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Being a guardian of the interface between illness and disease is a challenging and active process. What do the stories of babies Toby, Tyla, and their 20 or so friends, all of whom have been treated for skull asymmetry, tell us about this?¹

According to their parents, they were all born ‘beautiful’ with a lovely rounded head but at the age of a few weeks this became misshapen. The parents consulted health professionals and were reassured that the head shape would get better and was simply related to the baby being put ‘back to sleep’. The evidence of the parents eyes however, was that things were getting worse with time. The treatment for skull asymmetry with orthotic devices, according to the narratives, does produce results. Treatment for what is usually regarded as a selfcorrecting condition is not available on the NHS and parents often go to huge lengths to fund raise.

There is a lack of evidence that helmet moulding for positional skull asymmetry does work and is better than simple positioning measures or doing nothing at all. Equally there is a lack of evidence that helmet moulding does not work.²

There are some important things we should be doing in primary care. There are preventative measures. There are also occasional children where the condition does herald significant pathology; not all skull asymmetry is positional and benign, so a thorough assessment is needed. Perhaps most of all what we need to be doing is offering parents an explanation, including an honest account of the evidence, and of course, taking the parent's concerns seriously.

Common conditions of the normal child: skull asymmetry in a 4-month old child.

Why:	Up to 50% of children have some degree of skull asymmetry.
	▸Brachiocephaly = symmetrical posterior flattening acquired postnatally and usually caused by ‘Back to Sleep’. ▸Plagiocephaly asymmetrical posterior flattening, there at birth (usually related to intrauterine position), but accentuated by ‘Back to Sleep’. ▸Greatly increased incidence of skull asymmetry since ‘Back to Sleep’ campaign (although this has been hugely successful in reducing ‘cot death’ incidence). Parental worry; will head be normal shape? Professionals worry as there are occasional serious conditions associated with skull asymmetry. In most cases purely a cosmetic problem with no impact on brain development.
How:	History:
	Obstetric/birth history — intrauterine moulding can be related to mal presentation. Children who are floppy tend to have malpresentation. Birth trauma moulding tends to resolve in first few weeks of life. Prematurity predisposes to plagiocephaly and babies have higher risk of associated central nervous system problems such as hydrocephalus. Developmental history. Ask about how much time baby spends on tummy/back.
What next and when:	Examination:
	General development Look for dysmorphism (premature synostosis of cranial suture +/- syndrome, for example, Crouzon's) Head size; can be difficult to measure largest circumference. Record head (= brain) growth in parent held record and monitor this. Head exam; check for fontanelle and any ridging of cranial sutures. Look at ears. In plagiocephaly accentuated by sleeping position, the head resembles a parallelogram: the ear ipsilateral to flattening moves forward and is associated with cranial bossing on affected side. In craniostenosis; the ear is pushed back (not forward). Eye movements: if the baby has a squint, he/she will preferentially look one way and so encourage plagiocephaly. Check for other visual problems for example, hemianopia. Neck movements; exclude torticollis, traumatic sternomastiod tumour. Shoulder and upper limb; examine for muscular symmetry. Muscle tone — babies with general floppiness will tend to develop plagiocephaly/brachiocephaly as they move less, so do query underlying neurological or metabolic problem. Hips — limited movement in one hip will encourage baby to lie one way.
	If all normal, then spend more time on tummy or side if awake and playing — that is: ‘Back to sleep and over again’. If torticollis refer to physiotherapy. Refer if abnormal findings — especially note: developmental delay; weakness or hypotonic; suspected craniostenosis (neurosurgical referral); head circumference crossing centiles; head circumference out of keeping with weight and/or height; abnormal hip position.
	Head helmets; (popular in the US and here!) to give baby a perfectly round head. Problems: cost thousands of pounds! Positional skull asymmetry improves with age anyway; helmets have to be worn 23 or more hours a day; treatment should start <7 months age, lasts months. Potentially not tolerated by child, applied and monitored by non-medical practitioner in most cases.
	Monitor the situation/review!
Patient information:	Information sheet for parents on plagiocephaly/brachiocephaly: http://www.nhsdirect.nhs.uk/articles/article.aspx?articleId=1892 Exercises for torticollis (parent information sheet): http://www.orthoseek.com/articles/congenmt.html
References:	Saeed SA, Wall SA Dhanwal DK. Management of positional plagiocephaly. Arc Dis Child 2008; 93: 82–84.
Who are you:	Peter Heinz, Consultant Paediatrician, Addenbrookes Hospital.
	Anna Maw, SpR Paediatrics, Addenbrookes Hospital.
Date:	September 2008