Looking back at family photos, it should have been obvious. The tilted head - cocked to the left, slightly turned to the right - was there each time we snapped pictures of our sleeping newborn.
But we didn't see it then. Even when our daughter's skull flattened on the right side; even when, as a 4-month-old, she still had trouble holding her head up, my husband and I never imagined there was cause for alarm.
It wasn't until my out-loud musings caught the attention of another mother that we finally realized Ava had a problem, and that the problem had a name: torticollis.
It's a relatively benign condition, sometimes called "wry neck." Often, it's resolved through stretching and physical therapy not long after a youngster has begun toddling around. But untreated, it can result in more serious problems later in life.
Although torticollis has long been recognized in medical literature, therapists report an increase in the number of cases referred to them during the past several years. And that, they say, is a likely result of babies spending too little waking time on their bellies.
Some institutions, such as Baltimore's Kennedy Krieger Institute, have created clinics that focus on patients with the condition.
"During my first 20 years, if I saw 10 kids [with torticollis], it was a lot," said Diane Nemett, lead physical therapist with Kennedy Krieger's two-year-old Cranial Cervical Clinic. The clinic evaluates children with torticollis and plagiocephaly, a related condition that leaves children with an abnormally shaped head.
These days, Nemett says her caseload includes 10 torticollis patients "at any given time." In the past two years, the clinic has seen about 100 children.
Many doctors and therapists blame the increase on changes in the way modern parents handle their infants.
Concerns about SIDS (Sudden Infant Death Syndrome) have persuaded many parents to put their babies to sleep on their backs, instead of on their stomachs. In fact, a nationwide "Back to Sleep" campaign has promoted the practice since the early 1990s.
Meanwhile, a host of baby-oriented devices, from portable infant carriers to bouncy seats and toys designed to entertain infants from above, encourage babies to spend the majority of their waking time on their backs, according to therapists who treat the condition.
Less "tummy time" means fewer opportunities for babies to strengthen their neck and trunk muscles - exercise that may have helped resolve mild to moderate cases of torticollis 20 years ago without help from a doctor or physical therapist, experts say.
"No one is saying, 'Don't back-to-sleep your kid,'" said Ann Marie Pace, a Cleveland-based therapist conducting a clinical study of babies with torticollis. "It's when babies are awake that we need to have parents aware of how important belly time is."
While the exact origins of torticollis are still murky, medical professionals believe that a variety of factors - from fetal position to the birth process - may result in an injury to or shortening of the sternocleidomastoid muscle, or SCM, on one side of the body. The muscle runs from just under each ear to the front base of the neck.
Other times, a flat spot on the back of the head, or plagiocephaly, makes it difficult for a newborn with poor head control to move around. That essentially locks the child - and the SCM - in one position, said Dr. Melissa Trovato, director of the Kennedy Krieger clinic.
In either case, the muscle on one side shortens or tightens, and the infant's head tilts toward the affected shoulder and rotates in the opposite direction. If left untreated, the condition can lead to scoliosis and lopsided facial features, according to medical literature.
Often, both torticollis and plagiocephaly occur in the same child - although therapists and doctors say they've seen children with one and not the other.
"It's hard to know which came first sometimes, but we have to treat both," Trovato said.
Experts say an evaluation can also rule out other causes for the tilt - causes rooted in underlying problems with the eyes, neurological system or skeleton.
The earlier the torticollis is noticed, the easier it is to treat, say doctors and therapists who deal with children with the condition.
But for some parents, a diagnosis can be hard to come by. Unlike other conditions and diseases, information about torticollis remains largely out of the mainstream, and some doctors still subscribe to an old line of thought - that babies will "grow out of it."
"In fairness to pediatricians ... prior to 1992, they did tend to grow out of it more than they do now," Nemett said. "We feel it is a value to start [therapy] as early as possible."
Jen Whiddon said she had to work hard to convince her former pediatrician that her younger son, Michael, needed help - even though the boy, now 2, had trouble turning his head to one side and was throwing up all over the floor.
"I honestly think she thought I was crazy," said the Columbia mother, who runs a day-care center in her home. It took her months, she said, to coax her doctor into a referral. When she finally brought Michael to the Kennedy Krieger clinic at 6 months, the diagnosis was torticollis and reflux.
"It was so great finally hearing, 'Yes, there is a problem and let's fix it before it becomes a big problem,'" she said. "I felt so vindicated when I got in there."
In Michael's case, the treatment was relatively simple - physical therapy and a home program that included stretching, positioning and other exercises. By the time he was 16 months old, he was considered "resolved" and discharged from physical therapy, she said.
Doctors and therapists say most children with the condition can be helped with physical therapy and by instructing parents on at-home stretching and different ways to handle and position their children.
But in tougher cases, a doctor may prescribe the use of a collar, Botox injections or surgery.
Ultimately, "torticollis is one of these diagnoses that has a beginning and pretty much has a finite end," said Pace, the Cleveland therapist. Her Ohio-based clinical study is looking at how the way babies are positioned affects their rate of recovery from torticollis.
Pace said that while the study is continuing, she expects its findings will mirror what therapists have always believed: that babies who spend less time in car and bouncy seats and more time on their bellies - with parental supervision - will get better faster.
It's a mantra that people such as Julie Quinn, a pediatric physical therapist and team leader with the Baltimore County Infants and Toddlers Program, repeat to parents of children with the condition.
Infants tend to cry when put on their bellies, and parents often will avoid that position as a result, she said. But babies put on their stomachs early on will get used to the position, which helps to increase their range of motion and strength, she said.
Some parents say that after dealing with a diagnosis of torticollis in one child, they were more vigilant with the next. "I made sure with the third one that she really had head support," said Brenda Sroka of New Freedom, Pa., whose middle child had torticollis. "I put her on her stomach right from the beginning to avoid a head tilt."
Some have turned to the Internet for support. The nonprofit National Infant Torticollis Association maintains a Web site with information and links to other resources, and a mailing list on Yahoo provides a forum for parents of more than 2,300 children with the condition.
One caveat: "Resolution" of a case of torticollis doesn't necessarily mean that parents are done with tilted heads forever. Therapists say children who are tired or sick may revert to their old crooked norm for comfort for a while - before springing back to a neutral position.
Ava's therapist likes to joke that we can expect to see her cocking her head to the left in her wedding pictures one day - a consequence of the stress of the day.
But that's the future. For now, we finally can claim a bit of success. More than a year after my daughter's original diagnosis - a year that included regular visits to physical therapists, as well as appointments with an orthopedist and a physiatrist - we're told we finally may be nearing the end.
At 18 months, my little girl finally can hold her head straight.
Checking your baby
If your baby displays any of these symptoms, talk with your pediatrician to determine whether the child has torticollis or plagiocephaly:
The baby?s head is always tilted to one side.
When you look at the baby?s head from the top, one ear seems farther forward. The back of the baby?s head looks flat.
One eye looks smaller than the other or one cheek seems fuller.
Tips for preventing a head tilt or misshapen head:
Alternate the way the baby faces in the crib or changing table and the position you use to carry or feed him.
Use rolled blankets to make sure the child?s torso is evenly positioned in the infant seat.
Make sure the baby gets plenty of ?tummy time? while awake, working up to at least 10 minutes per hour.
During ?tummy time,? place interesting toys in front of the baby to encourage head lifting.
Place the baby on his stomach, on your chest while you recline.
Carry the baby with one arm under the chest, the other supporting the stomach or hips.
Have your pediatrician evaluate your baby as soon as possible if you see any flattening or asymmetry.
Kennedy Krieger Institute
Torticollis sources on the Web
National Infant Torticollis Association: infant-torticollis.org
Kennedy Krieger Institute: kennedykrieger.org
Maryland Infant and Toddlers Program: marylandpublicschools.org/MSDE/divisions /earlyinterv/infant_toddlers
Torticollis Kids forum on Yahoo: hhealth.groups.yahoo.com/group/torticoll iskids