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Neurosurgery Update: Plagiocephaly vs. Craniosynostosis—When to Refer · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

• 0:00
  As a parent, like, well, less is more. But like in this case,
• 0:03
  like, well, yes, but actually if there's something more could be better.
• 0:08
  And if there's something, it will get worse over time. And when we diagnose
• 0:13
  it early, we can fix it earlier.
• 0:15
  You can't be too cautious when it comes to your baby's head shape.
• 0:17
  Exactly. And we have a really nice setup where it's us. We have the head shape
• 0:21
  clinic. We have our mid-level providers.
• 0:25
  And the setup that we have at University Health, we see them almost on the same
• 0:30
  day that we get the phone call.
• 0:32
  We get them in and we get, when we need to get the imaging, the head CT team
• 0:36
  gets them in really quickly and there's no sedation required because babies,
• 0:41
  when they drink milk, they're in their milk coma, they go to sleep and it happens
• 0:44
  in two minutes and it's done.
• 0:46
  I think that the most important thing is like when a mom, especially when it's
• 0:50
  not a first time mom, when moms have multiple kids and when the mom's like, something's wrong.
• 1:11
  Children's Hospital. Today, I'm thrilled because here in the podcast studio
• 1:16
  with me is Division Chief of Pediatric Neurosurgery at UT Health San Antonio,
• 1:21
  Dr. Isabella Tereshevitz.
• 1:24
  Dr. Tereshevitz, or Dr. T, as you're known, thank you so much for being here
• 1:28
  in the podcast studio. Thank you for having me.
• 1:31
  I know you're so busy and you've been working on some big cases,
• 1:35
  and I so appreciate you taking the time to talk to me. Thank you.
• 1:39
  So the critical treatment window for infant head shape abnormalities,
• 1:44
  helmet therapy, and preventing major surgery through early detection is what
• 1:48
  we're talking about today.
• 1:50
  Can you explain the difference between positional plagiocephaly and craniosynostosis
• 1:56
  and why distinguishing between the two is so crucial?
• 2:00
  Yes. So craniosynostosis is the premature fusion of a suture,
• 2:05
  which is like a line between bone plates.
• 2:09
  And when this happens, it creates abnormal increased pressure in the brain and abnormal head shape.
• 2:16
  And so it is very different than positional plagiocephaly, which is a flatness
• 2:21
  on the back of the head when the babies sleep on the back of their heads.
• 2:26
  And so distinguishing a true craniosynostosis is really important because we
• 2:31
  need to refer them to a pediatric neurosurgeon for an early intervention.
• 2:36
  We like to do those surgeries at three to four months of age so we can offer
• 2:41
  a minimally invasive surgery.
• 2:43
  Now, sometimes when they're not diagnosed early, we get them later for the diagnosis.
• 2:48
  And when we get them later, saying at six, seven, eight months of age,
• 2:52
  then we have to do a bigger surgery and we cannot offer the minimally invasive surgery anymore.
• 2:58
  And so it's important to diagnose those patients early on so we can do a smaller
• 3:04
  incision and patients can stay in the hospital for a shorter period of time.
• 3:08
  They will not require a big blood transfusion. And I think overall,
• 3:13
  it's just a better surgery to offer. Because it's an endoscopic?
• 3:17
  Yes, immunally invasive and endoscopic depending on the suture that is involved.
• 3:21
  We use an endoscope for the sagittal suture when it's involved.
• 3:24
  And when it's a shorter suture, such as metopic and coronal switchers,
• 3:27
  we don't have to use the endoscope, but we use minimally invasive instruments.
• 3:32
  So, Isabella, who is responsible or who is it up to to make that crucial decision
• 3:39
  that this baby needs to get in and see a neurosurgeon quickly?
• 3:42
  Is it the newborn team, the parent, the pediatrician?
• 3:46
  I think it's a combination of multiple people involved in that child's care.
• 3:51
  I would say initially, whomever feels like there's something abnormal looking should send the baby to,
• 4:00
  a head-shaped clinic or the orthotics clinic or the craniofacial clinic or the neurosurgery clinic.
• 4:07
  So I would not wait because anytime you have a craniosynostosis concern,
• 4:11
  it won't go away with time. It will just get worse.
• 4:15
  And so we have a head-shaped clinic here at UH. we have a craniofacial clinic
• 4:19
  that is nationally recognized.
• 4:21
  We also have the helmet clinic, so the orthotics clinic for positional plagiocephaly,
• 4:26
  and that fits our kiddos for helmets after the craniosynostosis surgery is done.
• 4:32
  So anytime that a child has an abnormal head shape, I would say the parents
• 4:37
  might be concerned, the pediatrician, if the pediatrician is concerned,
• 4:40
  if the nursery doctor that sees the babies, the pediatrician sees the babies
• 4:44
  initially should send us a referral.
• 4:46
  Anyone, a PT that works with a child, an OT that works with a child has a concern.
• 4:52
  Let's just send that referral into our coordinator and we'll see the child sometimes on the same day.
• 4:58
  So you just met my daughter who's in college and after 35 hours of labor 20
• 5:05
  years ago, so she had to be vacuumed out.
• 5:09
  So she had kind of a cone head when she came out, which was a little alarming,
• 5:13
  but it turned out to be fine. So that's totally...
• 5:17
  Yes, that's totally fine. That goes away after a week or so.
• 5:21
  But a craniosynostosis is something that doesn't go away because that suture is fused.
• 5:26
  And as the head grows, that abnormality just gets worse and worse.
• 5:30
  So whenever you feel a ridge or whenever the abnormal head shape gets more accentuated,
• 5:36
  then the patient should be referred to neurosurgery.
• 5:38
  And there's a simple way of seeing this.
• 5:41
  I would say anytime a parent or a practitioner looks at the patient's head from
• 5:46
  above and it's either a head, so normally a head should be pretty much round.
• 5:51
  And we have a fontanelle that's right behind the hairline or the imaginary hairline
• 5:56
  if the baby's completely bald.
• 5:58
  So we have a soft spot there. And so the metopic suture is the suture that we
• 6:02
  have splitting the forehead in half.
• 6:06
  And so if looking from above, the forehead is not flat but has a triangular.
• 6:11
  Head shape, pointy head shape, that's not normal. We shouldn't have a head shape like that.
• 6:16
  If looking from above, the head shape looks like a football,
• 6:21
  very long, oblong head shape, that's not normal either.
• 6:24
  And then if we look at the face of the baby and the forehead is flat,
• 6:30
  the nose is crooked, and the ears are asymmetrical, that's also not normal.
• 6:34
  It's not going to go away on its own. And if initially, yes,
• 6:38
  for sure, the pediatrician will see the baby very frequently because you have
• 6:42
  to make sure that the infant is keeping its weight and, you know, all those things.
• 6:47
  You see that baby as a pediatrician very, very often.
• 6:50
  If it gets worse or if you're keeping track of that and it's not getting better,
• 6:54
  then you send that baby to a head shape clinic.
• 6:57
  So Isabella, what's the difference between a baby who comes to you at three
• 7:01
  months versus 12 months?
• 7:03
  So at three months, we will offer an endoscopic minimally invasive surgery,
• 7:07
  and at 12 months, it's a vault surgery.
• 7:09
  So the vault surgery is an ear-to-ear incision.
• 7:14
  And we do a planned vault surgery, which means that we're expanding the entire
• 7:20
  skull to create more volume because we miss that window of the baby's head growth.
• 7:26
  And we will create an in-situ volume expansion. And then after that surgery,
• 7:32
  the baby will not need to wear a helmet because we would have expanded that
• 7:37
  volume right away in surgery.
• 7:39
  A three-month-old baby will just remove that suture and close this small incision
• 7:45
  and then put the baby in a helmet with gaps within the helmet to allow head
• 7:49
  growth in a specific direction.
• 7:51
  It's like a mold that the helmet will have to be worn for 23 hours a day for
• 7:56
  12 months, and then the head will grow in a specific direction and create,
• 8:04
  that added volume that the baby needs for his head.
• 8:09
  Are these abnormalities usually noticeable at birth, like with my daughters
• 8:13
  that turned out to be fine, or do they develop over time?
• 8:17
  They're pretty much noticeable. When you know what you're looking for,
• 8:20
  I see them as soon as I walk into my clinic room when I see those patients. Really?
• 8:27
  So, yes. And that's why I go out to clinic practices and I show them those skull
• 8:32
  models so they can, once you see one, you know exactly what you're looking at.
• 8:36
  Sometimes it's kind of hard to understand what you're looking at.
• 8:40
  There's something not right with that head shape. But once you see one,
• 8:44
  you absolutely know what you're looking at.
• 8:46
  But what I've described earlier with the triangular forehead,
• 8:52
  so the most frequent head abnormality is sagittal and then it's metopic.
• 8:56
  So when you look from above, it's that football long head shape.
• 8:59
  That's sagittal craniosynostosis, also known as scaphocephaly.
• 9:03
  And the metopic is the second most prevalent one.
• 9:06
  Metopic craniosynostosis or trigonocephaly because it looks like a triangular
• 9:10
  forehead. Those are the two most frequent ones that we see in kiddos.
• 9:15
  So are there subtle findings at birth that clinicians sometimes dismiss as molding
• 9:21
  from delivery? I know a lot of our listeners see 40 patients a day.
• 9:25
  They've got so many things going on and of course no one wants to miss anything. Sure.
• 9:30
  Well, metopicraniosynostosis, you can't really miss this for molding because
• 9:34
  when you have a triangular forehead.
• 9:37
  And it's a clear triangle. It's a clear triangle. And maybe what can be done
• 9:42
  is if you're questioning it, you know, chat GPT, Google it and look for images
• 9:48
  because it's very striking.
• 9:50
  Scaphalocephaly sometimes can be mistaken for molding.
• 9:54
  I would say if you are the practitioner and you're not sure,
• 9:58
  you can put your fingers over the midline and feel a ridge. There's a clear
• 10:01
  ridge, a bony ridge that can be felt when the suture is fused.
• 10:05
  You don't have that in normal babies that have simple molding. Mm-hmm.
• 10:10
  So in your experience as a neurosurgeon,
• 10:14
  at what well-child visit do these concerns most commonly emerge?
• 10:18
  They're pretty much there from birth. Really?
• 10:22
  Okay. Yes. So I would say, especially when the parents are concerned,
• 10:28
  I would listen to those concerns.
• 10:30
  And as soon as they are voiced to the pediatrician, I would send them to the
• 10:36
  head-shaped clinic and the craniofacial
• 10:37
  clinic. We're always happy to see those babies in the families.
• 10:41
  And if it's normal, I'm happy to reassure a family.
• 10:44
  So to my next question, when should a pediatrician stop assuming a head shape
• 10:48
  issue will round out on its own? Never? Never.
• 10:52
  That's it. I mean, that relieves a lot of stress. Yes. And the funny thing is
• 10:57
  that I give my cell phone number to all the pediatricians in our catchment area, in our community.
• 11:03
  So if they want to text me, if they want to text our coordinator,
• 11:07
  they can call us. We will see those families as soon as we can,
• 11:10
  and we see them within that same week, and we'll reassure the families,
• 11:14
  and everyone will be happy.
• 11:16
  And I'll put your contact information, whatever we can, in the text for the podcast.
• 11:21
  And another message I know when I saw one of the talks you gave recently is.
• 11:27
  Don't do imaging on your own.
• 11:28
  So the main message that I want to send is don't do x-rays because x-rays is
• 11:36
  something that is not recommended.
• 11:39
  When you do x-rays for a craniosynostosis, it's two, three views,
• 11:43
  and that ends up being more radiation than a 3D low radiation protocol.
• 11:48
  And so just send the babies to us. I can recognize a craniosynostosis diagnosis
• 11:54
  with just looking at the patient clinically.
• 11:57
  And then we can order the CT even when the patient sees us in clinic,
• 12:02
  especially when the tiny babies, as I said, when the moms either feed them or
• 12:07
  give them a bottle, they will sleep for a couple of minutes.
• 12:10
  And then we can slide them in the CT scanner for a low radiation protocol.
• 12:14
  Call and then it's done on the same day and we get the confirmation for the
• 12:20
  diagnosis very quickly.
• 12:22
  And that helps us plan our surgery as well.
• 12:25
  Are there any other red flags we didn't go over that would prompt an immediate referral?
• 12:31
  Any regression of milestones that can happen because of increased intracranial pressure.
• 12:38
  And are there any certain head-shaped patterns that are commonly missed?
• 12:42
  Is the triangle forehead commonly missed? The football, it's a horizontal football
• 12:48
  head looking down, right? So it's an elongated head shape.
• 12:52
  Sometimes the bicoronal craniosynostosis is missed.
• 12:58
  It doesn't happen very often, but I have seen several ones that have been missed. It looks...
• 13:06
  It looks like a square head shape. Again, it's an abnormal head shape.
• 13:11
  When you look at that baby compared to their siblings, it's absolutely not normal.
• 13:17
  So the mom was concerned. The pediatrician didn't really know what to do with
• 13:20
  that head shape, but ended up
• 13:22
  sending the patient to us because there was something not normal looking.
• 13:27
  And it was early at two months, so ended up being referred to us early and having
• 13:33
  a minimally invasive surgery.
• 13:35
  So I applaud the pediatrician for recognizing that. So I think that anytime
• 13:39
  that there's something that is not normal looking, just send it to us and we'll
• 13:42
  be happy to take care of it.
• 13:44
  How much should clinicians rely on head circumference versus head shape?
• 13:49
  So a single suture craniosynostosis, if it's just one suture that is closed,
• 13:55
  the rest of the sutures will overcompensate. And most of the times the head
• 13:59
  circumference will be normal versus slightly higher.
• 14:03
  So just looking at that, I don't think we can make a diagnosis.
• 14:09
  Multiple suture craniosynostosis. So kiddos that have a syndrome,
• 14:13
  they tend to have a smaller head.
• 14:16
  So just one suture, you can't say much, but multiple sutures,
• 14:20
  the head will be small, and then
• 14:22
  you have an increased risk of having even more pressure in your brain.
• 14:28
  Let's talk about helmets. When is a helmet appropriate versus unnecessary?
• 14:32
  So for the minimally invasive surgeries, you need a helmet to guide the head
• 14:39
  growth in a specific direction, And also we remove a significant amount of bone
• 14:43
  and then it's for protection until the bone grows.
• 14:46
  So after the surgery. Absolutely.
• 14:49
  For the big vault surgeries, we don't need a helmet because we plate the bones
• 14:53
  internally. So it's solid enough that the patient does not need a helmet.
• 14:58
  Now for positional plagiocephaly, which is when the head is flat because of
• 15:04
  positioning. Or flat head syndrome. Exactly.
• 15:07
  When you have a flat head because of sleeping on one side and because you have
• 15:11
  torticollis, so when you have your neck is crooked and you need physical therapy
• 15:14
  to straighten your neck and then you have your flat head, then you will need
• 15:18
  a helmet sometimes to kind of help reposition,
• 15:21
  your head and grow your head in the other direction.
• 15:24
  So those are the conditions when you will need a helmet.
• 15:28
  Can you tell us about the ideal age window for helmet therapy to be the most effective?
• 15:33
  So when you are very young, because the skull is very pliable and very soft,
• 15:38
  the softer the skull, the better you will respond to helmet therapy.
• 15:43
  If you're older, closer to 8, 9, 10 months of age, then your bone,
• 15:49
  as a baby, your bone is not soft anymore as much as when you're younger,
• 15:53
  and then the helmet therapy is not going to work as well.
• 15:58
  So as a pediatrician, if you see a flathead at 10 months of age and you're referring
• 16:02
  to the helmet therapy group, most probably they will tell you,
• 16:06
  well, at 10, 11 months, if you have a flathead, it's pretty much what your head
• 16:11
  will look like because the helmet therapy won't work.
• 16:14
  Really? So if you do find a patient that has a flat head and the family cannot
• 16:21
  counterposition and do the counterpositioning measures to help,
• 16:25
  remold the head with just simple counterpositioning, then send to the helmet
• 16:29
  therapy group early on so they can work on the helmet therapy being effective,
• 16:34
  early, early on when the babies are young, when the skull is soft,
• 16:38
  and then there's a lot of growth potential in the skull and the brain.
• 16:43
  Otherwise, when they're older, the helmet won't work.
• 16:46
  And we will have an episode on our sister podcast, Pediatrics Now for Parents,
• 16:51
  and we'll mention tummy time. I know our pediatrician listeners,
• 16:55
  of course, know how crucial tummy time is. Absolutely.
• 16:59
  You can't stress that too much with a patient, right?
• 17:03
  Absolutely. Tummy time is important, and especially for kiddos that have torticollis,
• 17:07
  I tell the families, PT will show you how to stretch the neck.
• 17:10
  Every time you do a diaper change, stretch the neck because that's also very
• 17:14
  important. Tummy time is also important for them to learn how to move their
• 17:18
  neck, how to have a stronger core.
• 17:21
  And all of these things are important for the fat head.
• 17:25
  Are some babies mistakenly sent for helmets when they actually have craniosynostosis?
• 17:30
  Yes, yes. And that's when our partners within the orthotics team send those
• 17:36
  babies back to me for a diagnosis of craniosynostosis.
• 17:40
  What do you wish pediatricians knew about timing referrals for helmet therapy?
• 17:44
  Timing is crucial. So the earliest the time a diagnosis, the better it is for
• 17:51
  outcomes and for a smaller surgery.
• 17:55
  And if you're unsure refer absolutely the sooner the better.
• 18:01
  We talked about imaging so it doesn't you don't really need any x-ray just send,
• 18:08
  never x-ray absolutely do not order any x-rays if there's one thing i would
• 18:13
  want everyone to remember from this podcast is when in doubt send to neurosurgery,
• 18:19
  and when in doubt do not order x-rays just send to neurosurgery we will be happy
• 18:24
  to see the patient in our head-shaped clinic, in our orthotics clinic,
• 18:28
  in our craniofacial clinic, and we will take care of the imaging.
• 18:32
  Because they also don't want to send a patient unnecessarily too,
• 18:37
  but in this case, just send. There's no such thing as unnecessarily. That's a good point.
• 18:43
  And there's no other imaging that they should try to get? No.
• 18:47
  Can you tell us just quickly what actually changes anatomically once the treatment window is missed?
• 18:54
  For the minimally invasive?
• 18:56
  So if I cannot do the minimally invasive, then I will do the bigger surgery.
• 19:00
  And again, we are an expert center for any type of craniocinostosis.
• 19:05
  So we have amazing results with the bigger surgery as well.
• 19:09
  So I'm just thinking with my parent hat right now, if this was my child,
• 19:14
  I would want the minimally invasive just for the length of stay in the hospital,
• 19:21
  for the minimally invasiveness of it, the smaller incisions.
• 19:26
  And, you know, in the future, when that child, when the mom and the child or,
• 19:31
  the dad and the child are at HEB shopping, no one sees those incisions,
• 19:35
  right? So it's just nicer, I think, overall.
• 19:39
  No one even knows that they've had surgery because those incisions, you can't see them.
• 19:44
  So if this is something that we could offer to a family, that's what I would want for my family.
• 19:50
  So I would love to offer this to any family that has a craniosynostosis condition.
• 19:54
  Now, if they come to us later, and I've had patients that came to us at 10 months,
• 20:00
  12 months, 2 years, 3 years, even six years with a craniosynostosis condition that required surgery.
• 20:05
  So we've done it at that age, but it requires a bigger incision and it's a bigger surgery.
• 20:11
  And patients have done great and they've had amazing outcomes,
• 20:15
  but it is a big incision. It's from one ear to the other. It's a wavy incision.
• 20:20
  And for the rest of your life, there is a scar that is more visible.
• 20:25
  Much, much bigger recovery, longer stay in the hospital, more blood loss,
• 20:30
  and it's a more difficult recovery.
• 20:32
  So how do you cancel families who think the asymmetry is just cosmetic?
• 20:39
  So multiple articles have been published showing that it is related to increased
• 20:45
  intracranial pressure.
• 20:47
  And so to quote the numbers, for single suture craniosynostosis,
• 20:52
  kids have abnormal pressure in at least 45% of the cases. Which kid will have it? We don't know.
• 20:59
  And what we have seen in our patient population is that once we do the surgery,
• 21:05
  after several months, when they come and see us in clinic, they just catch up
• 21:09
  on their milestones and they just do so much better.
• 21:12
  So which parent would not want that?
• 21:18
  And craniose nososies patients have, you know, research has shown that they
• 21:23
  have issues with speech, developmental delays. So this is associated with intracranial pressure.
• 21:28
  So when you open up those sutures and you relieve that pressure,
• 21:32
  everything kind of falls into place and gets better.
• 21:36
  What's the biggest misconception parents may have about infant head shape?
• 21:41
  Do you find that, moreover, it seems like it'll probably be fine thinking that
• 21:46
  when it's not? No, I think that they come to a neurosurgery office and they
• 21:49
  think it's going to be brain surgery, when technically it's bone surgery.
• 21:53
  So it's not as dramatic, but it is a serious surgery.
• 21:58
  And the other thing that we tell them is that we have a multidisciplinary team.
• 22:03
  It's the craniofacial team where you are followed for the first five years of your child's life.
• 22:09
  And you have a multidisciplinary team that will track the milestones and the
• 22:14
  outcomes for the first five years. And at some point, you will get a developmental
• 22:19
  assessment, a speech therapy assessment.
• 22:23
  You know, a dentist will be following you, an orthodontist will be following
• 22:26
  you, ENT will be following you, plastics, OMFS, neurosurgery.
• 22:30
  So it's a global team, and that team has specific things that we're following
• 22:36
  to make sure that you're followed in a specific way, that everything is known.
• 22:45
  To send you to referrals when you need specific services to make sure that everything is done correctly.
• 22:51
  What gives you hope about awareness and early detection improving? What gives me hope?
• 22:57
  I mean, when I see the outcomes of our patients, I think that we're offering
• 23:03
  an amazing service line to our patient population.
• 23:05
  And then when I see early referrals, when I see kiddos that come in to us when
• 23:10
  they're two weeks old, three weeks old, I feel like our pediatricians are recognizing
• 23:16
  the diagnosis early on and it's working.
• 23:21
  What inspired you to become a neurosurgeon? It must be so fulfilling.
• 23:25
  Every day you're helping a child, helping a baby to have a much better life.
• 23:31
  You know, I thought about this recently because initially I wanted to be a fashion
• 23:34
  designer. Oh, really? Yes. Because you traveled to Paris, I hear, to shop.
• 23:40
  I worked, I studied in Paris, but no. You did? I did. You studied fashion? No, no, no medicine.
• 23:48
  But I really wanted to do craniofacial. Once I was in medicine,
• 23:53
  that was my thing. So craniofacial is my passion. And there you go.
• 23:56
  You're just like, this is it. I do arts and crafts with heads. I make them pretty.
• 24:02
  So it's an art form. Yes. And then you also, I know you did a brain surgery
• 24:08
  recently for a tumor. You do that as well. We do that. We do tethered cords
• 24:12
  and spina bifida. We do a lot of trauma.
• 24:15
  My partner and I, we take care of tethered cords. We do a lot of spine trauma,
• 24:19
  brain trauma, tumors, hydrocephalus.
• 24:22
  We just take care of it all.
• 24:24
  And we have a team of female pediatric neurosurgeons. Absolutely.
• 24:30
  That's pretty awesome. I like to promote on Pediatrics Now having a life outside of medicine.
• 24:35
  Do you want to mention a couple of things or what you like to do that helps you unplug?
• 24:40
  I don't say balance anymore because what is balance? Who's balance?
• 24:44
  Well, I have a blended family. We have four kids.
• 24:49
  I also am a mom of a child with special needs. So I understand families that
• 24:54
  have challenging medical situations.
• 24:57
  And so what do I do to unplug? I have a Great Dane, a big dog.
• 25:02
  We also go to the ranch once in a while. We travel. And where's your ranch?
• 25:06
  Is that in Texas? Yorktown, yes.
• 25:09
  I cook. I like to cook. I'm a good cook. So sometimes I think that if I was
• 25:14
  not a neurosurgeon, maybe I should have been a cook.
• 25:16
  I like to have friends over and we cook for them. So we like to entertain and we like to travel.
• 25:23
  Do you have a favorite dish you like to make? Sea bass. Ooh.
• 25:26
  Yes, sea bass and seafood.
• 25:29
  And I also once every two, three months or three, four months,
• 25:32
  I see my best friends who are in Montreal. So we meet somewhere around the world
• 25:38
  and we just have a girl's trip.
• 25:40
  Are you from Montreal? Yes.
• 25:43
  And then what brought you to the United States? My job.
• 25:47
  I was recruited here to do pediatric neurosurgery. So you guys got me here for my job.
• 25:52
  I know that the program has really grown and is thriving. Yes.
• 25:57
  And what's your dog's name? Great Danes. Buddy.
• 26:01
  And in this podcast, we talk about for pediatricians, it's a review so that
• 26:07
  you can catch this early, which is so crucial.
• 26:10
  There's so much pressure on pediatricians, so much coming at them,
• 26:14
  but it's this critical window at about up to about three months.
• 26:17
  Yes. So for me, I would like to see them early on. So one month,
• 26:23
  two months, three months. I do surgeries up to six months.
• 26:27
  The most common craniosynostosis are sagittal and metopic. So sagittal is a
• 26:32
  long football head shape. Metopic.