Cranial Disorders and Head Shape
The skull of a newborn is composed of mobile bony plates separated by spaces, called “sutures,” that allow the head to grow. During your child’s regular pediatric appointments, your pediatrician will monitor your baby’s head circumference and track progress in developmental milestones.
The pediatric neurosurgeons, craniofacial plastic surgeons, and neurologists at Mount Sinai Kravis Children’s Hospital are dedicated to the diagnosis, treatment, and management of complex skull issues in infants and toddlers, including the use of minimally invasive surgeries when possible.
What are the symptoms?
Subtle abnormalities may be a sign of craniosynostosis (early closure of the sutures), positional plagiocephaly (flattened head), or hydrocephalus (fluid build-up in the brain), which affect brain growth and development.
These disorders may lead to physical and developmental problems, including effects on your baby’s head shape, facial development, and brain growth and development.
Evaluations in Head Shape
The bones in your baby’s skull are normally separated by spaces referred to as suture lines. These sutures allow the skull to expand for your baby’s rapidly growing brain in the first few years of life and eventually fuse to complete skull development. Our craniofacial experts will evaluate whether your child has a premature fusion of one or more cranial sutures, clinically known as craniosynostosis.
- Metopic Suture
Located between the two frontal bones, the metopic suture extends from the top of the forehead toward the nose. It begins closing in the first few months of age and is typically closed by one year.
- Coronal Sutures
Extended from both sides of the anterior fontanelle (soft spot) toward the front of the ear. They begin to close around two years of age.
- Sagittal Suture
It runs midline on top of the head from the anterior fontanelle to the posterior fontanelle. It begins to close around two years of age.
- Lambdoid Sutures
Extend across the back of the head from the posterior fontanelle. They begin to close after two years of age.
What should I do if my child has signs of craniosynostosis or positional plagiocephaly?
Call our office at 212-241-0954 or email email@example.com for a consultation. We will schedule your child for a clinical evaluation, order imaging (if applicable), and may opt to monitor your child over time to ensure proper development. If we think your child may require other resources or special services, we will refer you to the appropriate team of specialists. Many children require only routine follow-up with their primary care provider.
What happens if you diagnose my child with craniosynostosis?
We will take you through the steps of pre-surgical evaluation, surgical treatment options and after-care. Our experienced craniofacial team will answer all your questions and prepare you and your family with a treatment plan that works for you.
In response to evidence that sleeping on the back reduces the risk of SIDS (Sudden Infant Death Syndrome), babies are put on their backs to sleep. The recommended “Back to Sleep” campaign, though the safest position, commonly results in increasing frequency of positional plagiocephaly, or the flattening of the back of the head. Your baby’s flat head can be symmetrical or favor one side and sometimes can be worsened by a condition called torticollis, where the neck muscles on one side are too stiff.
In positional plagiocephaly, flattening of the back of the head is often accompanied by changes in the shape of other parts of the head to compensate and allow brain growth. These can include anterior displacement of the ear and slight prominence of the forehead on the same side affected by the flattening.
Usually, the head flattening and compensatory changes improve on their own as the child becomes more mobile. As this is a cosmetic concern and should not affect brain development, repositioning, physical therapy and occasionally a helmet may be used, when appropriate.
Seeing the difference between plagiocephaly and craniosynostosis requires a clinically trained eye. Though plagiocephaly is much more common, a missed diagnosis of is craniosynostosis can lead to delayed treatment and worsening of your child’s condition.
Evidence-based guidelines recommend that even in moderate to severe cases of positional plagiocephaly, helmets may be considered if observation, repositioning therapy and physical therapy are unsuccessful.
Plagiocephaly Treatment Options
Repositioning, Tummy Time, and Therapy
Conservative management is first line therapy and includes emphasis on mindful repositioning and encouragement of tummy time while the child is awake. Physical therapy can also be used as supplementation for any motor conditions that contribute to worsening the flattening, such as torticollis, a side preference, or weakness. These exercises usually help strengthen these deficits reducing time spent on the back of the head, leading to improvement of head shape.
If your child does not respond to conservative treatment, has severe motor deficits, or is diagnosed at a later age, then helmet therapy may be considered.
Helmet therapy, or cranial orthosis, has been used widely to:
- Improve head shape in positional plagiocephaly
- Guide growth of the skull after minimally invasive craniosynostosis repair
If it is determined that your child would benefit from a helmet our team will provide you with a referral. Children are recommended to wear these helmets for 23 hours per day, for a variable period of time. Most children wearing helmets will have regular follow-up visits with the orthotist to track progress and determine when helmet therapy is complete. It is important to continuously monitor for skin damage when helmets are used.
In craniosynostosis there is a premature fusion of one or more cranial sutures, resulting in restricted growth of the skull in ways that are unique to each suture. The appearance of the head shape will differ depending on which sutures are fused.
Craniosynostosis is a condition treated with surgery, as there are no medicines or non-surgical measures that are effective at correcting the problem. Our experienced craniofacial team consists of experts in the diagnosis and treatment of craniosynostosis involving all sutures and will take you through the steps of pre-surgical evaluation, surgical treatment options, and after-care. We will answer all your questions and prepare you, your child, and your family for the treatment plan with the best outcome.
Craniosynostosis can be detected as early as birth. It is important to diagnose craniosynostosis in a timely manner to facilitate normal skull and brain development, as well as allow for the option of a minimally invasive surgical approach.
It can at times be difficult to differentiate normal physiologic development from craniosynostosis. A formal diagnosis can usually be made with a physical examination, but sometimes more subtle findings may require imaging. An ultrasound evaluation of the suture lines can assist in diagnosis and does not emit radiation. Sometimes an x-ray or CT scan is necessary for more definitive evaluation of the suture lines or for surgical planning purposes. If a CT scan is required, Mount Sinai’s pediatric CT scanning protocol will minimize the radiation dose for your child.
Your child will have a narrow, triangular-shaped forehead head, often with a midline forehead ridge, and eyes appearing close together. There is also often widening of the back of the head.
Your child’s forehead and brow will be flattened, and one eye may be shaped differently on the affected side. Forehead prominence is present on the opposite side. When bilateral craniosynostosis occurs, the entire forehead tends to be tall and flat.
Your child will have a long, narrow appearance of the head when viewed from above. There can also be fullness (bossing) and increased height of the forehead or back of head.
One side of the back of your child’s head may appear flat. The ear on the affected side is pulled back and there is often a bulge of bone below and behind the ear.
Craniosynostosis Treatment Options
Surgical planning is carefully considered and developed on a case-by-case basis by our pediatric neurosurgeons and craniofacial plastic surgeons. As a team, we discuss appropriate surgical options for your child.
Our goal is to provide a true understanding of your child’s unique condition, how we will perform the surgery, immediate and future recovery expectations, and what to monitor at home. We assure you that we’ll always be available to answer all of your questions and design the best plan for your baby.
Our pediatric neurosurgeons at Mount Sinai offer minimally invasive endoscopic surgical procedures to infants who are younger than three months of age (and in select cases in older babies) with craniosynostosis.
- Surgical Approach
This surgical approach involves making a 2-3cm incision over the affected suture. Using an endoscope for visualization, a strip of bone is removed at the fusion point creating free movement of the cranial plates at that location in your child’s skull.
The hospital stay post-operatively is about one to two days. Typically, after surgery, your child’s head may appear puffy or swollen at the surgical site. We will have a post-operative visit two weeks after surgery to evaluate your child’s progress and to check the incision site. After the incision has healed, a helmet is typically used to guide the growth of the skull for a period of several months to a year. Helmets are worn throughout the day and night, only removed for bathing, and they require frequent evaluations and adjustments by the helmet clinic.
Open Cranial Reconstruction
In babies older than three months with craniosynostosis, our pediatric neurosurgeons and pediatric plastic surgeons work together to perform a surgical repair known as “cranial vault remodeling.” This allows the neurosurgeon and craniofacial plastic surgeon to correct the head shape and any associated upper facial abnormalities simultaneously.
- Surgical Approach
Craniosynostosis surgery usually lasts three to four hours and involves reshaping the skull bones to achieve a normal head shape. The precise type of reconstruction varies based on the type of craniosynostosis and your child’s individual anatomy.
Children who undergo cranial vault remodeling typically spend three to five days in the hospital PICU after surgery and return home as the swelling of the scalp and eyelids diminishes.
These children do not require helmet therapy to correct the head shape, as the entire correction is completed during the surgery.
There is not just one person dedicated to the care of your child. We work as a team with pediatric neurosurgeons, craniofacial plastic surgeons, and neurologists. For cases that require more involved specialty care, our team has geneticists, specialized pediatricians, specialized rehabilitation physicians and physical therapists, and pediatric ENTs. As a team, we discuss all options for your child.
Saadi Ghatan, MD
Peter F. Morgenstern, MD
Peter J. Taub, MD
Pediatric Craniofacial Plastic Surgeon