Latest / Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner / Shaping the Standard: A Cranial Remolding Pioneer on Diagnosis, Treatment & Coverage

Transcript

Shaping the Standard: A Cranial Remolding Pioneer on Diagnosis, Treatment & Coverage · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

• 0:02
  Today, we're talking about cranial remolding, a topic many pediatricians see
• 0:07
  regularly, but one that can still raise important questions about timing,
• 0:11
  diagnosis, and treatment.
• 0:13
  I'm joined today by Jim Brookshire, Clinical Director of the Cranial Remolding
• 0:18
  Program in the Department of Neurosurgery here at UTHealth San Antonio.
• 0:23
  He's an internationally recognized expert in positional deformities.
• 0:27
  His research has helped establish treatment guidelines that are now recognized as standard of care.
• 0:34
  Jim, thank you so much for joining me here in the podcast studio.
• 0:38
  Thanks for having me, Holly. I'm really, really looking forward to our time
• 0:43
  here, and this is going to be a lot of fun.
• 0:45
  Working here, doing what you do, you say you were born to do this?
• 0:50
  I'm an orthotist and a prosthetist.
• 0:53
  Prosthesis or artificial limbs is, that's kind of the glory,
• 0:58
  you know, you got the Paralympics, you're helping people walk.
• 1:02
  There's big reward, which is wonderful. I'm not taking anything away from that by any means.
• 1:08
  That's what everyone wants to do, especially with Dancing with the Stars.
• 1:11
  You know, you see, you know, someone with a prosthesis up there and they're dancing. It's amazing.
• 1:17
  I always found that working at pediatrics is very rewarding because they're so resilient.
• 1:24
  Going into pediatrics, it was just, I mean, you're making such a difference immediately.
• 1:31
  And it's super rewarding. and dealing with these parents that are highly anxious as a result,
• 1:40
  of having a child that is their prized possession, so to speak,
• 1:46
  or just, you know, their newborn baby that has a deformed head and them coming
• 1:50
  to you saying, oh my God, what did I do wrong?
• 1:53
  And to be able to kind of get them off the rocks and bring them down and let
• 1:58
  them know that it's something that primarily occurs in utero.
• 2:02
  And then as a result of us putting them on their backs now with the back to
• 2:06
  sleep program, that deformity is a growth pattern that continues on.
• 2:11
  And it's really not their fault.
• 2:13
  It's just, you know, Holly, you and I were raising our stomachs,
• 2:16
  you know, and most everyone our age and older.
• 2:21
  In 1993, 94, they came out with the back to sleep program where the American
• 2:27
  Pediatric Association said, hey, listen, if we put these children on their backs,
• 2:32
  we were finding that it reduces sudden infant death syndrome.
• 2:35
  So, and then we conducted one of the largest studies of its kind.
• 2:40
  We did, we took, I was there for.
• 2:43
  About seven years, and we took all of that, all of the scans and the data from
• 2:49
  that seven years, and we did a retrospective study on how to treat these patients,
• 2:55
  because nobody had really published this.
• 2:57
  I mean, everyone was trying to figure out how to kind of do it, but we had,
• 3:01
  done it enough, and we had set kind of these standards, and I went through and
• 3:07
  wrote clinic standards for how I treat them and kind of blended how they evaluate them.
• 3:13
  And so that's kind of my, you know, that was my introduction to it.
• 3:18
  And I never left it because we were doing, you know, craniosynostosis,
• 3:23
  which is where the sutures within the skull prematurely fuse and cutting those
• 3:29
  and managing those accordingly.
• 3:32
  And there's a different set of standards for those as a result to them being
• 3:36
  surgical instead of being positional.
• 3:39
  And so we just kept going and going. And so anyhow, that's kind of the background
• 3:46
  of how I got into it before I came here.
• 3:48
  And Jim, I think it's just incredible. Your research has helped establish those
• 3:54
  treatment guidelines that are now recognized as standard of care.
• 3:57
  When it comes to head shape abnormalities, what is most often missed in clinical
• 4:03
  practice in the general pediatric setting that's.
• 4:06
  Yeah, you know, everyone says it's plagiocephaly. Well, plagiocephaly means oblique head.
• 4:13
  But there's also brachycephaly, which means short head.
• 4:17
  Well, if you have a short head, think of this. If a baby is head down in the pelvis,
• 4:24
  and the baby never flips or moves, then the baby's head shape takes on a shortened,
• 4:32
  kind of shape as a result of being down on the pelvic floor.
• 4:37
  And that is actually much more common.
• 4:41
  But so you get the shortened kind of head called brachycephaly.
• 4:47
  And then if they're turned and head down slightly, then it can also be,
• 4:52
  you blend plagiocephaly and brachycephaly, and that's called asymmetrical brachycephaly.
• 4:58
  That is much more common than plagiocephaly, but everyone calls it plagiocephaly,
• 5:03
  because that was how they kind of noticed it first, but.
• 5:08
  The ticket is, and you have to treat them both.
• 5:13
  And, you know, that we know of, and there's some research going on,
• 5:18
  is there's no relationship between development and head shape.
• 5:23
  So, I mean, think of it this way. So what I always tell patients is,
• 5:29
  and they always say, how do you know that? Well, one thing we know is that's,
• 5:32
  from a real simple standpoint.
• 5:36
  If you look at the Peruvians, Mayans, Aztecs, Inca, all of them bound heads,
• 5:42
  whether it be flattened them with boards or you string a rope or.
• 5:51
  Animal skins, things like that to kind of shape these heads.
• 5:57
  This was considered common. It wasn't just necessarily like,
• 6:03
  you know, if they were part of a royalty or anything like that.
• 6:08
  That was how they identified each other within that tribe or community or culture.
• 6:13
  And so just think of this, as they were building pyramids thousands of years
• 6:19
  ago, binding their heads at the same time.
• 6:22
  And we still haven't figured out how they did that from an architectural,
• 6:27
  you know, civilization standpoint. Yeah. So, I mean, brilliant civilizations. But it was working well?
• 6:32
  And it was working well, right?
• 6:36
  Some of the surgeons I used to work with, in particular, Thomas Larson back
• 6:39
  in Texas Children's, he used to always say, the brain doesn't have a form.
• 6:44
  It just, it will establish neuropathways based on the need.
• 6:50
  And, you know, it doesn't need to be a certain shape.
• 6:54
  However, and there isn't necessarily a medical necessity for it,
• 6:59
  which that can be argued, but realistically, if you look, if you have a head shape that is off...
• 7:06
  How are you going to get any protective equipment to fit your head effectively
• 7:12
  and work effectively if it doesn't fit right?
• 7:15
  So that in itself is point enough to warrant getting the head corrected within
• 7:25
  a certain amount of time.
• 7:26
  And I don't know if you know this, but the head, as the head grows,
• 7:31
  it gets thicker, and the bone, the type of bone that starts to develop becomes much more integral, and.
• 7:40
  The way that it lays down becomes more structured, and so it becomes harder,
• 7:46
  to manipulate the older they get.
• 7:49
  And the growth actually slows down.
• 7:53
  And, you know, a helmet, the way it works is that when they grow,
• 7:56
  they grow into the shape of the helmet.
• 7:59
  And the helmet is the shape that we want it to be at the end of the treatment.
• 8:04
  So we're not pushing and pulling like braces for your teeth or anything like that.
• 8:08
  We're just getting them to grow into the mold, so to speak. I always,
• 8:12
  I always. So interesting. Yeah, I always refer to, you know,
• 8:16
  in Japan, they grow these square watermelons, right?
• 8:20
  What do they do? They take a round watermelon, they put it into a square box
• 8:24
  and they leave the stem coming out, you know, in a particular opening.
• 8:28
  What they do is they let that watermelon grow into that shape and they have
• 8:31
  heart shapes and, you know, square and all of these different kind of ornate designs.
• 8:38
  But all they've done is they've just manipulated that watermelon into the mold. That's all we're doing.
• 8:46
  And so that's why we really like to get them at a younger age.
• 8:51
  What is the ideal window? Really, the ideal window is four to six months of
• 8:55
  age because we need, you know, I'm looking for, if it's a severe case,
• 9:00
  20 to 30 millimeters of growth.
• 9:02
  Well, you know, from four to six months of age, they're growing anywhere from
• 9:07
  10 to 20 millimeters a month.
• 9:09
  So we want to get them in and out as quick as possible. So that's why that kind
• 9:14
  of that age is so critical.
• 9:17
  How do you distinguish positional plagiocephaly from craniosynostosis in a busy clinic?
• 9:24
  Well, I mean, it does take a trained eye.
• 9:28
  Realistically, you know, there's certain head shapes that you look at and you
• 9:33
  can identify based on the head shape what directed that growth.
• 9:39
  Like I was talking about with brachycephaly, it's going to be short and it's
• 9:42
  going to be sometimes tall and wide.
• 9:44
  Plagiocephaly, it has kind of a shift to it. You know, one ear will often be,
• 9:49
  forward compared to the opposite side.
• 9:52
  The forehead will be, you know, pushed out a little bit, things like that.
• 9:56
  But with craniosynostosis, you have a lot of facial features where it doesn't look right.
• 10:04
  You know, narrow eyes, overly wide eyes, eyes that are drooping, things like that.
• 10:11
  Just facial asymmetry that.
• 10:14
  Throws alarms, you know, to the, to the naked eye saying, you know,
• 10:19
  something does not look right here.
• 10:21
  And if you look at them from the sagittal plane or, you know,
• 10:24
  the side, you can actually see kind of this, you know,
• 10:29
  you know, real narrow kind of, instead of being a roundish shape,
• 10:33
  it'll be kind of narrowed and pointed or things of that nature.
• 10:37
  Not to mention when you palpate the head, you can feel ridging.
• 10:40
  That's kind of the telltale. And that's what craniosynostosis is,
• 10:44
  is where you have this bone that's closed up and grown together,
• 10:49
  and it starts to create a ridge.
• 10:50
  And what that does is it actually can be dangerous because it causes intracranial
• 10:55
  pressure, which can lead to seizures, retardation, blindness, things of that nature.
• 11:00
  But yeah, I mean, there's a whole, there's a process that we go through to distinguish
• 11:07
  one from the other, but those are just kind of the real quick kind of hot buttons
• 11:10
  that you look for trying to identify that, you know, when you see a patient.
• 11:15
  It's so helpful. And Jim, what are your key red flags that should prompt an immediate referral?
• 11:22
  If I see the ridging immediately, I want, you know, it's funny you should say
• 11:28
  that because I have nightmares and I wake up at night thinking,
• 11:33
  oh my gosh, did I miss that?
• 11:35
  You know, It's like, that's the last thing you wanna do as someone in my field is.
• 11:43
  Misdiagnose someone for a positional deformity or vice versa.
• 11:47
  But once again, in that evaluation, if we see any sort of ridging or narrowing or things like that,
• 11:57
  one of the things that's really interesting about our clinic is my counterpart and I,
• 12:03
  And this is something I learned at Texas Children's Hospital is,
• 12:08
  if I sense that craniosynostosis may be present, what I'll do is I won't say,
• 12:14
  what I see, but I will actually excuse myself from the room and go get my counterpart.
• 12:21
  And I was like, hey, come take a look at this. Tell me what you see.
• 12:25
  And I won't let him know what I'm seeing, but he will actually either verify,
• 12:32
  or contradict what I'm thinking.
• 12:34
  And it's a really good way to get a second opinion because there's very few
• 12:38
  places that have more than one cranial remolding specialist.
• 12:42
  And so we really utilize that to our advantage.
• 12:46
  And you see patients at the Medical Arts and Research Center,
• 12:49
  or known as the MARC, here in the San Antonio, South Texas area. Yeah, yeah.
• 12:54
  And we have our own surgeon. So I don't like to send a patient.
• 13:00
  Is that Dr. Tarasavich? Dr. Tarasavich. Known as Dr. T? Yes,
• 13:03
  Dr. T. Wonderful individual. Great surgeon.
• 13:08
  But what I'll do is we'll just send them over and have an evaluation done before,
• 13:14
  we move forward with anything else if we feel like, you know,
• 13:18
  craniosynostosis may be prevalent. And they'll.
• 13:23
  Do a CT scan and they've been able to kind of reduce the radiation that they,
• 13:30
  endure as a result of, we don't want these kiddos to have to experience that.
• 13:35
  But, you know, it's critical.
• 13:38
  You know, you have to be able to rule it out because we definitely want to make
• 13:41
  sure that we can catch it ahead of time.
• 13:44
  And with craniosynostosis, what's interesting is that you want to catch it at,
• 13:49
  you know, four months or sometimes five or less.
• 13:54
  Because then if it is prevalent, then they can go in endoscopically and they're
• 13:59
  able to remove the bone just by simply cutting away the bone.
• 14:02
  Versus if they get older.
• 14:04
  Remember I was talking about that bone, how it changes in the thickness and
• 14:09
  the way that it's laid down and the structure of it.
• 14:12
  So as you get older, it gets thicker. And then just being able to remove it,
• 14:18
  it has to be often removed with a much more...
• 14:22
  Like, you know, saws and exertion and things like that, that you don't have
• 14:27
  the benefit of with endoscopic.
• 14:30
  The other thing is that you want to get them young because you get that rapid growth.
• 14:33
  So once you put them in the cranial remolding orthosis after that surgery,
• 14:37
  you get a much better response.
• 14:39
  And then you're able to, even though Dr. T does a great job in the surgery and
• 14:45
  in releasing that suture and getting the shape that we're looking for,
• 14:48
  what we get is we kind to finish it off.
• 14:51
  And then the helmet does two things. It provides protection,
• 14:55
  but it also is, once again, it's remolding and.
• 14:58
  It's setting a good cephalic ratio and the oblique diagonal difference and all
• 15:03
  of the little anomalies that we want to correct to get it to a normalized kind of indices as a result.
• 15:10
  So, and speaking of, are there cases where imaging is overused or underused?
• 15:16
  It used to be that way. But the beauty is, is that at the Mark, we have 3D scanners.
• 15:22
  And so what they're able to do is they're just simply cameras and lasers,
• 15:27
  medical grade lasers that are completely 100% safe for the child.
• 15:33
  And so we can- No radiation? No radiation at all. So we can just take an image.
• 15:37
  And as a result of that, it gives us a 3D picture.
• 15:40
  It's a topographical, obviously but we can do measurements and we can look at
• 15:46
  different angles and those head those shapes and through our,
• 15:50
  education just pure experience we're able to tell if something is going on there
• 15:56
  and so we can make a really educated
• 15:59
  decision as a result of that and so that's that's why we're kind of the first
• 16:03
  stop before they move on to someone like the
• 16:05
  the neurosurgeon but and they don't need to do their own any type of imaging
• 16:10
  before sending to you any sort of x-ray?
• 16:13
  You mean the pediatrician? Some will, but it.
• 16:19
  It's better for us to just do the evaluation because we may be able to save
• 16:24
  them completely from having any x-ray.
• 16:27
  I remember Dr. T saying in a talk, she was saying, please don't do any imaging.
• 16:31
  Just if you're suspecting something, send the child to us. Oh, absolutely.
• 16:35
  I mean, this is all we do.
• 16:37
  And we know what we're looking for because here's what happens.
• 16:42
  If you do imaging and then you send them to us and then we, it may be,
• 16:49
  it may not reveal what we're looking for and we know exactly what we're looking for.
• 16:55
  And so we don't want to have them, if they come to us, we're going to have to verify it again.
• 17:01
  And so what it does is it just alleviates the amount of radiation that that child has to endure.
• 17:06
  So we have a really refined system in our policies, so to speak,
• 17:18
  and operating procedures are just proven.
• 17:21
  And we're super proud of that, Holly.
• 17:23
  We take a lot of pride in it. And we talked about UT Health being on the cutting edge for AI.
• 17:31
  You mentioned the dean coming to talk to you all about AI for a talk and just
• 17:36
  how AI is going to help with everything, help free you up to have more time
• 17:42
  to do other things and to help.
• 17:44
  I'm involved in some groups nationally. I mean, what we're doing is we're trying
• 17:50
  to figure out how AI can best help us utilize the knowledge that we have so
• 17:56
  that we can see more patients and.
• 18:01
  Reach more patients and be more effective doing it, so to speak.
• 18:04
  Obviously, you know, we can utilize AI for helping with notes and things like
• 18:08
  that. But I think where AI will actually help is that,
• 18:15
  In the future, a baby would come in, and they would be able to set the baby
• 18:21
  into a chair, and AI would conduct the scan,
• 18:26
  take the scan, interpret it, and be able to make an educated kind of development
• 18:35
  plan, so to speak, of how the patient will be treated.
• 18:40
  And so that's on the horizon, definitely.
• 18:43
  I mean, 3D printing and things like that and just product and material science
• 18:50
  and kind of the physics of cranial remolding is definitely moving in that direction.
• 18:56
  Are you going to be 3D printing helmets?
• 18:58
  We already are. You already are? We don't, but the manufacturer we use does.
• 19:03
  Wow. Yeah. That's amazing.
• 19:06
  And now, at the same time also, Medicaid is accepted.
• 19:11
  Oh, yes. Yeah. So House Bill 426 at the capital level in Austin was passed. Yes, here in Texas.
• 19:22
  Last September, it went into play where positional deformities are now covered
• 19:28
  by Medicaid, which hadn't happened since the early 2000s.
• 19:33
  And so we're excited about that.
• 19:36
  We're busy beyond busy. But the nice thing about it is where financial, you know.
• 19:44
  Individuals that could not afford the helmets financially are now able to get,
• 19:51
  some support from the state to be able to correct a baby's head shape.
• 19:57
  And, you know, it's interesting, Holly, is that we, you know,
• 20:01
  we talked about cranial remolding not being a medical necessity,
• 20:04
  but one of our big arguments in going to the state over the last two years was...
• 20:10
  Was, hey, listen, if, put it this way, if a child has anxiety,
• 20:17
  and depression and they go to a psychologist, okay, and that psychologist says,
• 20:22
  well, it's a medical necessity for me to give you XYZ.
• 20:27
  Drugs to be able to manage this anxiety or depression, whatever.
• 20:32
  Isn't that a medical necessity?
• 20:34
  Well, what if a baby has a deformed head and they go to school and they're made
• 20:39
  fun of as a result of their head shape, and then it turns into anxiety and depression.
• 20:45
  Is that not a medical necessity? It's a great point.
• 20:49
  Yeah. So that was kind of the platform we used and they unanimously obviously voted it in.
• 20:55
  So you all were like at the legislative? Oh, absolutely. Yes. Yes.
• 21:00
  I was on the team that actually put together that proposal.
• 21:05
  I was not on the floor because I cannot be on the floor as a result of being
• 21:09
  a provider within the medical industry that we are.
• 21:14
  And you just came from the Medical Arts and Research Center Clinic where you saw a patient.
• 21:19
  What does the visit look like? Can you tell us a little bit about what we're in the room?
• 21:25
  What happens in that room? Well, they'll come in. In my room, I have a scanner.
• 21:30
  And every time they come in, I'm going to scan because that scan you can take
• 21:36
  previous scans. You can overlay them and they'll tell you everything you need
• 21:40
  to know about the treatment and how it's going. So my last patient,
• 21:44
  came in, and we thought they were going to be finished with the treatment.
• 21:51
  They had been in for about three months, and the patient was moderate,
• 21:56
  moderate, severe, close to being severe, brachycephaly.
• 22:01
  And so we brought him in, and I did the scan, and took a look at the scan,
• 22:07
  and the growth wasn't adding up to the correction.
• 22:13
  And so I looked at the skin, it was growing in areas that I didn't want it to grow in.
• 22:20
  And it was, it was continuing, it wasn't growing in length, it was growing in width a little bit.
• 22:27
  And so mom explained to me, yeah, well, you know, the patient has been sick
• 22:33
  and we've been out of the cranial remolding orthosis for a certain,
• 22:38
  you know, I think it was like three weeks.
• 22:41
  And I like to see him once a month. So I knew that we were near the end of the
• 22:45
  treatment and it was starting to wane a little bit there.
• 22:49
  That's tough. Yes, you know, adherence to the standards is what we battle.
• 22:58
  And so, yeah, so I went ahead and we hadn't reached normal limits and the patient
• 23:05
  was still quite young and so she wasn't rolling, which is a big, big deal because,
• 23:11
  once they can roll from back to stomach, then they're going to roll,
• 23:13
  move, shift, turn quite frequently throughout the night.
• 23:16
  Then we don't have to worry about the deformity coming back.
• 23:21
  But because the baby is still quite young and mom is forthright with the fact
• 23:26
  that they weren't wearing it 23 hours a day, I went ahead and kept them in it.
• 23:29
  I made a slight adjustment to the device, put them in it, and then I'll see them back in a month.
• 23:35
  And you're supposed to wear it 24-7? Yeah, 23 hours a day. 23 hours a day.
• 23:39
  Yes, that's correct. And the reason why, back to what we were talking about
• 23:43
  earlier, is we want to make sure that when they're growing, they're growing
• 23:47
  into the shape of it. And so that's how it works.
• 23:50
  When they grow into the shape of it, and then we take them out of it,
• 23:53
  and they're rolling, moving, turning, then it continues to shape naturally.
• 23:57
  23 hours a day is critical, because we don't know when they're going to grow,
• 24:00
  and especially during sleeping, because they're laying down.
• 24:05
  I have some patients that they may live out in the country and are on well water
• 24:09
  and they don't bathe every day.
• 24:11
  The outcomes are amazing because they'll leave the helmets on constantly.
• 24:16
  However, during the summertime, we like for them at diaper change to take it
• 24:20
  off and wipe it out with a damp cloth.
• 24:23
  It's because in sweat is salt, yeast, and bacteria. And if you don't remove
• 24:27
  that from the skin and there's long periods of the skin being in contact with
• 24:31
  it, the yeast can cause a yeast infection. the airborne yeast.
• 24:35
  And then we, you know, it can cause skin irritation, things like that.
• 24:39
  So we like for them to wipe it down at each diaper change during the summer
• 24:44
  months, mainly, because here in San Antonio, as you know, it's, it's sweltering.
• 24:49
  And then, you know, clean it maybe each evening with rubbing alcohol inside
• 24:54
  and out. And then, and then that's how we keep it sanitary.
• 24:58
  But they're, like I said, they're closed cell foam, hypoallergenic, latex-free devices.
• 25:03
  So they don't harbor a lot of bacteria, but on the surface, there can be bacteria.
• 25:07
  And, and, you know, we just want to make sure that the babies are in a sanitary
• 25:12
  environment as much as possible.
• 25:15
  How late is too late for helmet therapy to be effective?
• 25:18
  I mean, realistically, we used to treat them, you know, we, we,
• 25:25
  we used to get babies at eight, nine, 10 months, because a lot of times the
• 25:29
  pediatrician would say, you know, let's just keep going. Let's just keep going,
• 25:32
  let's just keep going, but.
• 25:34
  With repositioning because they wanted to see, you know, kind of a conservative
• 25:38
  treatment and try and avoid the helmet.
• 25:41
  But usually we get them between four and six months. So they're out of it before
• 25:46
  a year of age, but right around a year of age, that bone is really thick.
• 25:51
  And another thing happens, their dexterity becomes very developed and that's when they can, you know.
• 25:58
  Pinch which opposition and spherical for the hand movement becomes really,
• 26:03
  really quite good, and they can remove the device.
• 26:07
  And so we want to make sure they're not taking it off. Plus,
• 26:10
  they just become more cantankerous. The bone is thicker.
• 26:13
  But the biggest thing is that the growth is so much slower. Because think about
• 26:18
  this, by the time they get to between 10 and 12 months of age,
• 26:22
  the head is already between 75% and 85% the size it will be as an adult.
• 26:28
  So we've lost all that correction and growth.
• 26:31
  And so then you have this laborious kind of treatment over months just to get them to normal levels.
• 26:37
  And sometimes it's a waste of time for both the patient parent and for the practitioner,
• 26:43
  because at that point, adherence becomes very difficult for them because all the things I mentioned.
• 26:50
  And they're just not seeing those results like visually like you do when they're
• 26:54
  four to six months of age. And I mean, Holly, if you put a cranial remolding
• 27:00
  orthosis on a baby and they're four months of age.
• 27:05
  By the fourth or fifth day, you can see the results. I mean,
• 27:08
  it's visual. I mean, it's spectacular.
• 27:10
  And so, but if you say you start at 10 months of age versus four months of age,
• 27:17
  you're not going to see that kind of correction maybe throughout the whole treatment if you don't.
• 27:24
  If they're not growing rapidly or their heads, you know, at a large size already.
• 27:29
  I celebrated this weekend, my niece's one-year-old birthday,
• 27:32
  and I hadn't seen her in a couple of months. And I know pediatricians see this
• 27:35
  all the time, but I couldn't believe how much she had changed.
• 27:38
  Oh, it's amazing. It is just amazing. Leaps and bounds, right.
• 27:43
  What are a refresher, what to look for? Well,
• 27:48
  mom will be the first kind of, that will be the first indicator because she's
• 27:54
  been in the bathtub with the baby and she just looks down on the baby from different
• 27:58
  angles and it just doesn't look right.
• 28:01
  And I always tell pediatricians, listen, if mom sees it and you don't send them,
• 28:08
  they're going to go down the street and find somebody that will.
• 28:13
  And Jim, what are a few myths you still hear from well-intentioned providers or parents?
• 28:18
  That they can reposition out of it and it's going to completely be normal in time.
• 28:24
  If I see a patient at four months of age and it hasn't resolved,
• 28:28
  it's not going to resolve.
• 28:30
  Because think of it this way, Holly, if I have a tire and it's got a flat spot
• 28:36
  on it and I roll that tire, where do you think that tire is going to end up
• 28:40
  when it's done rolling? It's going to end up on the flat spot.
• 28:44
  Well, why would a baby come off of that flat spot that they're sleeping on to
• 28:49
  move to the other side if they're nice and comfortable in that little cradled
• 28:53
  flat spot that they can sleep on every night?
• 28:56
  And so that's what happens. And it usually is accompanied by torticollis.
• 29:00
  And so get them in for treatment.
• 29:03
  Get them in for an evaluation because it's just that much easier on the parent
• 29:08
  as well when they're younger than when they get older.
• 29:11
  And you can just, you know, you can get, you can get a better outcome.
• 29:15
  The other thing is that sometimes all the patients that come from other countries
• 29:19
  and they'll have like, you know, pantyhose, like, like strapped on the head.
• 29:25
  Like you cannot fix a head with a pair of pantyhose.
• 29:28
  Yeah. So there's, there, there are no like wives tales, so to speak that, or, or I don't know.
• 29:36
  Don't try this at home. Yeah. Don't try this. Yeah. Yeah. You're not going to
• 29:39
  be able to put baking soda and, and turn it around 10 times and have it correct
• 29:44
  on its own. There's biomechanical principles in play here.
• 29:49
  Absolutely has to be manipulated artificially to get that correction and get
• 29:54
  symmetry reintroduced into the head.
• 29:56
  Remember, we're not trying to do anything other than kind of reset the way it's
• 30:02
  growing so that once we take them out of the helmet and they're rolling,
• 30:05
  moving, turning, it shapes naturally so that, you know,
• 30:10
  genealogy can come into play and their heads can look like their parents' heads.
• 30:14
  When should a pediatrician refer to neurosurgery versus directly to a cranial remolding program.
• 30:22
  Well, I mean, if they're trained on craniosynostosis and they understand what
• 30:27
  ridging looks like and what the difference between a positional deformity and
• 30:31
  craniosynostosis looks like,
• 30:34
  then by all means, and some pediatricians do, but they're more than welcome
• 30:39
  to send to us initially so that we can do that pre-screening.
• 30:43
  And because it bottom line is that we're not going to treat that craniosynostosis
• 30:49
  but we know what to look for if it's if it's there and so it gives us the ability
• 30:55
  and and the other thing is that we can.
• 30:58
  We we have a direct line to to the surgeons and so it gives us we we can act
• 31:03
  really quick on that to be able to get them in and seen by the surgeon,
• 31:08
  if and when that time comes the golden rule is we want to see them at four to six months of age.
• 31:15
  Don't try and reposition too long because, you know, as long as I've been doing it,
• 31:19
  I can look at a head and say, you know, I mean, obviously if they're extremely
• 31:23
  severe, of course, there's going to be some, some flattening there that you just can't not see.
• 31:31
  But sometimes they can disguise themselves really well.
• 31:35
  And there can be a lot of obliquity going on in the head and twisting and things like that,
• 31:41
  that the naked eye doesn't necessarily pick up right away, but there can be
• 31:46
  other indicators that are kind of
• 31:48
  telling you, hey, something doesn't look right. And so let us measure it.
• 31:54
  Let us put some numbers to it and let us quantify what is exactly going on.
• 32:00
  And then we can set up a treatment plan if it's needed.
• 32:03
  And if not, hey, great. But at least we didn't miss that treatment window that
• 32:09
  is really, will give the, you know, give the patient the best overall outcome.
• 32:15
  And I really appreciate you being here in the podcast studio, Jim.
• 32:19
  I like to promote on Pediatrics Now having a life outside of medicine. I love fishing.
• 32:25
  What type of fishing? Well, I like trout fishing, freshwater fishing,
• 32:31
  but I also like to do redfish and trout and flounder like that along the Texas
• 32:36
  coast here, which I'll be doing next month, which I'm very excited about.
• 32:40
  Do you cook the fish that you catch? You know, I used to a lot,
• 32:44
  but now I like catch and release.
• 32:47
  But I also like to do things like play the piano. I really enjoy music.
• 32:51
  I like to do water skiing and lots of outdoor things if I can.
• 32:56
  Why are people not water skiing, though, as much? I water skied growing up and
• 33:01
  learned to slalom. And like the kids now, it's like these banana boat things
• 33:05
  or this big inner tube that you get bounced around. That does not look nearly as fun to me.
• 33:11
  You know, wakeboarding and scurfing and things like that actually have become much more popular.
• 33:17
  So we have a Sea-Doo that we like to ski behind.
• 33:22
  It's kind of like a jet ski that you sit down on. Yeah, so I like to do that,
• 33:27
  and just spend time with my family and travel when I can. Are you a really good water skier?
• 33:33
  No, I did a lot of snowboarding. I'm actually originally from California.
• 33:36
  And so I like to go, I would get a season pass every year and we would go 50,
• 33:42
  60 times a year snowboarding.
• 33:45
  And group surfing as well.
• 33:47
  Living a little bit north of San Diego.
• 33:50
  It was a wonderful opportunity. Believe it or not, you could actually go snowboarding
• 33:55
  and surfing in the same day. Wow.
• 33:58
  And there's not a lot of places in the world you can do that.
• 34:02
  But yeah, I enjoy my kids and.
• 34:07
  Traveling and doing those sorts of things. And I like to stay involved with my church,
• 34:14
  Do you have any trips coming up planned or something? I am going to do South
• 34:19
  Pottery next month. And while I'm there, we're going to do some,
• 34:22
  obviously, playing on the beach and fishing. I just came back from North Carolina.
• 34:28
  I was there just last week teaching at Eastern Tennessee State University at
• 34:32
  their orthotics and prosthetics program.
• 34:35
  That's not vacation. No. I
• 34:37
  did that for a couple days, but it was in the Smoky Mountains. Wonderful.
• 34:41
  And then I traveled down through the mountains there to Asheville and spent
• 34:44
  a few days there. Oh, I've heard that's beautiful. South of Biltmore, that was wonderful.
• 34:50
  I do like to teach a lot if I get a chance. I actually instruct here.
• 34:54
  We just graduated our first class of doctorate of nurse practitioners that have
• 34:59
  a specialty in pediatrics.
• 35:02
  We certified them through schooling and rounds with myself in our clinic so
• 35:07
  that they can, when they go out,
• 35:10
  into the field working at their clinics, they're able to identify,
• 35:14
  evaluate, and refer as a result of their knowledge from our course.
• 35:18
  So we're very proud of that.
• 35:20
  One pediatric specialist I had on the show, I asked her what she likes to do
• 35:24
  in her spare time, and she said, multitask.
• 35:28
  So we're like, okay, we need to focus on doing fun things, unplugging.
• 35:32
  We want it's not balance really but doing things to refresh reset that's funny
• 35:38
  you should say that i always tell my kids you know get off the get off the electronics
• 35:43
  you know while i'm on my phone.