He gave me a little grin with his head cocked to one side. Yes, it was an adorable introduction to this 9-month-old new patient, but when the head tilt persisted through our entire first visit, mom and I discussed her son's history.
The boy had been diagnosed with torticollis or wry neck early in infancy and had already been checked by an orthopedic specialist who found no bony abnormalities or neck masses. His parents had been diligent, but their little guy's head tilt continued to be noticeable despite home exercises.
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The child's physical exam was otherwise unremarkable, and while in the outside world you never want your child to be labeled "unremarkable," in medicine, that's always a good thing. My young patient was both active and interactive with a reassuringly normal neurologic exam.
Mom was interested in beginning a formal physical therapy program to help stretch the infant's tight neck muscles and improve his range of motion, and I agreed. I also recommended an evaluation by a pediatric ophthalmologist.
Abnormal head position can occasionally be associated with subtle vision abnormalities. Experts at the American Association for Pediatric Ophthalmology and Strabismus describe several ocular conditions which, when present, can lead small children to tilt the head in an effort to help them see more clearly.
Children with eye misalignment or strabismus may head tilt to avoid seeing double, while those with eyes of different strengths may turn so that the stronger eye is closer to the object of interest. Some children who need glasses may also tilt so that the eyelids narrow, very much like affected older kids and adults squint to briefly improve their vision.
The American Academy of Pediatrics reports that while head tilt can be found in children with eye disorders, hearing deficits, acid reflux, throat or neck infections, or rarely, brain tumors, the No. 1 cause of early head tilt is congenital muscular torticollis, a condition usually seen within the first six to eight weeks of life.
In literature from the Hospital for Special Surgery in New York, orthopedic surgeon Shevaun Mackie Doyle explains that congenital muscular torticollis, which has an incidence as high as 16 percent, will feature one-sided shortening of an infant's sternocleidomastoid, the long straplike muscle of the neck.
Doyle notes that the cause of this muscle shortening is not completely understood, but may be due to in-utero crowding, decreased blood supply or trauma to the SCM, or to a baby's frequently preferred head positioning after birth. The good news is that surgical correction of congenital torticollis is rarely needed since physical therapy is shown to be effective in 90 to 99 percent of cases.
The New York specialist advises parents to promote frequent "tummy time" while a baby is awake, encourage their little one to look to both sides and use both hands and feet during playtime, and avoid keeping an infant in the same position for long periods of time.
• Dr. Helen Minciotti is a mother of five and a pediatrician with a practice in Schaumburg. She formerly chaired the Department of Pediatrics at Northwest Community Hospital in Arlington Heights.