Friday, March 17, 2017

Flat heads/physical therapy/chiropractor resources

In 1992, the American Academy of Pediatrics initiated the "back to sleep" program in order to try to combat Sudden Infant Death Syndrome. Since this program began, the rate of SIDS has decreased by over 40% .
An unintended consequence though was the number of babies who have flat heads from spending so much time on their backs. Nice round heads are becoming a real rarity.
Newborn’s skulls have a lot of plasticity, so they are pretty susceptible to external pressure. Up until about six months of life, the skull is naturally thin and flexible. It can easily change shape. It turns out that if you drop a cell phone on your baby’s head it will actually leave a little dent! (Don’t worry he’s fine.)
Babies  don’t have a lot of motor control during their early months, so they can’t always easily re position.
This flat head condition is called plagiocephaly. It occurs about once in 300 births.  Interestingly, little boys are twice as likely to have issues with this, and right side flattening is more common than left.
Positional plagiocephaly does NOT affect brain growth or development, and by ages 4-6 months, most heads have developed a normal shape. But early intervention and recognition can speed up the rounding process
Let's start tummy time early and often. It doesn’t need to be hazing. Even one minute at a time can count.
The first tummy time can be within their first couple of days, having your baby simply laying on you. Don’t worry about the cord (you most likely aren’t that firm of a surface.) Tummy time is an excellent way for them to develop muscles and work on their head control.
Infants lack head control, but they should be able to turn their heads to either side at rest. There are little steps that you can start early to try to avoid letting them have one favorite side.
  • Try to  give each side equal attention.
  • Make sure you swap feeding positions.
  • Offer objects from either side.
  • Alternate directions on the changing table.
  • Consider changing the position of the crib or the orientation of the baby in the crib to reduce the baby’s tendency to look in the same direction.
  • When awake and supervised, prop the baby onto one side with a foam wedge or a towel rolled lengthwise along the baby’s back.
  • Change positions when feeding, carrying, and holding the baby.
  • Provide supervised upright play as soon as the baby has upright head control.
  • During quiet alert times, also encourage mid-line control. Place their hands together and have them look straight at you.
Pay attention to  places other than the crib where their little head is up against a hard surface. Anytime that the baby doesn’t have their heads in contact with a firm surface is a bonus!
It is not recommended that babies have a pillow for night sleeping, but I am fine with one of the memory foam infant pillows for changing tables. There are quite a few options for this available on Amazon.
Janet Green Babb, one of the PT’s listed below, says that one product that her clients have found helpful is a pillow called Mimos Baby Pillow.
Some babies, particularly those with shortened neck muscles may develop a more serious kind of flattening. You may hear this condition referred to as torticollis.  If you find that they don’t easily move their head from side to side easily I would suggest a visit to a Physical Therapist or Chiropractor. It is never too early for an evaluation. I have some resources listed below.
If all of your tummy time and intervention have not been as successful as we like, the next referral will be to the cranio facial or neurosurgery team for an evaluation. Either of those specialists  might end up sending you along to the  pediatric orthotist team. The orthotists do some scanning (no radiation) and become part of the team that is monitoring your child’s head shape. In some cases, the kids may end up with helmets. Insurance companies vary greatly with their coverage of helmet therapy. The orthotist team at UCSF is top notch.
Although helmet therapy is usually not started prior to 5 months of age, there is little downside to having a referral sooner. For those of you interested in further details about the cranial helmet remolding process, see the information at the very bottom of this post. Although we sure do see a lot of kids with flat heads, very few of them end up needing a helmet.

Annie, one of my mom’s whose baby ended up requiring a helmet shared her story and wisdom. Her little guy is a second child with a mellow temperament so she wonders if that led to a bit more time hanging out in his infant seat.
Her doctor repeated the need for tummy time at each visit, but Annie thinks that with a bit of hindsight, if she had seen a helmet in her future she would have been more aggressive with it. At 2 months she did end up at the chiropractor who loosened up the neck muscles.
These treatments made a big difference in his favoring one side over the other, but this little guys head was seriously flat and keeping him off of it did not seem to be helping as much as we needed it to. Annie adds a healthy dose of perspective:  “There are worse things, We are fortunate to live in a place where this can be fixed.”

Physical Therapists
Pinnacle Kidz is a terrific pediatric physical therapy resource in our neighborhood. The owner Bethany, has been making a big difference for quite a few of my patients.
1772 Church Street
The UCSF physical therapy is still over at 500 Parnassus, Room MU-09. At some point they will likely move over to Mission Bay, but not in the near future.
Ph: 415-353-4972
Fx: 415-353-4974
Janet Green Babb is a physical therapist that we have been working with for years. Her office is out in the avenues, but many folks find it worth the “schlep.”
4200 Irving Street San Francisco, CA 949122
Janet notes that It is interesting how many babies are experiencing flat heads and preferential head turning. Early intervention seems to be so effective in preventing further asymmetry and for promoting midline and symmetrical orientation.
Starfish Therapies is a pediatric physical therapy provider with several locations in the Bay Area.
They have one of their clinics right in the wonderful KidSpace at 2401 Mission St. here in SF
To inquire about services call 650-638-9142 or email


Michelle Foosaner Diamond, PT at Children's Therapy Associates
Children's Therapy Associates
They will do home visits in SF with a prescription from your pediatrician. Michelle says that  as few as 1-3 physical therapy visits can teach parents how to prevent the progression of, or correct, positional plagiocephaly when initiated early enough in development.
Laurel Condro at the Feldenkrais center is another excellent option for physical therapy.
She does group classes as well as individual therapy

Claudia Kindler, a local chiropractor in Noe Valley, shared the following statement:"I love working with all of my patients but I hold a special place in my heart for infants.  Their transition into the world is impressive but not always smooth.  I love holding them and feeling their spine and all of their joints and muscles. Because they are so “new”, they are an open book.  As I investigate their spine and come across a subluxation, or a point of interest to me, the infant frequently pauses and makes eye contact.  They are telling me, “Yes, that spot is the problem”.
In working with torticollis in an infant, I am curious how the baby is transitioning- do they prefer to nurse on one side to the other?  Do they only look to one direction?  Do they detest tummy time?   These patterns provide me skeletal clues that should be addressed.  When I feel their neck, upper back and shoulder girdle, I note skeletal challenges that are limiting symmetrical development.  With simple, small and gentle adjustments to the spine and shoulders the skeletal system can relax and return to optimum functioning."
Two other chiropractic options are Sandra Roddy Adams and Laura Sheehan.
They both work out of an office in the inner sunset at 915 Irving Street
Laura Sheehan R.N., D.C.
415-681-1031 or
Laura says that she has helped many a flat head round out and sometimes with only one visit if it's due to upper cervical strains.
Sandra Roddy Adams happens to be my chiropractor, but she works with all ages. She can be reached at 415-566-1900.

Dr. Austin Davis works on infants and the whole families. One of my readers contacted me to get him added to this list because she has found him enormously helpful
Life Chiropractic

The following information is provided by the UCSF Orthotic and Prosthetic Center

How The Helmet Works

Approximately 85% of head growth occurs within the first 12 months of life.
During this time the head is moldable and responds to light contact/pressures over extended periods of time. Static positioning (laying in one position for long periods of time) on the back or one side of the head often contribute to the development of plagiocephaly. In a similar fashion, the helmet places contact over the areas that are more prominent and allows space over flattened areas. This encourages the head to grow in the “path of least resistance”. The helmet does not push in areas of the head; it directs growth of the flattened areas of the head.

Depending on the severity of the flatness and the child’s age will determine the treatment options. Under the age of 4 months we typically observe and have parents actively reposition the baby throughout the day, nights and naptime. Babies this young with a mild flat spot can be fully corrected with repositioning alone.

Around the age of 5 months the effectiveness of repositioning is reduced and most health care providers will recommend the initiation of a helmet if the flatness is significant. Ideally if a baby needs a helmet we are starting the treatment between the ages of 5 and 8 months of age.


As with all areas of medical care, health insurance is complicated and specific to each individual plan. The authorization staff at UCSF will perform a check with your insurance around the time of your first appointment with an orthotist.

Craniofacial Evaluation

After your pediatrician/family physician has placed a referral for a cranial remolding helmet evaluation. First you must see a Craniofacial specialist to confirm the baby’s presentation is plagiocephaly and not something else called cranial synostosis. This appointment is a requirement prior to making a helmet and is much better if this is done before your first appointment with the orthotic team.

The Helmet Process

Beginning the process for cranial remolding helmets can be daunting for families. The practitioners at UCSF are here for you as you go through this journey. Below is an explanation of the helmet process at UCSF.

 First Appointment – Evaluation

o The first appointment you have with an orthotist (person that is
educated and trained in cranial remolding helmets) to assess your
baby’s head shape, size and gather relevant information. Now is a
good time to ask questions you have about the treatment and what
your expectations should be.

o Measurements: regardless of how the orthotist chooses to capture to
shape of your baby’s head (by hand vs scanning) measurements will
be taken to use as a way to track changes over time. These
measurements will be referred to throughout the helmet treatment to
ensure progress is being made

o Impressions: In order to make a helmet the orthotist must capture
the shape of your baby’s head. The two primary ways are with a cast
and with a laser scanner. The most important piece is that the shape is
well captured and matches the shape of your baby’s head; this will
make the helmet fitting process (we will discuss later) much easier. It
is common for babies to become fussy during this point in the

 Casting: Plaster of paris will be used to lay over the baby’s head
to capture the shape of his/her head. This process is messy and
takes about 15 minutes.

 Scanning: The baby will have a laser scan taken to create a
virtual 3-D image of his/her head. The scan itself can take as
few as 3 seconds, but the baby must be extremely still
(typically multiple attempts are made).

 Fitting Appointment

o The helmet has been made and is ready to fit to your baby. The
appointment will take 1-2 hours, so bring diapers and food just to be
safe. The orthotist will put the helmet on the baby’s head and mark
the helmet in areas that are too long and need to be removed. The
orthotist will take the helmet off and on the baby’s head multiple
times throughout this appointment to ensure it is fitting properly. It is
common for babies to be upset/fussy throughout this appointment.

o The helmet should not be immobile on the baby’s head. A small
amount of shifting and rotation on the baby’s head is acceptable, so
long as the helmet is not: coming in front of the baby’s eyes, touching
the baby’s ears, or squishing the forehead.

o You will be given a break-in schedule to slowly increase the amount of
time your baby wears the helmet. Even after she/he has built up to
wearing the helmet full-time you will need to monitor the skin for
excessive redness every time you take the helmet off. Red marks
lasting more than an hour or skin irritation require the helmet to be
removed and your orthotist should be contacted for an adjustment.

 One week follow-up appointment

o Over the first week of having the helmet you and the baby slowly
increase to wearing the helmet full-time (23 hours/day). This
appointment is to check the fit of the helmet now that they are able to
wear the helmet full-time. Minor adjustments are expected at this

o Typically, redness that lasts less than an hour is okay. If you are
concerned about the redness on your child’s head make sure to
discuss this with the orthotist at your appointment.

 One month follow-up appointment

o These appointments should occur every 3-5 weeks to assess the
progress being made with the helmet and to accommodate for any
growth that has happened in the last month. Typically the orthotist
will take measurements and/or a scan to evaluate the changes in your
baby’s head shape.

o In general, a change in your baby’s head shape happens if there has
been growth over the last month. It is common for babies to have
large growth spurts followed by smaller growth spurts. There may be
some appointments where you see a large change in your baby’s head
shape, and some appointments where you see very little change in
your baby’s head shape. For this reason we are measuring and
checking the baby’s head shape every 3-5 weeks to ensure the helmet
is doing what it should be.

 Adjustments

o Despite trying to accommodate for growth on a regular basis (by
having an appointment every 3-5 weeks), sometimes the babies go
through large growth spurts and need adjustments sooner than
planned. This is okay.

o When to call the orthotist for an adjustment:

  • Redness lasts for more than 1 hour and is still very red
  • The helmet seems too tight
  • The baby is suddenly resistant to wearing the helmet when
  • previously they tolerated it well
  • Determining the end of treatment
o The typical length of treatment is 3-5 months, this will depend on the
age when the baby begins wearing the helmet and how severe of a
flattened spot is to begin with. With older babies we expect to have a
longer treatment time because their heads do not grow as quickly.
They can wear the helmet up to 15 months of age, beyond this age
there is limited evidence to support the effectiveness of the helmet.

o Clinical markers are used to numerically compare your baby’s head
shape to “normal”. These markers are helpful in determining a
slowing of growth and provide an objective assessment of the changes
in the head shape over time.

o Satisfaction with head shape and appearance is the ultimate goal. This
is used in addition to the clinical markers to decide the end of the

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