This week, we take it back to the very beginning, looking at two conditions commonly seen by Laura in clinic that affect newborn babies – torticollis and plagiocephaly.

The term torticollis (sometimes referred to congenital muscular torticollis) means “twisted neck” and describes an abnormal neck posture, characterised by persistent rotation of the head to one side, and lateral flexion (a tilting motion) to the opposite side. Plagiocephaly refers to any condition characterised by a persistent flattened spot on the back or side of the head. It is sometimes referred to as Flat Head Syndrome.

Congenital Muscular Torticollis

Congenital muscular torticollis is the term used to describe torticollis detected at birth or shortly after birth. The main problem is tightness of a muscle in the neck called the sternocleidomastoid (stir-noe-kly-doe-MAS-toyd) or SCM for short. This large, rope-like muscle runs on both sides of the neck from the back of the ears to the collarbone.

Sternocleidomastoid

Image credit: Remedial Massage Gold Coast

Babies with torticollis tend to turn their head to only one side and their head is often tilted.

Right torticollis Left torticollis

Image credit: The Royal Children’s Hospital

Torticollis is relatively common in newborns – it is reported as 3-20 in every 1000 births.

Boys and girls are equally likely to develop the head tilt. It can be present at birth or take up to 3 months to develop.

The cause is relatively unknown; however, the most common theories are that it occurs due to the positioning of the baby in the womb or a difficult delivery at birth (often those requiring forceps or vacuum). Both of these put pressure on a baby’s SCM muscle which can cause it to tighten, making it hard for a baby to turn his or her neck. Other theories include infection or injury to the blood vessels supplying the SCM muscle.

Signs and Symptoms

Babies with torticollis will act like most other babies, except when it comes to activities that involve turning the head. A baby with torticollis might show the following signs and symptoms:

  • tilt the head in one direction (this can be hard to notice in very young infants due to a lack of head control)
  • restricted neck movement – the baby will have problems turning their head from side to side and will often keep their head turned only to one preferred side
  • tight or contracted SCM muscles
  • a firm mass/lump may be felt within the SCM muscle – this is a fibrous lump in the muscle which is often first noticed within the first 4 weeks and usually disappears within 8 months
  • if breastfed, have trouble breastfeeding on one side (or prefers one breast only)
  • work hard to turn toward you and get frustrated when unable to turn his or her head

Some babies with torticollis develop a flat head (positional plagiocephaly) from lying in one direction all the time. More about this to follow!

Plagiocephaly – Misshapen Head

Plagiocephaly (play-gee-oh-kef-a-lee) is a very common problem of the skull, and means a misshapen, flat or asymmetrical head shape. It is important to note that plagiocephaly DOES NOT affect the development of a baby’s brain, but if let untreated, it may change their physical appearance by causing uneven growth of their face and head.

Plagiocephaly occurs because the bones in a newborn baby’s skull are thin and flexible, so the head is soft and may change shape easily. Flattening of the head in one area may happen if a baby lies with their head in the same position for a long time, as seen in those babies with torticollis. In these “positional” deformities, the occiput (back part of the head) is most often flattened. When viewed from above, the head will take on a parallelogram shape and the forehead on the affected side is typically prominent. The ear on the affected side may be pushed forward compared with the other side and there may also be facial asymmetry, with the affected side having a fuller cheek.

Pagiocephaly - misshapen head

Image credit: The Royal Children’s Hospital

How do I prevent my child developing plagiocephaly?

A baby’s head position needs to be varied during sleep and when they are awake to avoid them developing positional plagiocephaly.

  • Sleeping position – your baby must always be placed on their back to sleep to reduce the risk of SIDS (Sudden Infant Death Syndrome). Do not use pillows in the cot for positioning.
  • Head and cot position for sleep – a young baby will generally stay in the position they are placed for sleep, until they can move themselves. Alternate your baby’s had position when they sleep. Place your baby at alternate ends of the cot to sleep or change the position of the cot in the room. Babies often like to look at fixed objects like windows or wall murals, so changing their cot position with encourage them to look at things that interest them from different angles.
  • Play time – when your baby is awake and alert, tummy time is strongly encouraged. Place your baby lying down on their front or on their side to play from as early as 1 or 2 weeks of age. Place toys that your baby likes to look at in different positions to encourage them to turn their head both ways.
  • Vary your holding and carrying positions of your baby – avoid having your baby lying down too much by varying their position throughout the day, e.g. use a sling, hold them upright for cuddles, carry them over your arm on their tummy or side.

Treatment

Treatment for torticollis and plagiocephaly will vary depending on the nature and severity of the deformities. A paediatric physiotherapist can assist with conservative management. Treatment may include:

  • Passive stretching – your physiotherapist will teach you stretches that can be performed on your baby to assist in turning their head and correcting the head tilt. These will need to be done on a regular basis, several times a day.
  • Playing positions and active movement – people’s faces, voices and toys can stimulate a baby to actively correct their head and neck posture. It is important to make sure that the child is turning their head rather than the whole trunk
  • Carrying positions – to encourage active movement and to stretch the tight muscle
  • Tummy time – your baby needs to spend time on their tummy every day while they are awake to strengthen the muscles in their neck, shoulders and back. The aim of this is to reduce the pressure on the back of the skull
  • Counter positioning – this involves consistently repositioning the infant’s head so that they do not rest on the flat spot. Increased tummy time and side lying play when the infant is awake is also encouraged

Physiotherapy has been found to be effective in the treatment of torticollis and plagiocephaly. The earlier physiotherapy is started, the better the outcome.

Surgical Treatment

If physiotherapy and conservative treatment does not correct the torticollis posture, then surgery is an option to be considered (usually after 12 months). Surgery for torticollis involves a surgical release of the SCM muscle to lengthen the muscle with the aim of correcting the head and neck posture.

Helmet Therapy

In moderate to severe cases of positional plagiocephaly and/or where conservative management has failed, helmet therapy may be recommended. A lightweight helmet is custom-made by an orthotist using 3D images to fit the child’s head, which helps to reshape the skull by taking pressure off the flat area and allowing the skull to grow into the space provided.

Wearing a helmet doesn’t hurt and babies usually get used to it very quickly. The helmet must be worn for 23 out of 24 hours every day, usually for a duration of 2 to 6 months, depending on the severity of the child’s condition. Regular adjustments will be made to the helmet to ensure proper head growth and optimal correction of the deformity.

Helmet therapy

Image credit: Cranial Tech

The good news is that most babies with torticollis and plagiocephaly get better through position changes and stretching exercises. It may take up to 6 months to go away completely, and in some cases can take a year or longer.

The even better news is that Laura is very experienced in treating babies with plagiocephaly and torticollis and will be able to help with any concerns you may have!