“Flat head syndrome” (Plagiocephaly)

Definition: plagiocephaly comes from the Greek word “plagio”, meaning oblique and “cephaly” referring to the skull.

The baby’s skull is made up of bones that have not yet fused, allowing the skull to grow as the brain grows. This also makes it prone to changing shape where pressure is applied overtime.

Positional plagiocephaly occurs as a result of pressure from outside forces on the baby’s skull (such as sleeping on one side). This pressure leads to flattening on one side, which can cause a shift in the placement of other bones in the skull, leading to a change in head or face shape and appearance.

Nelson’s Textbook of Pediatrics, 20th Edition (page 2821)

It is much more common now, as a result of “back to sleep”, where doctors now recommend having babies sleep on their backs as part of safe sleep campaigns.

How common is it?

By 4 months of age, the incidence is 20%, which means that two out of every ten children will have plagiocephaly. Infants under 4 months of age cannot reposition their heads well, and so may sleep or lie down with their heads in the same direction every time. It is most commonly seen at this age, although it can be seen as early as 6 weeks old. It generally starts to get better around 6 months of age because of better head control.

What are some risk factors?

  • Sleeping on their backs with their head in the same direction each time.
  • Congenital torticollis, a condition where the muscle in one side of the neck is shortened and tighter, leading to difficulty in turning the head.

There are some other risk factors, as shown in the table below:

Nelson’s Textbook of Pediatrics, 20th edition (page 2819)

Can you prevent positional plagiocephaly?

Yes, there are things you can do to prevent it, and also to treat it should it occur! I have listed the prevention and treatment options.

  1. Alternate positions: whenever your baby is on his or her back, whether that is during play or sleep, try to get your baby to lie on both sides of their head. There are a few tips to help you achieve this, outlined below. The earlier you start this, the more time your baby will have to get used to it!
    • During sleep:
      • Change the direction they are sleeping in each time they go to sleep. Babies usually look toward a light source or into the room, so if you change the sleep position (i.e., their head at the head of the bed, alternating with their head being on the foot end of the bed), they will likely turn their head naturally.
      • If you are using a mobile, change the placement of the mobile.
    • During play:
      • You can use brightly coloured or toys that make light or noise to get your infant’s attention and get them to turn their head in different directions minimizing the time on one side.
    • Hold your baby in different ways during feeding, playing, or sleeping.
    • Supervised tummy time! 10-15 minutes at least three times a day, or as many times they would like. This would also help with development of gross motor skills like rolling and sitting up.
  2. Physiotherapy: useful for repositioning strategies. Also, if your baby has torticollis, physiotherapy will help release the tightening on the affected side, allowing your baby to move his or her head more freely in all directions.
  3. Helmet therapy: can be used in severe cases. As the skull is growing rapidly in the first few weeks of life, the purpose of the helmet is to help development occur symmetrically. The protects the areas that are flat while the child’s skull grows into the flat spot. Helmet therapy can speed up symmetrical development of the skull compared to repositioning alone. In Canada, according to the Canadian Paediatric Society, the maximum age to consider helmet therapy is 8 months. There is minimal benefit after 10 months of age (Zitelli and Davis’ Atlas of Pediatric Physical Diagnosis, 6th Edition, page 892). However, it can be expensive and needs to be worn essentially all day for many months. It can also cause irritation, discomfort and pressure sores.

Interesting fact: right-sided plagiocephaly is more common, which is thought to be due to mothers being right-handed and baby being in right side down position to nurse causing flattening of that side. (Zitelli and Davis’ Atlas of Pediatric Physical Diagnosis, 6th Edition, page 892).

In a nutshell, positional plagiocephaly is very common, as babies lie on their backs and do not have great head control until 4 months of age. The natural course of positional plagiocephaly is that it improves overtime. Prevention can be through repositioning therapy and physiotherapy. Treatment includes the same, and if the asymmetry in skull shape is severe, helmet therapy can be considered.

I would love to hear your experiences with positional plagiocephaly. Did you have helmet therapy? Did you choose not to? What are your thoughts?

Toxic Stress: What’s Love Got To Do With It?

What is Toxic Stress?

Stress is a hard-wired response of our mind/body to certain situations.

Positive Stress: There’s a level of stress that is healthy, and can even be good, to be experienced as a child. At a mild level of stress that does not last long, a child can learn to overcome the stressful event and gain confidence in their own abilities. They can build resilience skills. This is a positive level of stress.

Tolerable Stress: When an infant/child experiences a higher degree of stress this can exhaust their coping mechanisms, and this can impact their development and how they cope with stress. If the stressful event is short lived, or there are protective factors such as a supportive caregiver to help them navigate their way through their stressful experience, this can help a child cope and protect them from the negative effects of stress.

Toxic Stress: At a severe level of stress, particularly if it lasts a long time, without supportive factors, a child’s development can be affected. This can impact their ability to learn, their ability to form healthy relationships, their ability to complete school and hold a job as well as their mental and physical health. Toxic stress can include abuse, financial strain on the family and intimate partner violence.

https://developingchild.harvard.edu/science/key-concepts/toxic-stress/

What can cause Toxic Stress?

Family stressors, trauma, financial difficulties, poverty, neglect, abuse, among others. A child’s ability to cope with the stress can change the impact the stressful event may leave on the child. The genetic makeup of the child can change the impact the stressful event can leave on the child. Moreover, the developmental stage at which the child experiences the stress can change the impact the stressful event leaves on the child.

How can toxic stress impact my child’s health?

There are complex mechanisms by which mental and physical health and wellbeing can be affected, resulting in chronic disease that can last a lifetime. Some of these negative effects include:

  1. Negative impact on child development
  2. Learning problems
  3. Behavioural problems
  4. Mental health problems such as depression
  5. Social problems
  6. Increase in infectious diseases
  7. Heart disease
  8. High blood pressure
  9. Diabetes
  10. Earlier adult death
  11. Premature aging

https://www.cdc.gov/violenceprevention/childabuseandneglect/acestudy/about.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fviolenceprevention%2Facestudy%2Fabout.html

Maternal mental health during pregnancy has been found to impact a fetus’ immune response, and chronic stress/anxiety in mother during pregnancy can lead to more illnesses in newborns.

So, what’s love got to do with it?

When I say love, I basically mean responsive caregiving. That could be from a parent, a guardian, anyone who is in a position to care for a child. When you think back to people who were there for you during a difficult time, those are likely the people that made a difference to how you got through it. Caregivers that provide support, unconditional love, a non-judgemental, understanding listening ear – they can all help mitigate the negative effects of toxic stress.

Animal models have helped understand the impact of supportive caregivers on the stress response. During the early period of a baby’s life, the family environment can impact how we respond to stress. In fact, even if we are genetically susceptible to negative stress responses (such as high levels of anxiety, reduced resilience, etc), our environment can work to impact which genes are turned on/off (epigenetics). That is, a supportive caregiving environment can affect the way our genetic code is expressed, to help a child mentally and physically cope with stress in a much healthier way.

In studies of rodents, those whose mothers were highly nurturing showed well regulated stress response in the body, whereas those who were born to low nurturing mothers showed a dysregulated stress response. A supportive environment provided at any time in a child’s life is beneficial, but there are also certain times this is more beneficial than others as their brains are developing.

The Science of Early Life Toxic Stress for Pediatric Practice and Advocacy (Pediatrics, Volume 131, Number 2, February 2013)

The Adverse Childhood Experiences Study

Also known as the ACE Study, is a study that investigated childhood abuse and family challenges and their impact on later life health and wellbeing. The higher the ACE score (which is based on factors that contribute to toxic stress), the greater your likelihood of developing health problems as a result. If you are curious about your own ACE score, check out the CDC Website on the ACE study, and scroll down to Survey Questionnaires.

Conclusion

So, there is some evidence that the environment in which we raise our children can impact not only their mental but also physical health.

Can you think of a time an event in your childhood left you stressed and how adults around you impacted how you coped with this stress? I would love to hear your thoughts!

Bronchiolitis

What is bronchiolitis?

The airway consists of a large tube, called the trachea, which breaks down into to smaller tubes (bronchi). These bronchi break down further into bronchioles, so, sort of like mini bronchi. It is these smaller airways that are affected in bronchiolitis. “Itis” means inflammation. So, bronchiolitis is inflammation of the smaller airways.

There is a build up of mucus which can block the smaller airways also. It affects children under the age of 2 years, as their airways are smaller.

What is the difference between bronchiolitis and bronchitis?

Bronchitis is caused by inflammation of bronchi, whereas bronchiolitis is caused by inflammation of the bronchioles. Bronchitis tends to occur in older children and adults.

What is the difference between bronchiolitis and the cold?

The common cold affects upper airways, including ear, nose and throat, whereas bronchiolitis affects lower airways.

What causes bronchiolitis?

Respiratory Syncitial Virus (RSV), among other viruses can cause bronchiolitis.

What are the symptoms of bronchiolitis?

Cough, stuffy and/or runny nose, fever, wheezing. Other, more serious symptoms include difficulty breathing, sucking in of the skin in the neck, in between the ribs or under the ribs, poor feeding or difficulty sleeping. Be sure to take your baby to the doctor/ER if any of the more serious symptoms occur.

How long does it last?

Like many viral illnesses, it usually lasts 7-10 days, but the cough can last up to a few weeks.

How is it treated?

If your doctor gives you the go ahead to look after your baby at home, there are several things you can do to help your baby through their infection (see previous post on getting your baby through respiratory illness). Sometimes, symptoms tend to get worse before they get better (for example, if your baby has RSV bronchiolitis, symptoms may get worse around days 3-5 of illness and then get better afterward).

  1. Saline nasal drops and aspiration (before feeds and sleep)
  2. Frequent, smaller amounts to drink
  3. Control fevers with tylenol/advil if your doctor has cleared you to use it
  4. Ensure immunizations are up to date
  5. Avoid other triggers and allergens (smoking and allergens can make breathing problems worse)
  6. Avoid sick contacts and practice good hand hygiene to avoid another illness
  7. Sometimes, babies can respond to inhalers (speak to your doctor to see if your baby may need them)

If your baby has severe symptoms including poor feeding, seek medical attention right away.

Literacy: Part One

Literacy refers to the ability to read and write and do basic arithmetic, which is divided into different levels based on one’s ability to understand and use the information to function within society and at work.

According to Statistics Canada and Human Resources Development Canada, literacy is measured on a score of 0-500 (5 Levels), with a minimum score of 300 required to be able to have a job and Level 3 to be the basic level at which an individual can function well in society.

Millions of Canadians cannot read well enough for daily activities.

What can we do about it?

Children are born with the ability to learn rapidly, as their brains are taking in information and making connections. What they learn in the first few years of their lives will set the foundation for the rest. Literacy skills are like a muscle – the more this muscle is worked, the more it will grow. If it is not worked, it will get weaker.

Children spend the first few years of their lives learning to read. After this, they read to learn.

Children learn language before they start school, and it is their caregivers they learn the most from during this time. Over the next few weeks, I will be discussing literacy and its importance, as well as how caregivers can help their children develop early literacy skills.

What are some effects of low literacy?

  1. School problems
  2. Not completing school
  3. Unemployment
  4. Negative impact on health
  5. Poverty

I will discuss this in more detail in the coming weeks.

I will leave you with this question: When should you start reading to your child?

Respiratory illness in babies

This is intended to be educational. This should not be used to substitute medical advice. If you have concerns about your child’s health, see your child’s doctor.

There are various causes for respiratory illness in babies, including having a cold, croup, bronchiolitis, or more severe infections. Some signs and symptoms include:

fever, cough, sneezing, runny nose, stuffy nose, breathing difficulty, noisy breathing, fast breathing, sucking in of areas in the neck, between the ribs and below the ribs, turning blue in the mouth, wheezing, lethargy, reduced appetite, not peeing as much or as frequently

If you have concerns that your baby has a respiratory illness, please see your baby’s doctor.

5 ways to get your baby through a respiratory illness

This is intended to be educational and should not be substituted for medical advice. If you have any concerns, please see your child’s doctor.

One key feature to keep in mind about the baby’s airway, which is different from the older child and adult is this:

babies are obligate nose breathers, which basically means they breathe exclusively from their noses. We can also breathe from our mouths as we get older and therefore this advice really is intended for babies.

That being said, you can imagine, when a baby gets an illness like cold, and their noses become blocked, they can have a hard time with feeds and even sleep. Try to imagine eating/drinking or sleeping if your nose is blocked and you could not breathe from your mouth.

Here are 5 tips to get your baby through a respiratory illness:

  1. Saline drops in the nose with aspiration of mucus – the ideal time to do this is before feeds/naps.
  2. Ensure your baby is drinking well and making good number/volume of wet diapers. Fluids in smaller volume, more frequently will help also. You should speak to your doctor about whether pedialyte is an option for your baby (usually depends on age).
  3. Ensure your baby gets plenty of rest. But, if they are not waking to feed, this could signify lethargy and your baby should be taken in to see their doctor immediately.
  4. Control fever with tylenol/advil as long as your doctor has cleared your baby to use these.
  5. Make sure your baby is fully immunized, they are not in contact with other sick people, and everyone practices good hand hygiene. Keep in mind that having one respiratory illness doesn’t mean your baby cannot catch another illness.

*For some respiratory illnesses, your doctor may have prescribed puffers, in which case, be sure to use them as directed.

Protect your children from the flu…

In short, influenza is far more of a concern to the Canadian population than the coronavirus. Across Canada, from August 2019 to January 18, 2020, there have been 12,165 cases of Influenza A and 8,423 cases of Influenza B isolated https://www.canada.ca/content/dam/phac-aspc/documents/services/surveillance/respiratory-virus-detections-canada/2020-2021/week-3-ending-january-18-2020/pub1-eng.pdf.

Why is influenza a concern?

Influenza is a virus that has the potential to cause significant illness, hospitalization and even death. Children under the age of 5 years old are at highest risk of severe illness.

When is flu season?

Cases of the flu start to rise as early as October to as late as May and peak between December to February.

How can we protect our children?

I will only be discussing the flu shot and not the nasal spray. The flu shot is not effective in babies under 6 months of age, but here are some things you can do:

  • Pregnant women get your flu shot: immunity can be passed to your baby through the placenta
  • Breastfeeding women: immunity can be transferred through breastmilk
  • When your baby turns 6 months old, get them their flu shot. If a child is younger than 9 years of age when they get their first flu shot, they will need to get a second one a month later. After this, it should be once a year.
  • The flu shot should be given once every year, as the flu virus changes, and there are highly educated people working very hard to make sure the vaccine also changes to keep up!

You cannot get the flu from the flu vaccine

The flu shot is not live and therefore you cannot get the flu from it.

Other general tips:

  1. Handwashing is very important. The virus can stay alive on surfaces for hours. If you are sick, make sure you wash your hands to prevent spread also.
  2. Avoid sick contacts.
  3. If you are sick, try to minimize spreading the infection, i.e., cover your mouth when you cough, don’t go to school/work

Vitamin D for your baby

Sunshine! When the sunlight hits our skin, vitamin D is converted to an active form that can be used by the body!

Vitamin D is important for your baby to build strong bones and teeth. When vitamin D levels are low (deficiency), this can have a negative impact and in its most severe form, vitamin D deficiency can lead to a condition called rickets.

The daily dose recommended for primarily breastfed babies is 400IU daily.

Babies are at risk of vitamin D deficiency when they are exclusively breastfed because only a small amount of vitamin D is transferred in breastmilk. Therefore, breastfed babies should get 400IU of vitamin D a day. Formula is fortified with vitamin D, so exclusively formula fed babies do not need supplementation with vitamin D (unless they have other risk factors). Discuss this with your doctor.

Sometimes, babies are fed with breastmilk and formula, and in this case, whether to add vitamin D supplement or not depends how much breastmilk the baby is getting. It would be wise to discuss with your baby’s doctor regarding whether you need to supplement your baby with vitamin D.

If you are pregnant or breastfeeding, you should also consider vitamin D supplementation and this can be discussed with your doctor.

Other sources of vitamin D:

  • milk has vitamin D added to it, and once your baby is on 500mL/day of whole milk, they would be receiving adequate vitamin D, so supplementation can be discontinued. Remember, not to start cow’s milk until at least 9 months of age and with advice from your doctor.
  • fish such as tuna, salmon
  • egg yolk
  • fortified cereals
  • fortified orange juice

Interesting facts:

  • Living in countries such as Canada, we may lack adequate sunlight, especially in the winter, and would require supplementation in our diets or in vitamin form.
  • The lighter your skin, the more effective this conversion, so those who live north of 55 degrees latitude, and those who have darker skin, would need supplementation, and to consider larger doses (i.e. , 800IU daily) in the winter time.

This is intended for information purposes and should not be substituted for medical advice.

Cow’s Milk Protein Allergy (CMPA)

This information is intended solely for education purposes. It is in no way intended to be medical advice. Should you require medical advice, please contact your child’s doctor.

Cow’s Milk Protein Allergy (CMPA) is the commonest food allergy in infants. Not to be confused with lactose intolerance.

Symptoms can include:

  • Skin: rash (including eczema).
  • Respiratory: runny nose, nasal congestion, sneezing.
  • Gut: loose bowel movements, frequent bowel movements, constipation, blood in stool, mucus in stool, reflux, vomiting, increased gas.
  • Behaviour: food aversion, colic, fussiness.
  • Growth: poor weight gain.

Symptoms of severe allergy or anaphylaxis include swelling of face/tongue/lips/throat, hoarse voice, breathing difficulty, dizziness, lightheadedness, fainting, lethargy, loss of consciousness. If there are any of these symptoms, call the local emergency service (i.e., 911)/go to ER.

Under advice and supervision of a doctor, treatment of CMPA includes a 2 week trial of:

  • If exclusively breastfeeding: mother should go on an elimination diet (eliminate dairy, and sometimes also soy).
  • Formula: Nutramigen or Alimentum.

Most children grow out of CMPA and milk can be re-introduced at a later date that can be discussed with the child’s doctor.

Why does my baby have reflux?

This information is intended solely for education purposes and is in no way to be substituted medical advice. If you have concerns about reflux in your baby, take your baby to their doctor.

In simple terms, their gut is still immature.

The mouth is connected to the stomach through the esophagus, essentially a tube lined with muscle. In adults, the esophagus is longer and has something called a “lower esophageal sphincter” (LES) at the bottom before it enters the stomach, which prevents food from moving back up.

In babies, the esophagus is shorter, the muscle has not fully matured and the LES has not fully developed yet, so food easily moves in both directions. When food moves up the esophagus, it can cause discomfort. Many babies with reflux are happy and do not have symptoms. In fact, they may even feel relief once they spit up.

For these reasons, keeping your baby upright after meals uses gravity to help keep food moving downward.

If your baby has symptoms of severe reflux, including arching their back, discomfort or crying with feeds or not gaining weight, they may have gastro-esophageal reflux disease and your doctor can help.

Reflux symptoms tend to get better as the gut matures overtime, and also around 6 months, as your baby is sitting more and eating more solids.

5 factors that can contribute to reflux:

  1. Overfeeding – consider feeding smaller amounts more frequently
  2. Gulping in a lot of air – consider burping at regular intervals
  3. Position – lying down too soon after a feed, consider keeping elevated at least 30 min-1h after a feed
  4. Age (due to maturity of the gut) – generally resolves with maturity of muscles and sitting upright
  5. Fluid vs. solids – The younger they are, they drink mainly fluids. Reflux tends to get better with solid food introduction.