New study possibly links cognitive and motor delays with 'flat head syndrome' in young babies

In a new study, infants averaging six months of age who exhibited positional plagiocephaly (flat head syndrome) had lower scores than typical infants in observational tests used to evaluate cognitive and motor development.

Positional or deformational plagiocephaly may occur when external forces shape an infant's skull while it is still soft and malleable, such as extended time spent lying on a hard surface or in one position. This is the first controlled study to suggest that babies who have flattened areas on the back of their heads during the first year of life may be at risk for developmental delay. Led by clinical psychologist Matthew L. Speltz, PhD, from Seattle Children's Research Institute, these findings suggest that babies with plagiocephaly should be screened early in life for possible motor and cognitive delays. “Case-Control Study of Neurodevelopment in Deformational Plagiocephaly” published online on February 15 in Pediatrics.

“Developmental plagiocephaly seems to be associated with early neurodevelopmental disadvantage, which was most evident when testing motor skills,” said Matthew L. Speltz, PhD, chief of outpatient psychiatric services at Seattle Children's Hospital and professor of psychiatry and behavioral sciences at the University of Washington School of Medicine. “This suggests that babies with flat head syndrome should be screened and monitored for possible cognitive and motor delays. However, it's also important to note that our study examined babies at one particular point in time, so we cannot say with certainty whether these observations continue to hold true as these infants grow older. Our future studies will re-visit this population at 18 and 36 months of age, to see whether this association persists as these infants mature.”

“Statistically, there has been a dramatic rise in the diagnosis of positional plagiocephaly since the 1990's. This may be a result of multiple factors, including increased awareness and babies spending more time on their backs in strollers, car seats, infant seats, cribs and sleeping on their backs. This time period also coincides with the national Back-to-Sleep campaign designed to help protect babies against Sudden Infant Death Syndrome (SIDS), although it should be noted that a direct correlation with flat head syndrome hasn't been scientifically established,” added Speltz. “For every ten babies, one or two may have at least mild plagiocephaly. Many parents and physicians have dismissed it as a cosmetic issue or one that babies will grow out of as they develop, but our study indicates that we should look deeper.”

In the study, 472 babies with ages ranging from four to 12 months (average age six months) were screened for cognitive and motor development using the Bayley Scales of Infant Development III (BSID-III), a series of industry standard observational tests. These common tests observe babies for basic cognitive, language and motor skill development. During the BSID-III, trained examiners present a series of standardized test materials to the child and observe their responses to simple tasks that require problem-solving and memory, such as searching for a hidden toy, as well as the ability to imitate, vocalize, observe and respond to their environment. Infant motor skills like crawling, rolling from side to side, and being able to lift up from a tummy position are also observed and measured. Half of the babies in the study had exhibited and been diagnosed at the Seattle Children's Hospital Craniofacial Center with some level of flat head syndrome, while half were a “normal” control group.

For the study, cranial images and measurements of each baby's head shape and size were also obtained using a 12-camera, 3-D system that allows for 360o imaging of the head. The study found that those babies who exhibited some degree of flatness at the back of the head were more likely to perform worse on the BSID-III, by an average of 10 points for the motor test scale. The most significant lower scores showed in large muscle motor functions, such as rolling from back to side.

Though the findings indicated an association between flat head syndrome and developmental delay, they do not indicate a direct causal link, the researchers say. There may be a reverse correlation, if, for example, babies with pre-existing motor delays are more likely to end up with flatter heads because they may move less or remain in one stationary position for longer periods of time.

“Physicians, psychologists and parents all need to know that it remains very important for babies to continue sleeping on their backs,” added Speltz. “Regardless of any suggestion of plagiocephaly or developmental delay, the safest way for babies to sleep still aligns with the Back-to-Sleep campaign's recommendations to help prevent SIDS.”

For information on the national Back-to-Sleep campaign and the ongoing importance of babies sleeping on their backs, visit: http://www.nichd.nih.gov/sids/, http://www.healthychildcare.org/sids.html and http://pediatrics.about.com/library/blbacktosleep.htm.

For information on positional plagiocephaly, visit: http://www.seattlechildrens.org/medical-conditions/chromosomal-genetic-conditions/positional-plagiocephaly/ or http://www.nichd.nih.gov/health/topics/positional_plagiocephaly.cfm.

TIPS FOR PARENTS AND CAREGIVERS:

Flat spots in a young baby's head can be quite common, and by itself they are not a cause for alarm. Ask your baby's doctor about it.
If your baby is diagnosed with plagiocephaly, ask the doctor to screen for developmental delays in both motor and cognitive skills. Talk about the results.
Remember that babies develop at different times, and at different rates. What is “normal” for your baby may be ahead of or behind what is normal for another baby. Babies who start out slower often catch up later.
Always place babies to sleep on their backs: this remains the safest way to sleep. Place your baby's head at one end of the crib and switch to the other end the next night.
Encourage active “tummy time” when babies are awake: find ways to for baby to engage, play and move while on their tummy, several times each day. Watch your baby during tummy time.
Choose different positions and ways for babies to play and be held: variety of stimulation is important. Switch the arm you use to cradle your baby each feeding session; right one time, left the next.
Use strollers, car seats, infant seats, bassinets, cribs and play pens when necessary, but remember that babies need frequent lap time, cuddling, active play times and chances to move that aren't limited to being in stationary positions.
Develop motor skills: play with babies to get them moving. Encourage crawling, rolling, reaching, pushing, pulling, holding, grasping.

Develop cognitive skills: play with babies to get them thinking and talking. Encourage interactions with their environment, looking, listening, imitating, babbling, singing, talking, reading.

Speltz's study collaborators included Brent R. Collett, PhD; Marni Stott-Miller; Jacqueline R. Starr, PhD; Carrie Heike, MD, MS; Antigone M. Wolfram-Aduan; Darcy King, ARNP; and Michael L. Cunningham, MD, PhD.

About Seattle Children's Research Institute

At the forefront of pediatric medical research, Seattle Children's Research Institute is setting new standards in pediatric care and finding new cures for childhood diseases. Internationally recognized scientists and physicians at the Research Institute are advancing new discoveries in cancer, genetics, immunology, pathology, infectious disease, injury prevention and bioethics. With Seattle Children's Hospital and Seattle Children's Hospital Foundation, the Research Institute brings together the best minds in pediatric research to provide patients with the best care possible. Children's serves as the primary teaching, clinical and research site for the Department of Pediatrics at the University of Washington School of Medicine, which consistently ranks as one of the best pediatric departments in the country.