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'SARS-like' virus, reflux heartburn, corrective baby helmets

Duration:
28 minutes
First broadcast:
Tuesday 25 September 2012

In Inside Health this week Dr Mark Porter asks whether headlines identifying a 'SARS Like' virus may cause unnecessary alarm. While this new virus and SARS are both members of the same family, virologist John Oxford explains that they are more like cousins that behave differently.

And should you be worried about the shape of your baby's head? Lots of parents are. Margaret McCartney questions the growing trend for corrective helmets to treat so called 'flat head syndrome'.

Plus Mark Porter visits the first NHS hospital to offer a new approach to treating heartburn.

  • Mr Saj Wajed with the LINX reflux management device

    Mr Saj Wajed with the LINX reflux management device

  • Programme Transcript - Inside Health

    Downloaded from www.bbc.co.uk/radio4
    THE ATTACHED TRANSCRIPT WAS TYPED FROM A RECORDING AND NOT COPIED FROM AN ORIGINAL SCRIPT. BECAUSE OF THE RISK OF MISHEARING AND THE DIFFICULTY IN SOME CASES OF IDENTIFYING INDIVIDUAL SPEAKERS, THE BBC CANNOT VOUCH FOR ITS COMPLETE ACCURACY.


    INSIDE HEALTH

    TX DATE: 25.09.12 2100-2130

    PRESENTER: MARK PORTER

    PRODUCER: ERIKA WRIGHT


    Porter
    Hello and welcome to Inside Health - in today's programme: Heartburn - as many as a million people in the UK troubled by reflux related heartburn will eventually develop pre-cancerous changes in their lower gullet. But which million? We talk to one of the driving forces behind new research that may help identify those at risk.

    Clip
    It's not so much you produce too much acid, it's the fact that you produce acid in the wrong place. We have a design flaw between the gullet and the stomach and what happens is that there's a small sphincter there which is a one-way valve to allow food to go into your stomach but not the acid to come back is actually flawed in many cases.

    Porter
    And, continuing the reflux theme, we visit the first NHS hospital to offer a new approach to treating heartburn - and it can cure it.

    Clip
    I often tell patients that doing a reflux operation is like me getting the right shirt for them - you don't want it too loose because they'll get the reflux, you don't want it too tight because they'll get difficulty in swallowing. So it's exactly finding exactly the right collar and if it's the right collar it will do the job absolutely correctly.

    Porter
    Are you worried about the shape of your baby's head? Lots of parents are, and there is a burgeoning trade in corrective helmets to deal with what has become known as "flat head syndrome". But are helmets a welcome development, or an unjustifiable and unnecessary intervention cashing in on parental concerns? Inside Health's Margaret McCartney is not impressed.

    But first we go behind the headlines and reports of the emergence of a new "SARS like" virus. It has been discovered in a 49 year old man from Qatar, currently undergoing treatment in an Intensive Care Unit in a London hospital. But calling something a "SARS like" virus is very different from saying it causes SARS. Severe acute respiratory syndrome (SARS) is a type of severe pneumonia caused by a member of the corona virus family, and it shot to prominence in 2003 when an epidemic infected 8,000 people across the world, killing 750 of them.
    This new virus may be from the same family, but that doesn't mean we are about to see another SARS epidemic. John Oxford is Professor of Virology at Queen Mary University London, so what did he make of the headline?

    Oxford
    Well when I first saw it I was a bit perturbed, to put it mildly, but when I began to think about it I think well it's not SARS like is it, it's not spreading, so I began to relax and I then thought well it's going to be a corona virus, it's going to be towards the more weaker end of the family - that is common colds and that sort of [indistinct word].

    Porter
    So the corona virus family is what - there's a spectrum, there's lots of different viruses and at one end we've got common cold type symptoms, at the other we've got SARS?

    Oxford
    Yes, it is just as you say it is a spectrum, it's just like any family, like a human family, you're going to have your cousins who are going around kicking people and others who are very nice. And so virus families are like that. In general the corona virus family are fairly benign, SARS was this huge exception. So what does reassure me with this one is that this contact tracing, which is the huge thing when a new - a virus emerges, this is a new virus, contact tracing - is it spreading from the initial case to close contacts - hospital doctors, nurses, families - this does not seem to be the case and I find that very reassuring. That was not the case with SARS because as far as we can see the first man coming in with it into Hong Kong he infected 10 people in the Metropole Hotel, everywhere he went there was a litany of people coming in later on with SARS.

    Porter
    So if somebody's sitting on the train this morning reading the paper looking at the headlines, thinking there's a new type of SARS that's arrived in Britain's shores, the story's not quite that is it?

    Oxford
    No it's not. It's arrived in Britain for a particular medical reason, I presume that they felt with the person from Qatar they couldn't cope with him one way or the other so they were relying - they were kind of putting their dependence on the great institutions of Britain - the National Health Service and the Health Protection Agency and I can quite sympathise with that. But I don't think anyone - I won't be going on the tube today because I'm going to India later on but otherwise I would be and I would be in absolutely no fear whatsoever.

    Porter
    Are we better prepared now than we were say 10 years ago?

    Oxford
    I think we're better prepared in the sense we've had the SARS, we got confidence in the end that we could crack it and we did, everyone's much more prepared, on the lookout as well around the world. The world itself has built up its preparations, I mean when I think of China now compared to what it was even like at the time of the SARS in 2003, China scientifically has come leaps and bounds - they can do sequencing - they can do everything that we can do in China for example and that's very reassuring that other countries around the world that couldn't 10 years ago and now at the high levels of science and they're on the lookout for something.

    Porter
    Professor John Oxford talking to me earlier.

    Elsewhere in the news, researchers have come a step closer to being able to identify which of the millions of people in the UK with acid reflux and heartburn are at risk of developing pre-cancerous changes. Something that can happen to the lower part of their gullets and known as Barrett's Oesophagus. Janus Jankowski is Sir James Black Professor at Queen Mary University and one of the team behind the new research.

    Jankowski
    It's been described as the commonest condition affecting adults in the Western world. For example in the UK it's estimated there's somewhere between five to 10 million sufferers of this condition. And the reason that's such a big variation in that number is a lot of people out there have symptoms of heartburn, indigestion, difficulty of eating a meal but they actually don't describe it to their GP so it never actually gets onto the databases. And of that 10 million people we think approximately one million of them will have endoscopic damage, so if they were to come in for an upper GI endoscopy with a telescope test we would see evidence of damage at the lower oesophagus and of that we think probably half a million people would have the extreme form of the condition which is a pre-malignant condition called Barrett's Oesophagus.

    Porter
    And when you say pre-malignant that means that a proportion of those will go on to develop cancer, it's a pre-cursor to cancer?

    Jankowski
    Yes it is but I wouldn't want to overdo the conversation rates. So even if you do have Barrett's Oesophagus and you're listening to this you shouldn't panic because the cancer conversion rates are probably in a lifetime 3% for women and probably no more than 5% maximum for men.

    Porter
    You say if you're listening to this and you know you've got Barrett's Oesophagus but I suspect that the vast majority of people out there will know that they've got reflux but many of them won't even have had an endoscopy so no one will know what the lower part of their gullet looks like.

    Jankowski
    I agree and there's a significant problem in managing people with reflux disease. For example, I'm also a chair of a NICE advisory group and I think NICE, in credit to them, recognise the problem of this, that we simply do not have the appropriate capacity, let along training, of endoscopists to be able to manage this problem and therefore dealing with this in medical terms of what we call empirical treatment is probably the sensible way of managing this. So if you do have symptoms to have it treated early and fast.

    Porter
    Are there any clues at the moment as to which of the people - the millions of people out there with reflux are likely to go on to get Barrett's?

    Jankowski
    Yes there is and the paper which we had published, a huge national and international group published in Nature Genetics just a matter of days ago is the first evidence that Barrett's Oesophagus, which is the extreme end of gastroesophageal reflux disease, most people commonly know that as heartburn, can be hereditary. Up until now people thought that was an acquired disease, the patient had full control over getting the disease and now we know that's probably not the whole answer.

    Porter
    So it suggests that there's a family trait, if you have relatives who are affected you might be at increased risk yourself?

    Jankowski
    Well we've known that there's a - people with Barrett's Oesophagus who run in families and what we haven't been able to analyse is whether that's just shared personality traits and cultural habits, so for example if you eat high amounts of fatty food, particularly late at night, would that cause acid to come into gullet when you're sleeping? And what we've been able to show is there's definitely an independent genetic risk from these individuals. In fact it's probably likely that a large proportion of the population have genetic risk factors for this condition.

    Porter
    And that's exciting because potentially if we can identify them we can test them?

    Jankowski
    Absolutely, we're at the early stages in fact and the current paper identified two very strong genetic links that probably help to predict about 10% of these refluxes but I can tell you that we have other evidence that we're currently putting through into publication shortly that we'll be able to predict a larger proportion of the population.

    Porter
    That's all in the pipeline Janusz, what about people who've got reflux now, a lot of people out there will have the symptoms, they'll be well controlled with their medication, but they won't have had an endoscopy, so how should we be managing these people?

    Jankowski
    There's three basic guidelines I would give to people: Making sure the weight is within the normal body mass index, so that means your height and weight is actually proportional according to government charts and you can get them online, like an NHS BMI calculator, that's the most important bit of advice I'd give. Secondly, avoid eating high amounts of fatty food, particularly at night time. And the third thing is to have smaller regular mealtimes but try to make sure your last meal is three hours before you go to bed. And if you follow these three bits of advice you can be sure that you're probably doing 90% of what you ought to be doing to prevent this disease or nullify its main effects.

    Porter
    So when would you consider doing an endoscopy in someone who you suspect has reflux, has been responding well to treatment, would it be if their symptoms weren't easily controlled?

    Jankowski
    Yes, there's very good NICE guidance. If you've had reflux for 10 years or more, whether it's particularly well controlled or not, it's to do with the longevity of it, you probably ought to be having an endoscopy to rule out the possibility of Barrett's. Secondly and certainly if you have uncontrolled symptoms which you're on an unsatisfactory dose of acid suppressant drugs you should be getting endoscoped anyway. And the third thing is if you have any unusual symptoms which could trigger what we call alarm signs of significant change in symptoms or food sticking in the gullet you should have an immediate endoscopy.

    Porter
    And this is potentially a very serious condition, if you do get cancer of the gullet it's a nasty disease?

    Jankowski
    Absolutely, nowhere else in the world gets more oesophageal adenocarcinoma, that's one of the forms of oesophageal cancer, this is the centre of the epidemic, in the UK and particularly in the West Coast of Scotland. And sadly in fact the survival rates with oesophageal cancer, unless it's caught at the early stages, have not improved significantly over the last 30 years and the survival is probably less than 10% for five years.

    Porter
    Janusz Jankowski who is also involved in a large study investigating whether acid suppressing medication - like omeprazole - taken by most people with reflux, protects against sinister changes in the lower part of the gullet. Hopefully time will prove it does.

    In the meantime, what if you could fix the faulty valve at the top of the stomach that allows acid to reflux back into the vulnerable gullet? Not only would it cure heartburn related symptoms, but it might also reduce the likelihood of Barrett's disease and cancer too. Well surgeons have been trying to do just that for some time, and the latest development in the field is to use keyhole surgery to insert an elasticated device around the outside of the gullet. And Saj Wajed, from the Royal Devon and Exeter Hospital, is the first surgeon in the UK to use the new LINX system.

    Wajed
    Well this is the device and essentially it's just a set of titanium beads with magnetic cords and they form a necklace and as you can see there's the clasp there and as you join that together the beads form a ring and that ring is placed round the lower oesophageal sphincter and provides a valve for reflux.

    Porter
    I mean looking at it it reminds me of little sort of child bracelets you can get with elastic in the middle with little sweets on. I mean I've got my finger in it, I can feel gentle pressure but I could probably just about get two fingers into it, so it's quite a gentle thing isn't it.

    Wajed
    It's a very gentle thing and each device is custom made for the patient, so there's a sizing device, and we place the device appropriate size for the patient. And the idea is it doesn't give any compression on the oesophagus, it simply just closes it up and does what the normal muscle sphincter would do, therefore keeping the acid and the bile and the other juices in the stomach, preventing reflux but allowing enough give to allow patients to swallow.

    Porter
    So when you swallow something bulky then basically the elastic just stretches....

    Wajed
    Absolutely, so when the patient swallow the peristaltic function, the pumping function of the oesophagus, opens up the beads and allows food to pass through and then closes again once those have passed through.

    Porter
    It's a very simple device, you've got to get it in and you've got to get it around the junction between the top of the stomach and the bottom of the gullet, so how do you do that?

    Wajed
    We do that by keyhole surgery - we make a couple of small incisions in the abdomen - and just do a little bit of minimal dissection around the oesophagus and clasp it round like a necklace around the neck really.

    Porter
    And those incisions are where - so where does it...?

    Wajed
    One around the belly button and two underneath the ribs, but they're all less than a centimetre.

    Porter
    You say you tailor each device to that specific patient and how do you know how big their gullet is?

    Wajed
    Well we have a measuring device, there's a special measuring device which is made for this procedure and once the oesophagus is mobilised we put this around there and that gives a simple reading.

    Porter
    So this is done at the time of operation and then you select the right size - bit like getting the right shirt collar size.

    Wajed
    Exactly like - I mean I often tell patients that doing a reflux operation is like me getting the right shirt for them, you don't want it too loose because they'll get the reflux, you don't want it too tight because they'll get difficulty in swallowing, so it's exactly finding exactly the right collar and if it's the right collar it will do the job absolutely correctly.

    Porter
    Before this arrived what was the best procedure you could offer somebody?

    Wajed
    We would offer somebody what we call a fundoplication or a Nissen fundoplication to give it its proper title and that's a good operation for the right people but it is a little bit more extensive surgery, it involves changing the dynamics of the upper stomach to create a new valve using the body's tissues. And that's great to control reflux, it does give some people some side effects and bloating, flatulence and things, which some people find a little bit irritating and it is a bigger procedure which some people find less attractive.

    Porter
    So is this new technique simpler for you as a surgeon - is it safer and more effective for the patient?

    Wajed
    It's certainly a lot simpler, it takes about 45 minutes to put in, a standard anti-reflux operation will take two to three hours, the patients can go home the same day and they see results instantaneously. So from that point of view it's a much simpler and more straightforward operation for the patients and certainly simpler for the surgeon to do as well.

    Porter
    The downside is the cost - I mean up until you did your first operation here this wasn't available on the NHS and I think probably, possibly, you're still only the centre that's offering it at the moment.

    Wajed
    That's right. Well we had to make a business case because all new procedures have to be cost effective in the NHS and although the real benefit of this procedure will be seen by the PCTs who don't have to pay for the medication we still have to make it cost effective within the trust. And in order to do that what we had to show that because we could the operation in a much quicker time, therefore creating more operating space to other procedures, because the patient didn't require overnight stay and less investigations after the operation it was actually cost effective and we can actually do this, despite the cost of the implant, within the same tariff as an anti-reflux operation.

    Porter
    And do you see the same thing happening nationally, I mean you must be talking to your colleagues, is it likely that this is going to be introduced in other hospitals too?

    Wajed
    We would hope so, I mean I think you've got to remember it's still a specialist operation, it's got to be done by specialist surgeons in the background of a specialist centre. But certainly we'd expect to see other centres start developing this over the next year.

    Porter
    Millions of people in the UK have some degree of reflux, I mean it's one of the most common problems we GPs prescribe medication for, which patients need surgery?

    Wajed
    If you have a situation where you become dependent on drugs where every day you have to take a tablet or two tablets and without the tablets you get terrible heartburn, regurgitation, reflux of fluid at night, it interferes with your occupation then clearly something needs to be done about that. And although some people do manage well on medication many people do get breakthrough symptoms and I think this dependence on drugs - and you've got to remember that once a patient's prescribed a PPI, particularly in their 30s or 40s, the damage to the oesophagus is only going to increase with time. So I think for those group of patients then some form of surgical intervention which is there to mechanically repair the defective valve, which is ultimately the ethology of the condition, is a very attractive option.

    Porter
    And how effective is this procedure?

    Wajed
    This is a new procedure, it's only been out for two years, there's been limited experience in Europe but so far the results are extremely encouraging, we'd expect to see over 90% of patients be symptom free and off their medication. But as I say it is a new procedure but so far the results look very encouraging.

    Porter
    So effectively it cures the reflux in around 90% of cases and we would expect that to be on-going, is there any reason why this would stop working?

    Wajed
    There's no reason at all, it's a magnetic device, it should last for thousands, if not millions, of years, we would certainly expect it to last for the lifetime of the patient, would expect them to be symptom free and off medication for the rest of their life.

    Porter
    I can imagine a lot of people would be interested in having this done, I mean other than the cost what's the downside, I mean what can go wrong with this procedure?

    Wajed
    I mean it is an operative procedure, all operations do have a very, very small risk of complications, side effects, we're talking much less than 1%. There is an implant that goes into somebody and so that means they can't have MRI scans in the same way that somebody who has a hip replacement or a pacemaker would do. But with that aside there are no significant things. I think you've got to remember that if people don't have the procedure there are complications with refluxes, certainly people who aspirate at night and have choking and damage their lower oesophagus, without an operation there is certainly a risk. So although we do talk about risks with operations you've got to remind yourselves that there are risks of not having an operation, having medical therapy or no therapy at all.

    Porter
    But in terms of the side effects, if you were warning the patient, I mean are there any specific complications to this?

    Wajed
    No I mean all anti-reflux operations what we do is we're creating a new valve when patients have not had a valve in the past, so for a short period of time, a couple of days with the LINX procedure, a couple of weeks with the anti-.. normal anti-reflux, people do get some degree of difficulty in swallowing. So we advise them to go on a soft or a loose diet. But once they go through that six weeks periods and their gullet gets used to pushing against the new valve then that disappears and we wouldn't expect them to have any symptoms with that.

    Porter
    Saj Wajed from the Royal Devon and Exeter Hospital - and you will find more information on reflux, Barrett's disease and the various treatments, including that new LINX system, on our website. Go to bbc.co.uk/radio4 and head for the Inside Health page. And in case you were wondering it costs the NHS somewhere around seven thousand to treat one person with LINX, and closer to ten thousand to have it done privately.

    Time to move onto another, more controversial, type of device now and one that is aimed at much younger patients.

    Baby sounds

    Corrective helmets designed to ensure your baby grows up to have a perfectly shaped head. They are designed to treat positional plagiocephaly - flattening of the back or side of the skull seen in many babies and more widely known as flat head syndrome. The advertising and marketing of these helmets to parents has upset some doctors - including Inside Health's Margaret McCartney.

    McCartney
    First of all I'd seen some stories in local newspapers about parents who felt they had been forced to raise thousands of pounds by themselves so that their children would get this helmet, that wasn't available on the NHS, and which they thought would be necessary for their child so they would have a normal looking head. And I thought that was quite unusual because I'd never heard of it before in medical school and then I went on and I actually spoke to a friend of mine who was very concerned about her child's head and wanted my advice about whether or not I thought this was a good idea. And she showed me some literature she'd got from a clinic and I have to say I was really pretty horrified. The clinic were offering a sort of check day, an open day, an awareness day where you could bring your child along and be checked and then they would recommend for you if they felt it was necessary one of these helmets that costs a couple of thousand pounds.

    Porter
    And the helmets are working how?

    McCartney
    Well the clinics will say that they're put on at a stage when the baby's head is still moulding, when it's not properly settled into its adult shape yet, and they will say that the helmet's then applied for 23 out of 24 hours a day will reshape the baby's head so that any bumps and lumps really get sort of evened out in it.

    Porter
    So the child has to wear the helmet for 23 hours out of 24 but for how long?

    McCartney
    Months at a time really and I think the clinics would say that they would do it on an individual basis and bring the child back. But one huge emphasis that they do say is that the earlier your child is treated then the less months you may need treated for, which I think puts a really huge pressure on the parents to go ahead and accept the helmet sooner rather than later in the hope that the treatment will be of less duration.

    Porter
    And by early they're talking three or months are they?

    McCartney
    Absolutely yes and that's what they'll say on the website - the earlier the better, get your child seen by us quickly. Which I think is really incredibly worrying and stressful for parents who I really don't think are given balanced information about this.

    Porter
    And who better to provide some balance than a craniofacial specialist from Great Ormond Street Hospital? Consultant Plastic Surgeon David Dunaway.

    Dunaway
    When babies are born the skulls that they're born with are very, very soft indeed and ever since the early '90s it had been worked out that it was much safer for babies to lie on their back and that was shown to reduce the incidence of cot death very significantly.

    Porter
    But.

    Dunaway
    But. It does mean for a baby that has just been born, that has a relatively big head for its body and relatively weak muscles the baby's unable to turn very much and so the forces that act on the skull act in one place and that can cause a gradual flattening.

    Porter
    So they're lying on their back but baby's head is falling to one side or the other - looking to the left or the right?

    Dunaway
    Yes, so most babies do have a preference for one side or another and if that's allowed to persist you get more flattening on the side that they're looking to.

    Porter
    And presumably it does persist because once they find a comfortable position and the skull alters shape that's the side they tend to go.

    Dunaway
    Absolutely. So once you've got a flat bit on your skull it's so comfortable to lie there that you naturally show a preference for it.

    Porter
    But as the bones continue to grow they start to harden don't they, as the child gets older, does it matter that the baby's got a flat side of their skull, is it going to become permanent when these bones harden?

    Dunaway
    Generally it doesn't matter at all and for most babies they get a little bit of flattening and as they grow they increase their head control, they increase their mobility and it doesn't matter where you lie the baby it will turn in the cot in any way. And so the forces of lying are evenly distributed over the skull. And that for most babies happens at a very early age, when the skull is still mouldable and has a lot of plasticity and so the head just grows into a normal shape.

    Porter
    So the natural history for most of these children is if they're left to their own devices the skull becomes normal in the end?

    Dunaway
    Yes that's right. I think it's not uncommon in the normal population to see asymmetric skulls, none of us are perfectly symmetrical. So very mild degrees of flattening are very common but of course they're not a problem.

    Porter
    But at Great Ormond Street you must see an awful lot of people who are referred in because the mum or dad is worried about the flattening?

    Dunaway
    Most of the children we see at Great Ormond Street have been referred in by their paediatricians because they're worried about whether or not this is really positional plagiocephaly and there are a number of very rare conditions that can cause flattening of the head that do need treatment.

    Porter
    What's your take on the role of helmets?

    Dunaway
    They are unnecessary from a health point of view. We haven't got any evidence yet. There are lots of anecdotal reports that suggest that they are very effective. But of course the problem is that helmets are generally fitted at about the age of four months, at which time babies are becoming more active, they're starting to roll, so their head will naturally improve. So it's like trying to prove that a common cold cure works - you know you're going to get better from it, did you get better more quickly or in the case of helmets have you got more better than you would have done without them.

    Porter
    In practice the biggest problem with them is that they're expensive and unnecessary.

    Dunaway
    I think probably we know that babies who have helmets, their head shapes improve, but we know that babies who don't have helmets their head shapes improve as well.

    McCartney
    This is the crux, this is the really big point about this, there is no good randomised controlled evidence that say these helmets make a significant difference to the growth of children's heads. And so far when studies have been done they haven't found a difference between wearing the helmet and not, most children will get their heads more or less into the right kind of shape or what's supposedly the right kind of shape sooner than later, pretty much the children will end up normal.

    Porter
    But I suppose that's the problem as a young parent you're looking at your three or four month old baby who's got a bit of flattening on one side or the back of their head, as many do, and you're thinking well mine could be the exception - she or he could end up having that shaped head forever, I'd better do something about it. It's preying on their insecurities.

    McCartney
    It's horrible and I mean as a parent myself I know exactly how awful it is and you would do anything for your child, you really would, I mean there's nothing I wouldn't do for my kids and I think this is the problem - we're put into a position through our parenthood, a position where we will do anything for our children and if we're given advice that's alarming or inaccurate we're really not able to separate that very well if we're in that emotional state when we really would do anything for our kids.

    Porter
    So what did you do about it?

    McCartney
    Well I complained to the Advertising Standards Authority about one particular quite big clinic that advertise quite aggressively and also who offer awareness days, drop in clinics, where you can come and get your baby checked and they really were offering themselves as the first port of call, really sort of suggesting you should come to them before going to see your GP which I thought was very unfair because I would hope that a GP would give unbiased information not based on a commercial product, which this company was doing. And it was also not clear I think in the advertising either that there was no good evidence that these helmets really were necessary and made a difference. So I complained to the Advertising Standards Authority and they upheld all the points of my complaint.

    Porter
    Margaret, they may not be very popular here in the UK at the moment but in other countries they really have taken off - these helmets.

    McCartney
    That's right, in America in particular and we know that trends that often happen in America end up over here. And they're also very popular in Germany as well for some reason. So there definitely I think is this trend and I think with the aggressive marketing in the UK we can expect to see this more and more.

    Porter
    But are there any more natural measures that parents can take if they are worried about the shape of their baby's head? David Dunaway

    Dunaway
    There are some very simple measures that you can take, perhaps the simplest would be to rearrange the room so that when they lie in their cot everything that is of possible interest to them is on the opposite side of the cot and then they'll naturally turn their head that way. There are special pillows that you can get that will distribute the force over the back of the head much more evenly. And putting little wedges under the mattress of the cot so it's more comfortable for baby to lie looking in the other direction.

    Porter
    And presumably during the daytime you can put them - when you're with them - you can put them on their tummies as well?

    Dunaway
    Indeed, and in fact that's one of the things that we recommend is lots of tummy time. So when babies are with you try not to have them lying on the back of their head, have lots of tummy time and make sure that things in everyday life don't cause too much pressure, so don't tip the car seat too far back, make sure that the back of it isn't too hard or flat.

    Porter
    Surgeon David Dunaway. And there is more detail on those repositioning measures mentioned by David on our website - go to bbc.co.uk/radio4 and follow the links to Inside Health.

    Don't forget, if there is a health issue that confuses you that would like us to look into then you can get in touch by sending a tweet including the hashtag insidehealth, or by e-mailing me via insidehealth@bbc.co.uk

    I am off to Cornwall next week to find out about hepatitis E - it gets nothing like the publicity that surrounds its better known relatives, hep A, hep B and hep C, but that may be set to change.

    ENDS

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