Torticollis and Plagiocephaly: A Puzzle With Many Pieces

The orthotics profession has experienced a mass influx of an entirely
new patient population throughout the past 10 to 15 years – infants with
plagiocephaly and/or
torticollis. The Back-to-Sleep program initiated by American
Academy of Pediatrics (AAP) has taken the brunt of the blame for this epidemic,
but many parents and practitioners overlook the many other pieces to the

Back-To-Sleep Program

In the 1990’s the AAP identified prone positioning as a significant
risk factored for Sudden Infant Death Syndrome (SIDS). Hence, the Back-to-Sleep
program was implemented. It is a life saving program that is responsible for a
more than 40% reduction in the incidence of SIDS. Parents and health care
providers should continue to adhere to the AAP’s recommendation for
placing an infant supine for sleeping. The Back-to Sleep program is designed to
educate parents as to the importance of sleeping their baby on his or her back.
However, until recently, there was little education to partner with this
recommendation that educated parents as to the importance of tummy time during
awake, supervised periods.

  Torticollis and Plagiocephaly
  Image: © McEntire

Infant car seats

In the 1980s, states started passing laws requiring the use of infant
car seats. By 1984, nearly half of the population aged 0 to 4 years was riding
in some form of child safety car seat. Infant car seats are designed to protect
infants from being injured or projected out of an automobile in the event of an
accident. They are designed to restrict or stop motion in all planes to keep a
baby safe in the event of an automobile accident. As car seats became an item
in every household, the design became more elaborate with toy bars, a cushioned
head positioner, and snap-in and -out efficiency. In the mid 1990s – the
same time as the Back-to-Sleep Program became routine in homes – the
snap-in car seat hit the market, thus making it possible for parents to quickly
and easily transport their child in the car seat from car, to house, to the
stroller or wherever they went. Gone were the days of carrying your infant in
your arms to get from the house to the car. Unfortunately, we all began to use
the seats to contain our children for many of their waking hours, unknowingly
stopping them from using their own muscles for postural alignment and movement.
To add to this, we started strapping toys directly in front of them which
further inhibited the need to use their own musculature to explore the
environment, learn and play.

Equipment inhibitions

As a society, we have become reliant on a wide variety of convenience
equipment to help parents when caring for their children. In addition to car
seats we have bouncy seats, swings, exersaucers, baby walkers, jumpers, bucket
seats and the list continues. The equipment, while certainly convenient, can
inhibit the use of normal postural muscles. It may teach a baby that they do
not need to use their own muscles, eliminating spontaneous use of balance
reactions, encouraging abnormal postures – such as sacral sitting or
standing on toes – or teaching inappropriate motor patterns. Many babies
become so inexperienced with using their own musculature that physical therapy
is needed to teach symmetric motor patterns and to help them to develop a love

Frank A. Vicari, MD, a craniofacial/ pediatric plastic surgeon at
Children’s Memorial Hospital has witnessed the surge in cases of infants
with positional plagiocephaly (flat head) and torticollis (asymmetry of neck
muscle function).

“It’s important that families remember that car seats are for
the car. When used in excess for reasons other than their intended use, they
can be detrimental to a baby’s motor development,” he said. He
generally encourages families to throw away all of the equipment and pull out
the playpen or put a blanket on the floor. Then, in conjunction with this
recommendation, he suggests that they spend some time with a physical therapist
to learn ways of making tummy time easier.

Parental adjustments

One easy adjustment that practitioners can suggest to help parents
encourage their baby’s postural confidence and love of movement is to
carry their infant in their arms, making a conscious effort to alter their
carrying position including forward facing, holding on hip and holding baby
prone over their forearm. With every postural shift the parent makes the baby
needs to make one as well. Over time it adds up to a lot of repetitions of core
muscle activity.

When should parents begin to exercise with their newborn? First, it is
important to qualify what counts as exercise for a newborn or infant. Infants
are taught early in life to love movement, or in some cases, to avoid it.

Babies typically come home sleeping 18 to 22 hours per day. When we were
babies we spent these long periods of time on our tummies, became strong
quickly, and likely loved being there. Unfortunately, some parents today have
become reluctant and even afraid to place their babies on their tummy for more
than a few minutes daily. Probably one of the most common statement therapists
hear today is, “My baby hates tummy time.” While a true statement of
many babies today, it is, in typical infant development, an abnormal position
for a baby to hate. Most physical therapists expect that by the time a baby is
4 to 5 months of age, he or she should have built enough muscle strength and
had enough practice being on the tummy that this is the position where he or
she wants to live.

However, our parents are not wrong in their statements. How can we
expect a baby to get strong on his or her tummy when they are spending a few
5-minute sessions a day in comparison to huge numbers of hours on the back? In
the Head Shape Evaluation clinic at Children’s Memorial Hospital in
Chicago, it is recommended that infants spend approximately 50% of their awake,
supervised hours on their tummy or in a tummy-time equivalent. As health care
providers, it is our job to educate families on the importance of awake,
supervised tummy time and, just as importantly to give them a repertoire of
exercises and activities that will help today’s baby learn to love tummy

Effects of societal changes

Another social shift in the United States that began around the same
time as the Back-to Sleep Program and the popularity of click-in infant car
seats was the increase in the number of families with two parents working full
time. Based on data from 1998, both spouses were employed at least part time in
51% of married couples with children, compared with 33% in 1976. Other findings
from the Census Bureau report: Even married or single mothers with young
children were likely to work at least part time. Fifty-nine percent of women
with babies younger than a year old were employed in 1998, compared with 31% in
1976. (Daily Policy Digest, 10/2000) This often means a baby spends the day at
a care facility with several or many other infants, meaning they had to be
placed in some device due to limited adult caregivers.

Take a seat in a beanbag chair or recliner. What muscles do you feel
working? Very few, right? Now try sitting there for many of your waking hours.
This is what many infants experience, every day, for many hours. They are not
encouraged to explore their environment independently – instead objects of
entertainment are passively placed in front of them. Then at 12 months of age,
they are expected to walk and explore their environment independently, when
they have had little experience with using their own muscles.

Vitamin D

Low levels of vitamin D can soften bones, increasing the possibility of
developing plagiocephaly. According to the results of 2 studies reported in the
April 2010 issue of Pediatrics, U.S. infants may have inadequate
vitamin D status. One study showed vitamin D deficiency in a high proportion of
infants and their mothers in Boston, and the other found that most U.S. infants
are consuming inadequate amounts of vitamin D, based on the 2008 recommendation
of the AAP.

A number of factors decrease the amount of vitamin D a person will
synthesize from sunlight. These factors include living at high latitudes,
particularly during winter months, high levels of air pollution, areas with
routine dense cloud covering, the degree to which clothing covers the skin, the
use of sunscreen, and light skin pigmentation. Furthermore, there exists a
major public health effort to decrease the risk of skin cancer by encouraging
people to limit their sunlight exposure.

In April 2003, AAP published guidelines for vitamin D intake,
recommending that all infants have a minimum intake of 200 IU of vitamin D each
day, beginning during the first 2 months of life. In 2008 they increased the
recommendation to a daily intake of vitamin D of 400 IU/day for all infants and
children beginning in the first few days of life. Many families are still not
aware of these guidelines with regard to infants.

Therapeutic intervention

Occasionally, it is necessary to include use of a cervical collar into
the therapeutic regimen of an infant with torticollis with persistent head
tilt. It is recommended that the collar be used as a training tool for a
portion of the baby’s happy, waking hours. The goal is to provide an
orthosis that limits tilt to the affected side, while allowing tilt and head
righting in the opposite direction. Care should be taken to customize a collar
so that it does not limit rotation toward the side of the tilt. A noxious
buttress that contacts the insertion of the tight sternocleidomastoid, just
superior to the lateral surface of the mastoid process, is often effective in
encouraging tilt to the opposite side. Collars should only be worn when the
baby is supervised and are not recommended for use in car seat or other
positioning devices.

The window of opportunity for successful use of a collar to manage
torticollis is limited. The baby should exhibit emerging head righting and be
young enough that they will not take the collar off. This usually equates to an
infant between the ages of 5 and 15 months. As with infants who have
plagiocephaly, it is necessary to dissect the multiple factors that caused and
perpetuate the problem.

Head shape abnormalities, when non-synostotic, are a symptom, not the
problem. Health care providers should help parents get to the root of cause and
recognize that there are many factors that have influenced the development of
the abnormal head shape. Any infant with something that restricts his or her
symmetric movement is at risk for developing a head shape abnormality. Tummy
time alternatives should be discussed early with parents of babies who have a
cast or orthoses on any extremity, history of thoracic or abdominal surgery or
abnormalities, hearing loss, vision abnormalities or history of prematurity.

When fitting an infant with a
cranial remolding orthoses it is important to remind parents
that the orthoses does not negate the need for strengthening and exposure to
movement. The orthosis is one of several tools needed to help fix the head
shape abnormality.

For more information:

  • Safety Belt Safe U.S.A. Available at: Accessed
    May 17, 2011.
  • Schnarr B. The history of car seats – The ride that saves
    lives. September 10, 2008. Available at:
    Accessed May 17, 2011.
  • National Center for Health Statistics. National Vital Statistics
    Reports: Table of SIDS deaths and mortatlity rates. Available at: Accessed May 17, 2011.
  • MacDorman M, Mathews TJ. Recent trends in infant mortality in the
    United States. NCHS Data Brief, No. 9, October 2008. Available at: Accessed May 17,
  • Daily Policy Digest. Economic Issues. October 24, 2000. Available
    at: Accessed May
    17, 2011.
  • AAP clinical report on vitamin D intake. Pediatrics.
    November 2008;122(4):908–910.

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