Jena Schultz (00:14.446)
Welcome to Driving Development Podcast, the podcast for parents, therapists, and caregivers navigating child development in a world increasing in opinions and decreasing in critical thinking. I'm Jenna Schultz, pediatric physical therapist, educator, and mom of two. Each week we'll break down the research, challenge assumptions, and help you make informed decisions for your family. Let's get started.
Jena Schultz (00:48.492)
Well, hello again. It's been a minute. If you've been wondering
Hello, hello. It's been a minute.
Jena Schultz (01:03.79)
Hey everyone, it's been a minute.
Jena Schultz (01:09.262)
So it's been a minute. I I will admit that. If you've been wondering where I've been for the past few months, I actually had every intention of taking a little break from the podcast and from working. summer was coming to an end. I wanted to spend the last few weeks with my boys. So we did. We we got out, we did some cool stuff, you know, just everything before the chaos of school and soccer schedules and you know, whatever activities I've apparently put them in, got going. And then
you know, everything that I volunteered the family to participate in. school start got s and then school got started and then about a week into school, as things go with the intention of getting back into the flow of things. It
Jena Schultz (02:02.834)
So my kids went back to school for about a week and then as the plan with parenting never goes to plan, my youngest ended up getting hurt. And so what happened in that kind of immediate aftermath of his injury, he ended up having a fall and getting a pretty bad concussion and school fracture actually. So you know, there's there's good news and bad news. Obviously getting a head injury is never a good thing.
the good news though is that it was a linear non-displaced, non-depressed fracture of his skull. So outside of, you know, following general concussion protocols, we're not looking at having to do anything more in depth with neurosurgery or anything. There's some secondary effects that we've been juggling with some amazing therapists and working
Through any residual vision issues, all of that. So that's where I've been. The last month has been a lot. Again, I had every intention of coming back and starting up after the summer was over. It took me a little bit longer than I anticipated. But you know what was interesting though is that for about a month this last month, when I was going through and and focusing on everything that I could do to support my son as he recovered from his injury.
It was really stressful. I was anxious. I was overthinking everything, overanalyzing everything, honestly. And it felt oddly familiar. had been a while since I'd felt that feeling, but it did remind me of another period of parenthood, that also involved
Obsessing over my child's head. In fact, it was the same exact child and it was something where I analyzed it from 47 different angles and I think you all kind of know where this is going. It was a time in my life where I was obsessed with his head shape after he was born.
Jena Schultz (04:14.88)
Now he had positional plagiocephaly, which is flat head from position and utero. Nothing really I could have done to prevent it. And if you ever have had a baby with a flat spot on their head, you might know exactly what I'm talking about. You're just you notice it from all angles all the time. And you know, you're obsessing over it. You're asking the pediatrician, you're getting a million different responses from a million different
And so I thought, what better way to return to the podcast than to discuss something that has caused me an entirely unreasonable amount of stress and anxiety? and how it kind of emulated what I had gone through just now with my son. And so today we're talking about flatheads, and more specifically, we're talking about plagiocephaly, which is flattening across one side of the head.
But I wanna approach this topic a little differently because there's nuance here and I think there's a question that deserves considerably more attention than it gets, and it's not necessarily
Jena Schultz (05:25.09)
I wanna approach this topic a little differently.
Jena Schultz (05:32.396)
I wanna approach this topic a little differently. there is nuance to it, and I think there is a question that deserves.
Jena Schultz (05:46.018)
I think there's a question that deserves considerably more attention than it gets, and it's essentially how can two providers look at the exact same baby's head and give parents entirely different recommendations? So one provider might tell you something looks perfectly fine, and another might recommend physical therapy, and another
Jena Schultz (06:07.197)
One provider might tell you everything looks perfectly fine. Another might recommend physical therapy. Another might tell you that your baby needs a helmet.
Jena Schultz (06:19.937)
Same baby, same head. Different conversations. So who's right? Or more importantly, how are parents supposed to even make informed decisions when the recommendations they're giving don't seem to agree? So let's get into it and let's talk about it.
Jena Schultz (06:46.999)
First, before we get into the disagreement surrounding diagnosis and treatment, we need to understand what we're actually looking at. What exactly is flathead? Because not all flatheads are created equal, and not every unusual head shape is considered a flathead. Infant schools are super fascinating. Unlike adult skulls, baby skulls have tiny multiple tiny little bones connected by sutures that allow the skull to accommodate growth. So
Essentially means that the skull is still developing, making it susceptible to external forces that can influence its shape. Babies spend a tremendous amount. Babies spend a tremendous amount of time lying down, and many have a preferred direction in which they like to turn their head. That taking into account basic gravity can lend to flattening on one side of the head. Now
The first head shape I'm gonna talk about is plagiocephaly. Plagiocephaly is when there plagiocephaly is when there is flattening across one side of the head or asymmetrical flattening of the skull.
Jena Schultz (08:02.872)
Typically you'll notice that one side of the back of your baby's head appears flatter than the other. And when you look down at your baby's head from above, you may notice additional asymmetries. I typically find that parents will notice this more when their baby's practicing tummy time. It just makes it a bit more apparent. In
positional plagiocephaly or asymmetrical flat head, these changes can create a kind of parallelogram-like appearance of the head, which is like a very fancy way of baby saying that one side is flat.
So the other head shape that we have that we'll be discussing is brachcephaly. Brachcephaly, rather than flattening on one side of the head, is going to be flattening straight across the back of the head. So essentially, just the head is wider than it is longer. And I want to note that brachycephaly and plagiocephaly can can occur together and often do. But even head shapes have a million different diagnostic categories.
And there is a final one I'll kind of address briefly, and it's called scaphocephaly or scaphocephaly. This is a head shape that appears longer and narrow. So, like brachycephaly was wider than it is longer, scaphocephaly is longer than it is wider.
It's important to understand that this apparent appearance can have a few different causes, and one condition to consider with really all of these and to rule out is craniosinestosis. So that occurs when the sagittal suture, which we had mentioned before, closes prematurely. Now we don't want it to close prematurely. We want these sutures to stay over to accommodate growth of the school until they're ready to fully close. So when a suture closes and the head continues to grow.
Jena Schultz (09:59.452)
That can lead to some issues. That's why, before we go any further, I want to emphasize something. If you notice an unusual head shape, you really should have your pediatrician as a part of the conversation. But often I will find that parents will take the question to their pediatrician or to their specialist.
And not really get the answer that they were hoping for, the reassurance, maybe they'll get a wait and see response. So if you are concerned, going to a physical therapist can also help with identifying that. And you'll usually, almost always, every time actually, leave with tangible things to do to help your little one. A physician's evaluation helps to identify concerns that
may require additional investigation with neurosurgery. That's craniosinestosis. Depending on the clinical presentation, they might send to a craniofacial surgeon. Now this is exceedingly rare, but I do think it's important to mention because it is the thing that we would like to rule out. but what I also want to know one
But what I also want you to know is particularly important in assessing headshape is that the goal isn't to make parents terrified of every asymmetrical problem that they find in their little one. The goal is to make sure that we're addressing the right problem if it actually needs to be addressed.
Jena Schultz (11:33.143)
So I always get into research, but before we get into research I wouldn't discuss the expectation that every baby should have a perfectly round head. Like sure, if we existed in a vacuum, sure, everyone would have a perfectly round head. It's just not how things work.
And so if babies never had positional preferences, never spent time in lying down, came out looking like they were sculpted by Michelangelo or something, I d maybe that would be a reasonable expectation, but that's just not how things go. And we've created an environment where parents can find themselves obsessing over like a few millimeters of asymmetry. And I say that because I was one of those parents. You remember how I got into this? My son had a two to three millimeter asymmetry.
From position in utero, that is considered within normal limits, but I still couldn't unsee it. And with all of my education, and this is what I do for a living, there are lenses that are on your eyes when you're a parent that are not there when you're a professional. And so I just want to reassure you that there's a difference between normal variation in infant head shape and a measurable asymmetry that warrants intervention. So
A lot of kids, I think the numbers are up to about 60% now, when their babies have some degree of flattening. Now we want to see that that falls within a range of normal. So there's an interesting part in today's episode, numbers. So let's talk about what the riveting numbers of normal are. Feel free to skip ahead if you are not nerdy on the numbers like I am.
Jena Schultz (13:24.918)
So I often get asked, like, well, what is the range of normal? And the the things that I want to bring up is that there are different well, there there is not a standard across the board everyone needs to go by this recommendation, at least not officially. There is one that I think everyone should go by, and it's the children's health care of Atlanta standards. Research is affiliated with the CHOA published a study describing five levels of plagiocephaly severity.
and that was to provide clinicians with a more standard method of categorizing what is normal and what's not. And that was in 2017. So we're coming up on 10 years now.
It is the research-based expected norm. Unfortunately, not everyone is going by that. And so it's a way to quantify asymmetry relative to head size. It's also a way to tell a parent that their baby's head shape is outside a range of normal or within a range of normal. Now, I won't get into the exact numbers or how to calculate them.
that's a different time for another conversation, but I would want to know that the provider that I am working with, whether they're recommending a helmet or diagnosing my child with a flat head of any kind, I'd like to know what scale they're using and what metrics they're using.
Jena Schultz (14:55.114)
Because the research has been established and it's been established for the last ten years. And if someone is not going by these recommendations that are generally accepted by a lot of cranial orthosis places and pediatricians and clinicians, then we need to ask why. And then we need to follow the money. But we'll get to that in a second.
Jena Schultz (15:19.488)
So, how do we get to a point where there's the same baby with the same head but different recommendations from different people? So let's imagine a hypothetical baby. Let's call him Kevin. Kevin's five months old. You know what? No, Kevin's four months old. He enjoys staring exclusively to the right. He has he does not like tummy time, he is not interested in participating in any intervention to get him to look to the left.
Maybe he has a measurable cranial asymmetry. So his parents take him to a provider that classifies his head shape as moderate and recommend recommends physical therapy and moderatoring. The next visit is a provider that recommends a helmet.
Jena Schultz (16:13.61)
The third provider is someone that says the head shape looks completely fine, you don't have to do anything. I feel so bad for Kevin's parents. They're probably sitting in the car wondering wh how they went from, you know, a pediatrician appointment that told them that it was fine to another provider that said they needed to go do physical therapy two to three times a week, and then another ther another clinician that was like
actually just do a helmet, pay for a thousand dollar helmet. And different recommendations don't really necessarily mean that someone measured Kevin incorrectly. It just means that there's different classifications that people are using and interpretations of the available research. So they might take into account Kevin's age, the degree of asymmetry, how much you know, what his cervical mobility is and any responses to previous treatment.
if anything was done. And this is where I want to sort of distinguish
Between identifying asymmetry and interpreting asymmetry. So a measurement tells us something about the shape of Kevin's head, right? But it doesn't tell us everything about Kevin. And I'd like to know a little more about Kevin before deciding what he needs. So
Let's discuss how to treat plagiocephaly. So we need to understand why it develops. We'll come back to Kevin. But simply identifying that a baby has a flat spot doesn't really tell us what's contributing to it. So one of the most important and common contributors is sustained pressure on an area.
Jena Schultz (18:01.212)
Of the skull. So imagine a baby who consistently turns his head to the right. Hey Kevin. When they're lying on their back, that can contribute to positional flattening. And so the question I want parents and clinicians to ask is: why is that baby consistently turning to the right? Is it a positional preference? Is it a limitation in cervical mobility? Is there an underlying condition contributing to the positioning?
Is there a combination of these factors? Does the baby have reflux? There's truly so many things that go into it, and that clinical assessment is important. One of the things that we need to rule out is tortocolis. So
You might have heard this buzzword before. Congenital muscular tortocolis is the fancy word. It essentially involves a positional preference or restricted cervical mobility associated with the sternocleidomastoid muscle, though I take personal problem with that definition.
Some babies have noticeable limitations, but they can rotate their head, and so they have a preference and just kind of subtle asymmetry, maybe from position in utero, we can work through that. When a child has congenital muscular torticolas, we can also work through that. However, this tightness is much more involved. So part of the clinical assessment of ruling things out to get a full view of whether this asymmetry is contributing to flat head, we gotta make sure we're ruling out congenital.
Muscular tortocholis. So if your baby has a flat head and you have not asked the pediatrician or the pediatrician hasn't let you know any of those things going on with head shape and maybe what's causing it, maybe ask them whether they think they have tortocolis. And you can absolutely ask for a physical therapy referral or go seek one out on your own.
Jena Schultz (20:10.281)
Now that we've established what plagiocephaly is and why it can happen and why providers may disagree about the severity, I want to get into the question most parents actually want answered. And what the answer is essentially like, what can we do about it? Does it matter? Do we really need a helmet? For me, I'd like to know: can we correct a flathead without a helmet? And the answer is that many babies with flathead improve without helmet therapy, but the approach that we take
Depends on several factors and the training of the clinician that is doing the treatment. Baby's age, degree of asymmetry, cervical mobility, developmental activities, caregiver management, the response to management, it's all gonna influence whether we can do it. And so this is where identifying the underlying contributors makes it particularly important to finding the right intervention for babies with a flat head.
For babies with positional plagiocephaly, one of the goals is to reduce the sustained pressure on the affected area, and we can do that by distributing the pressure in other ways. And we want to make sure that the baby is not putting any force of gravity on that flat spot as well, but also turning a little one so that the counterpressure is happening on the other side is just as effective when they're younger and still able to be positioned, if not more effective, then helmet.
treatment. The only thing with that is that we absolutely need to be seeing the child before they're rolling over. So yes, we can correct a flathead without a helmet.
But it does take intervention from a very skilled and knowledgeable clinician, typically a PT or OT, that can be able to fully assess your child and see where they lie in severity scale and also where their secondary issues are forming, if any, of tortocolis, positional preference of turning one way, and then put the appropriate intervention in place.
Jena Schultz (22:11.369)
This needs to happen prior to a baby rolling. Once a baby is rolling, they are not going to typically hold the position that you put them in, and then the correction of the flathead is no longer as feasible as prior to rolling.
Jena Schultz (22:41.311)
What I think is particularly interesting is the Congress of Neurological Surgeons guidelines found that physical therapy was actually more effective than just repositioning education alone for flathead. And so it doesn't mean that repositioning is useless. It's a very important part of this puzzle.
But it means that structured physical therapy intervention offers additional benefits and is necessary, particularly because movement restrictions and other positional preferences are present that needs to be addressed through APT.
Jena Schultz (23:19.495)
Another caveat that I want to add is a baby that has movement preferences and issues but zero interest in following the home program that we put together, which actually means the parents aren't going to carry out what we tell them to do, isn't going to see the progress that we want. And so something that we need to take into account is making these programs realistic to get the outcomes that we're wanting. And if not, and
baby may need a helmet down the line. So when does a baby actually need a helmet? And I want to be very frank, we've been talking a lot about avoiding helmets. If your baby needs a helmet, that is completely fine. Like completely fine. But a lot of times parents are wanting to know what they can do to avoid it and when they actually need it. So let's start the conversation to maybe generate some strong opinions.
Jena Schultz (24:21.866)
Cranial remolding orthosis, the the fancy word for helmet, are designed to guide skull growth as the infant's head develops, and they are generally considered for selected infants that have a severity over mild. However, I have seen that there are children that get recommended a helmet when they might not actually need one, depending on the and so this is where this is where the
This is where the nuance comes in on interpretation. We might all get the same measurements, whether it's from a cranial scan or craniometer measurements or taking a picture and looking side by side, but interpretation of the measurement is going to be different depending on where you go. Some people, I like to follow the children's health care with LANA standards, will follow those. Some people will just kind of go based off looks.
And then other people may go based off of the recommendation that perfect zero, zero asymmetry, that perfect symmetry is the goal. Now, in an ideal world, sure, we would love perfect ace perfect symmetry. if you were to take the most handsome person on the planet and
Do a symmetry view of their face, it's not perfectly symmetrical. So realistically, the goal is not perfect symmetry. The goal is within normal limits, which is finding a degree of severity or a degree of asymmetry that is within the general population.
Jena Schultz (26:10.165)
There's a good body of evidence that even outside of that, when it is a mild asymmetry, that that improves on its own as a child ages. So the question isn't necessarily in our methods of measurement, but who is interpreting the measurement and what scale they're using. And maybe what kickback they'll get further.
and maybe what kickback they'll get for their recommendation.
Jena Schultz (26:53.438)
Now, I always like to bring up research, and this is a really interesting one for me. So in 2014, I'm just gonna read this verbatim real here real quick here, just to get you the information. Researchers published the HEDS H E A D S randomized controlled trial in the BMJ. The study included 84 infants between five and six months of age with moderate to severe positional skull deformation. The researchers compared
Helmet therapy with the natural course of the condition. At 24 months, they found no statistically significant difference in head shape improvement between the groups. Full recovery was reported in 26% of the infants assigned to helmet therapy and 23% assigned to the natural course group. The researchers concluded that helmet therapy should not be standard treatment for the population they studied. Now, before we throw every helmet in the Renewers dumpster, I want to talk about.
That important limitation. So the study excluded infants with muscular tortocolis, craniosynstosis, and certain clinical characteristics. It also wasn't designed to establish whether physical therapy was superior to helmet therapy, and we can't really take these findings and automatically apply them to every baby with every degree of plagiocephaly. It's just not our research works. And it's one of the reasons we have conflicting recommendations.
In 2016, the Congress of Neurological Surgeons published evidence-based guidelines recommending helmet therapy for infants with persistent moderate to severe plagiocephaly following conservative treatment, as well as selected older infants with moderate to severe deformity. However, the guideline acknowledged uncertainty about the optimal measurement thresholds and timing of treatment.
In other words, the research doesn't provide a single universally accepted answer for every clinical presentation, and that brings us back to
Jena Schultz (28:51.37)
poor Kevin. He just wanted to stare at a ceiling fan, and now he's the subject of an entire evidence-based clinical discussion in a podcast. Back to our original qu question then. So why might one provider recommend a helmet while another recommends continued physical therapy and monitoring, or we're really doing nothing at all? Because they may be using different treatment thresholds. They may be interpreting the same measurements differently, and they may have different
of clinical experience with particular patient populations.
Jena Schultz (29:26.078)
This doesn't automatically mean one provider's wrong. Like I want to be very clear about that, but it does mean parents need to understand the reasoning behind the recommendation. So if someone recommends a helmet, I think it's certainly reasonable to ask why and ask them to explain their clinical findings to support the recommendation. Also, ask what degree of asymmetry? Ask what measurement method and classification system did you use? What improvement is expected from this age based on the research norms that we know?
Are there any alternatives available and how will progress be monitored? Those are important questions because the ultimate goal isn't simply to get everyone to agree on a measurement, it's to make an informed decision and what's appropriate for your individual individual child. And I have found that babies with similar presentations have found success within their family doing completely different interventions.
Jena Schultz (30:24.893)
I want to return to something I mentioned at the beginning of the episode, how completely consumed I became with my own baby's head shape. Because I think this experience reflects something much bigger about modern parenting. We have access to an extraordinary amount of information. We have specialist screening tools, measurements, developmental milestones to track that our parents weren't tracking.
Products designed to address virtually every concern imaginable. And in many ways, I I think that's wonderful. I like innovation. I think that we need more of it constantly, always, but access to more information doesn't necessarily lead to a good thing. And sometimes it makes them makes things and decisions significantly more complicated, especially when there's different sources giving us different recommendations.
And when you're a parent who's worried about your child, it's incredibly difficult to separate a clinically meaningful concern from the pressure to do everything perfectly. but I think that's exactly why we need to have these conversations. Informed decision making requires more than just being presented with a problem and a proposed solution.
It requires understanding how that problem was identified, what the available research tells us, and what we don't know, quite frankly, and which options make sense for our individual circumstances. And so sometimes it requires accepting that there isn't one universally agreeing upon answer, which is really hard for me to say, because I think in my head that there is a universally
a superior option. And I'll tell you what it is. But just know it's not gonna agree with the helmet provider down the street or your pediatrician probably. Personally, I think every baby that has flat head needs to go see a pediatric physical therapist that is qualified to assess flathead. They should be able to go see a pediatric PT at the first sign of flathead.
Jena Schultz (32:47.719)
If you take away nothing else from today's episode, I want you to remember three things. Not every flat spot is the same, so understanding the underlying cause of an unusual head shape is actually more important. And also that's gonna look different for every kid. Second measurements are useful, but interpretation of
The measurements and who is interpreting and how maybe a bit more important. And third, there are effective conservative strategies for addressing positional plagiocephaly, and we need to start doing them at the first sign. I can get on my subbox. Physical therapy can play an interport. I can get on my subbox here.
Jena Schultz (33:51.559)
Research consistently shows physical therapy as the first line most effective treatment for flat head.
Jena Schultz (34:01.61)
Helmet therapy may be appropriate for selective infants, but the decision really should be individualized and based on a discussion in the first line treatment. No matter what, should always, always be a PT refer.
Jena Schultz (34:20.417)
And I'll leave you on this. If you receive conflicting recommendations or a recommendation that feels off about your baby's head, ask questions. You deserve to understand the reasoning behind the care being recommended for your child and a just because I said so rec
You deserve to understand the reasoning behind the care provided for your child and a just because I said so ain't gonna do it. I may be feeling a little salty because I was getting this with the mild concussion. I may be feeling a little bit salty because I've gotten this in the last month from a few doctors when I asked for an explanation.
But we deser you deser I deserve it. We deserve to know the reasoning behind the care that is being recommended for your child. Point blank.
Mic drop.
Jena Schultz (35:24.679)
And now after spending the last half hour discussing something I'm actually qualified to talk about, it's time for my unqualified opinion of the week. Today's opinion though is going to be like my ones in the past have been a little more lighthearted, but this one this one's gonna be this one's gonna be something that's just speaking to me today. volunteer at your kids' school. Like seriously do it. Like I I don't care if you're cutting out
seventy five laminated pumpkins in the workroom, chaperoning, sending donations, just volunteer. Right now we are under a pretty dire situation with the public school system.
personally we're in Texas and it feels that the way that we can overcome this and make sure that we are doing the best thing for our kids at this time and raising them in environment that they deserve and giving the teachers everything that d they deserve, we've gotta be showing up
I genuinely I genuinely believe that the community is what makes a school. So we spend so much time evaluating schools based on like their test scores and rankings, teachers, facilities, programs, funding, and you know, whatever those things matter. But what also matters is having a community of parents, caregivers, and companies and businesses that are invested in making the school a better place for their children, everyone's children to raise the future.
generation. That doesn't happen by accident. It happens when people show up, when they use their voice and when parents support teachers. So that is something that up until this year, quite frankly, I was really not doing. But I have gotten a lot more passionate about it.
Jena Schultz (37:17.329)
I can tell you from personal experience that the more I've volunteered, the more connected I've felt to our school. I've gotten to know the teachers, the administration, other parents, and I've developed an entirely new appreciation for how much work goes into making an elementary school function. And that's after working in the public school system as a school based PT for two years. Let me tell you, those parents let me tell you, those teachers are doing forty seven jobs. When I volunteer in the workroom, I'll be there for two hours.
And like get two projects done because it just takes so long to laminate and cut and do all the things.
Jena Schultz (37:57.861)
if you care about your child's education, which should be cared about, even if you don't have children, because that is going to be the future of the person that is sitting next to you that you're training to do your job, that is going to be taking care of you as you get older. Invest in the community that's providing it. Support makes a difference. Selfishly, it's also just really fun to be a part of something bigger than yourself and investing in kids in a way that is going to
give back to the community in a greater good way. So that's my completely unqualified opinion. It's my soapbox. Volunteer at your kids' school and for the love of God, just help someone with laminating something.
Jena Schultz (38:42.899)
Thank you so much for joining me for another episode of the Driving Development Podcast. If you found today's conversation helpful, share it with a parent who's navigating concerns about the baby's head shape, or with a therapist who might enjoy a deeper conversation about the research. And remember the goal isn't to do everything perfectly. It's to understand your options, ask good questions, and make informed decisions for your family. I'll see you next time.
