I’m taking a few days off this week, keeping my two-year old granddaughter occupied while her mom and newborn sister try to rest and dad’s at work. Being with my newborn granddaughter has gotten me to thinking about the babies I see at Kid’s Creek Therapy, some of whom I treat for infant torticollis. In today’s post I’m sharing with you some signs to watch for and some tips on preventing and treating infant torticollis.
What exactly is infant torticollis and what causes it?
Infant torticollis is a condition which results when one of the neck muscles, called the sternocleidomastoid, is tight or shortened. Sternocleidomastoid muscles (SCM) are found on each side of the front of the neck, starting just below the ear and attaching to the front of the collarbone. When both work together they bend the head forward, like when you look down to see your belly. When one side pulls it tilts the head to one side, like when trying to touch your ear to your shoulder. That same side also works to rotate the head to the opposite side, like turning to look over your other shoulder.
An infant with torticollis will look like his ear is tipped to one side and his little chin is rotated to the other, maybe a little or maybe a lot, depending on how involved that one side is. Torticollis also interferes with the baby being able to turn his head to either side. These muscles control bending, tilting and rotating the head in all those directions. It also can cause “flathead syndrome” or plagiocephaly, a flattening of the skull at the back and side of the baby’s head.
No one knows the exact cause of infant torticollis. Some cases are a result of a spinal defect or trauma. Often, it may be related to positioning in utero or prolonged positioning on the back in the first few months of life. It gets worse when left untreated or ignored (the bad news) but in most cases it resolves with physical therapy (the good news). Most pediatricians are quick to identify it and help parents get the intervention they may need or give suggestions for activities and positioning at home during the first few months.
As we all know, newborns are unable to hold their head up. They also are unable to keep their head and chin in the midline when resting on their back or in a car seat because the neck muscles are not strong enough until they can hold their own heads upright. The ages between 2-5 months are especially important to correct torticollis and prevent severe flattening of the head or cranium. If severe, even the face can become flattened on one side leading to significant asymmetries and problems with oral motor or orthodontic or jaw problems. When a baby has tightness on one side of her neck, it prevents her from turning to the opposite side and she stays “stuck” with her head rotated and tipped to one side or the other. The opposite side gets weak and the cycle continues until it affects development in prone position (i.e., on the tummy) and rolling and crawling.
Another condition often associated with torticollis is hip dysplasia, in which the hip joint is unstable or poorly formed. It is very important to stay close to your pediatrician with any concerns you may have at your regularly scheduled check-ups with baby.
As a long time physical therapist, I have seen a dramatic increase in torticollis cases since pediatricians began implementing the guidelines for “Back to Sleep” in 1992. Prior to that time, I saw only a few cases of torticollis and even fewer cases of “flathead syndrome.” While the Back to Sleep campaign has significantly reduced the number of cases of Sudden Infant Death Syndrome (SIDS), the prolonged positioning of babies on their backs for sleeping or in car seats and other “containers” has also led to more flattening at the back of the head.
What should parents do to minimize the likelihood of infant torticollis?
Torticollis does not affect the brain, and the skull will become more rounded as baby grows and spends more time on her tummy and starts moving her own head freely. In general, providing lots of tummy time and holding baby on his tummy (or a variety of positions) throughout the day is important. Babies love to be snuggled on top of mom or dad when both are reclined for a much needed rest (and don’t we love that time, too?)
For newborns, many car seats are now equipped with head supports at either side to keep his head in midline. Another easy positioning tip is to change the direction you lay baby down for a diaper change. For example, my daughter-in-law is right-handed but my son is left-handed. When they diaper the baby, each lays the baby down differently. One puts her down with her head at the “north end” of the changing table, while the other lays her on the “south end.” It used to be a point of contention until they heard me say one time how I tell parents to do that to give baby a chance to turn their head to either side to look up at them often throughout the day (Yes, I’m working on being a good mother-in-law, too!)
So how do we treat infant torticollis at Kid’s Creek Therapy?
When we evaluate and treat an infant for torticollis, we look for associated hip, spine, or other orthopedic problems and assess any developmental delays. We also teach parents appropriate positioning, varied positioning to allow rounding of the head and prevention of further deformity of the head and face shape. Treatment for torticollis includes gentle stretches to the tight muscles, soft tissue massage, and strengthening for any weakness of the neck muscles on the opposite side of the tight muscles (usually the other sternocleidomastoid muscle).
If a baby’s head shape is very severe, a pediatrician or physical therapist may also recommend wearing a helmet to decrease the pressure on the flattened side and allow it to grow into a rounded shape. Growth of the cranium, or skull, happens over a long period of time, even up and past a year old. However, it has the best chance of change in the first few months with intervention. I have told some parents that the baby’s head is like a pumpkin in the pumpkin patch. If the pumpkin grows and stays laying on its side, it will be flattened on that side as the rest of the pumpkin grows big and round.
Unlike the pumpkins, our babies will learn to roll themselves and turn their faces and heads to either side – they may just need a bit of help to get started and a physical therapist to guide their parents to prevent problems down the road. Our physical therapists at Kid’s Creek Therapy have many years of experience and are committed to helping parents give their children just what they need to help them overcome the difficulties related to infant torticollis. We are also trained in infant massage and teach parents who are interested how to implement massage at home.
Signing off for today – “big sister” just woke up. See you back at Kid’s Creek next week!
Karolee Stauduhar, Physical Therapist