of Pediatrics published guidelines recommending that all healthy infants be placed to sleep in the supine position during the first 6 months of life in an attempt to reduce the incidence of Sudden Infant Death Syndrome (SIDS). This "Back-to-Sleep" entrada has resulted in a dramatic 50% reduction in the incidence of SIDS in the U.s.. An unanticipated, and relatively modest sequelae of this plan has been the dramatic increase in the numbers of babies with acquired posterior cranial deformities, specifically occipital flattening with brachycephaly (Figures four & vii)(three). If recognized early, simply placing the baby prone while awake or alternate the signal of contact betwixt the occiput and bed during sleep tin can polish out this deformation.

Newborn with flattened occiput (positional deformation)

Postnatal deformation can also occur in the neonatal intensive care nursery when high-risk babies are kept paralyzed and intubated on their side for extended periods. These babies have long and narrow heads due to their relatively large heads and poor cervix musculus tone; the skull bones are soft and sparse and the skull is flattened past gravity alone. It is likewise important to notation that neurologically impaired infants with hypo- or hypertonia may accept a greater degree of positional deformity of their heads due to limited mobility when prone.

Toricollis

Torticollis is a head tilted to 1 side with the occiput rotated towards the shoulder and the chin rotated in the opposite direction and elevated (Figure 8a). The most common etiologies in newborns are congenital muscular torticollis (CMT) and anomalies of the cervical spine. CMT is due to stretching of the cervix during difficult deliveries, oftentimes in large babies, with resultant hemorrhage into the sternocleidomastoid musculus. With time, gristly changes occur in the muscle and it contracts resulting in torticollis. Since babies are initially somewhat floppy and considering this contraction is progressive during the first few weeks, it may not be noted for several weeks after nascency.

Among cervical spine anomlies, Klippel-Feil Syndrome is due to a segmentation aberration of ii or more cervical vertebrae. Other causes, such as cranial nerve 4 palsy in which the infant tilts the head to achieve normal vision, are listed in Table 1.

Whatever mechanism results in the head rotating or tilting, the side of the occiput that is posteriorly positioned is flattened since the child will preferentially prevarication on information technology. The contralateral occiput and the ipsilateral forehead will get more than prominent due to gravitational forces resulting in a parallelogram shape to the head. This is an case of posterior positional (or, deformational) plagiocephaly (Figures 4 & 8b). This is mostly a subtle cosmetic defect, which may be cleverly masked by pilus. In the more severe forms of this deformation, normal cranial ossification will lead to a permanently misshapen skull if action is not taken to even out the positional forces.

Figure 8B. Positional plagiocephaly due to supine lie in infant with torticollis

Cranial Malformations

The other, and far more than ominous, type of abnormal cranial development is craniosynostosis, or premature fusion of one or more cranial sutures. This malformation occurs in 1 in 2500 neonates as opposed to the one in 3 babies with a deformational anomaly. Craniosynostosis is classified as simple (one suture) versus compound (2 or more than sutures), and isolated (no other major malformations) versus syndromic (one of multiple associated anomalies).

The mechanism of skull malformation caused by a fused suture(s) in a developing skull was initially described by Virchow in 1851 (iv). He pointed out that cranial growth restriction will occur in the plane parallel to a prematurely fused suture and enhanced in the perpendicular planes (Figure 9). Thus, if the sagittal suture were fused early, ane would expect the skull to be restricted in the transverse dimension and to overcompensate in the anterior-posterior dimension in response to the growing brain resulting in dolichocephaly (type 1).

Mechanisms of head malformation in craniosynotonosis. Darkened lines represent synostotic sutures

Craniosynostosis is also classified based on the mechanism of malformation; namely, primary versus secondary. Primary craniosynostosis represents an intrinsic abnormality in the os or suture, such every bit fibroblast growth cistron deficiency, which results in premature fusion of a suture. Recent research has shown that craniosynostosis can be induced in animals through in utero pinch solitary, a deformational change resulting in a malformation (5). Suture patency is besides dependent on a growing brain, which exerts force per unit area against the developing skull. Failure of the encephalon to enlarge and expand properly results in secondary craniosynostosis and, characteristically, all sutures would be involved (Tabular array 2).

Table 2.

Etiology of craniosynostosis

Of the children with main craniosynostosis acquired by single cistron defects, the most common type would be isolated (i.e., no other defects) craniosynostosis involving a unmarried suture (Table 3). Less than 5% of the cases would be syndromic (a collection of malformations which aggregate together) (Table four). Infants with syndromic forms are most probable to announced markedly dysmorphic with abnormalities of their limbs, centre, genitourinary system, and multisutural craniosynostosis (Effigy 10) (6).

Infant with Pfeiffer Syndrome. An instance of multisutural craniosynostosis

Table iii.

Chief Craniosynostosis; Isolated (95%)

Tabular array four.

Examples of Primary Craniosynostosis/Monogenic etiology; syndromic (v%)

Differentiation of Malformation vs. Deformation: Position vs. Pathology

Children with syndromic forms of craniosynostosis are readily detected, though the specific syndrome often requires the expertise of a dysmorphologist. The greatest diagnostic challenge frequently involves the differentiation of a malformation from a deformation, considering information technology usually determines whether the kid will undergo major craniofacial surgery, with its significant risks, versus bourgeois direction. Proper diagnosis can ofttimes be achieved through a careful history and physical examination. If questions remain, radiographic procedures may be useful. Plain films of the skull may evidence perisutural sclerosis, and indistinctness of the suture. Facial views may reveal distinctive uplifting of the orbital roof ("harlequin eye deformity"), which represents a archetype finding in coronal craniosynostosis (Figures 11A & 11B). Plain CT scans of the head are of limited help in the evaluation of craniosynostosis. The best current imaging study would exist a CT browse of the head with 3D computer reconstruction (Figure 11C). There are iii major cranial shape abnormalities for which one must differentiate positional deformation from craniosynostosis.

Figure 11A. Photo of babe with left coronal craniosynostosis

Figure 11B. Facial 10-ray demonstrating "Harlequin eye deformity"

Figure 11C. Three dimensional computed tomography

Dolichocephaly (type 1)

In the presence of a prolonged positional insult (a premie lying on the side for an extended period of time) one should suspect a dolichocephalic cranial shape. If other physical findings of craniosynostosis (ridged sutures, progression over time) are noted, radiographic studies should exist ordered. Information technology is of import to note that only portions of the suture may be stenotic (Figures 12a & 12b), then a patent fontanel does non dominion out this anomaly.

Figure 12A & B. Posterior sagittal craniosynostosis

Brachycephaly (type ii)

A baby with brachycephaly due to a positional trouble is more likely to accept had a normal head at birth and after spent most of her time in the supine position. Parents oft report that the babe moves picayune when asleep thus flattening the occiput more the child that rolls side-to-side. It is important to exist wary of neurodevelopmental problems in this grouping since hypotonic infants are less likely to rotate and drag their heads when supine. In contrast, babies with bicoronal craniosynostosis were noted to have an abnormal skull at nativity that has rapidly inverse regardless of sleep position. On examination, infants with isolated positional flattening have normal facial features while those with bicoronal craniosynostosis will have restriction of facial growth since the synostotic coronal suture, which may be palpable, extends from the inductive fontanel to the cranial base.

Plagiocephaly (type 3 & type iv)

This skull abnormality represents the most common source of confusion. The clinician must differentiate between a positional abnormality and unilateral coronal or lambdoidal craniosynostosis. Babies with positional problems are reported to prevarication virtually exclusively on one side of their occiput. This is especially dramatic in babies with torticollis who are essentially fixed in this position when placed down. An interesting observation can assistance the clinician in differentiating positional plagiocephaly from unilateral coronal or lambdoidal craniosynostosis. In positional changes, the babies lie preferentially on their right or left occiput. Based on the laws of physics, one would look gravitational forces to result in widening of the plane drawn from the contralateral (non-flattened) occiput to the ipsilateral forehead and shortening of the airplane connecting the involved (flattened) occiput to the contralateral forehead. The resulting geometric shape (blazon 4) would exist a parallelogram (Effigy 13a). Conversely, early closure of a unicoronal (type 3a) or unilambdoidal (type 3b) suture would outcome in restricted growth in the vertical airplane perpendicular to the involved suture and compensatory overgrowth in the parallel airplane perpendicular to the normal coronal suture. This would result in a trapezoidal shape to the skull (Effigy 13b). If one were to draw a line down the middle of the skull, the volume of side A=B in positional plagiocephaly, while A>B in unicoronal or unilambdoidal craniosynostosis (7). Facial features are besides distinctive (8). Radiographic studies may also be utilized as previously outlined.

Management and Prognosis

Surgical management of craniosynostosis dates back to the late xix^thursday century, simply it was not until 1967 that a more comprehensive intracranial approach to syndromic craniosynostosis was showtime published by Tessier (nine). He noted that simple craniectomy or morcellization of the involved suture in early infancy resulted oftentimes in reossification of the suture. As a effect, he performed a frontal-orbital advancement with cranial vault remodeling between vi–12 months. This resulted in decompression of the cranial vault, provided protection of the globes and dramatically improved aesthetics. In bicoronal craniosynostosis, a strip craniectomy often needs to exist performed earlier 3 months of age due to increased intracranial pressure. Subsequent surgery includes a midface advancement procedure (LeFort Iii osteotomy) at 9–12 years and secondary orthognathic surgery to improve orthodontic-facial deformities (LeFort I, mandibular osteotomies) at age 14–18 years. Several splendid textbooks provide detailed surgical discussions (x, xi).

About infants with positional plagiocephaly improve spontaneously without intervention; nonetheless, early detection and prevention of positional problems can result in more optimal outcomes. Placing a baby supine remains a priority to protect against SIDS; notwithstanding, parents are encouraged to place their baby on their "nonpreferred" side using a wedge device and to attach interesting visuals to attract the infant's attention. For infants with torticollis, following clearance of whatever structural spine anomaly, referral to an experienced concrete therapist is besides beneficial. Recently, there has been considerable interest in the use of individually molded helmets in babies to remodel their plain-featured skulls. These expensive, cumbersome devices must be worn at all times for months with proper follow-up and adjustments. Such therapy should be initiated before 8 months of historic period to reach benefit.

Conclusions

Early diagnosis is critical in optimizing handling, or non-handling, of the babe with a misshapen caput. Timely identification of potentially silent associated malformations (such as congenital heart disease, sensorineural hearing loss, etc.) is also important. In addition, children with craniosynostosis are often at gamble for learning disabilities and should exist provided with early intervention services. It is essential that children with craniofacial abnormalities have a comprehensive evaluation. Referral to a multidisciplinary craniofacial plan is advised. Craniofacial teams are affiliated with the American Crack Palate/ Craniofacial Association (world wide web.cleftline.org) and include specialists in pediatrics, neurosurgery, plastic and reconstructive surgery, otolaryngology, oral surgery, orthodontics, spoken language pathology, genetics, nursing, psychology, and social piece of work. Financial and psychosocial considerations for these patients are considerable and circuitous (12). For all of these children and their families, the earlier the recognition and initiation of comprehensive treatment, the better the ultimate outcome.

Acknowledgments

Special thanks to Duane Superneau, Medico and Barbara Siede for their assistance with this article.

Dr. Bronfin is the Head of Ochsner'due south General Pediatric Section and the Medical Manager of the Ochsner Craniofacial Team

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3116745/

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