A team of pediatric craniofacial and neonatal specialists in Orlando has identified what they describe as a previously unrecognized pattern of skull deformity in the most fragile survivors of extreme prematurity. In a retrospective study published in the Journal of Perinatology, researchers led by Suzanne Greenleaf Martin of Orlando Health Children’s Neurosciences examined ten extremely premature infants with severe bronchopulmonary dysplasia, or BPD, who required prolonged high-pressure mechanical ventilation and eventual tracheostomy. What they found was striking: a constellation of accelerated head growth, premature closure of cranial sutures, and marked thickening of the skull vault that does not fit the classical descriptions of craniosynostosis syndromes seen in otherwise healthy infants. The finding, if confirmed in larger cohorts, could reshape how neonatal intensivists monitor head growth in ventilator-dependent infants and how craniofacial surgeons approach these complex patients.
Craniosynostosis, the premature fusion of one or more fibrous joints between the bones of the skull, affects roughly one in every 2,000 to 2,500 births in its typical forms. Because the skull must expand rapidly to accommodate a growing brain, early suture fusion forces the cranium to grow in compensatory directions, producing characteristic head shapes and, in some cases, raised intracranial pressure. Most cases are classified as primary, arising from genetic or developmental factors intrinsic to the suture itself. Secondary craniosynostosis, by contrast, is triggered by external or systemic influences, including metabolic bone disease, hyperthyroidism, or conditions that alter the biomechanical environment of the growing skull. The pattern reported in the new study appears to belong to this second category, but with features the authors say have not been documented together before.
The study population was narrowly and deliberately defined. The researchers reviewed charts of infants born at their institution between January 2020 and May 2025, including only those delivered at 22 to 28 weeks of gestation who went on to develop severe BPD and ultimately required a tracheostomy. Severe BPD is the most disabling form of chronic lung disease of prematurity, generally defined by a profound ongoing need for respiratory support well beyond the neonatal period. These infants spend months on mechanical ventilation, often at pressures far exceeding those used for typical neonatal care. Ten patients met all inclusion criteria, a small number that reflects both the rarity of this degree of respiratory morbidity and the single-center design of the review.
The most eye-catching quantitative result concerned head growth. Using standardized preterm growth charts and electronic growth chart calculators, the team tracked each infant’s head circumference percentile over time and found that the greatest four-week rise averaged 43 plus or minus 14 percentile points. That surge in head growth significantly outpaced concurrent changes in weight and length percentiles, a dissociation the authors report with a P value of 0.0023. In practical terms, these infants’ heads were growing dramatically faster than the rest of their bodies, the reverse of the growth faltering more commonly seen in chronic lung disease. The researchers also calculated a weighted mean sustained positive end-expiratory pressure of 10.6 centimeters of water across the cohort, a figure that quantifies the substantial ventilatory forces these infants’ chests and, potentially, their cranial circulation were exposed to for months.
Imaging told the rest of the story. Three-dimensional reconstructions of computed tomography scans of the head and maxillofacial region, presented in the published figures, revealed suture closure patterns described as atypical, alongside visible thickening of the calvarial bone, the dome of the skull. Calvarial thickening is not a feature of ordinary primary craniosynostosis and suggests an active bone-forming response rather than a simple failure of suture patency. The combination of rapid head circumference acceleration, abnormal suture fusion, and thickened skull bone led the authors to propose a novel phenotype of secondary craniosynostosis specific to this population of ventilator-dependent, tracheostomized infants with severe BPD.
The study was not the first to hint at this connection. The authors build on a 2023 report in the Journal of Craniofacial Surgery that described a similar phenotype of calvarial thickening and increased rates of premature calvarial suture closure in children with chronic lung disease. An earlier 2009 study had also associated rapid head growth in children following tracheostomy tube placement, suggesting that the airway intervention itself, or the underlying respiratory failure that necessitates it, may be linked to altered cranial growth dynamics. The new work sharpens the picture by focusing on a homogeneous group of extremely premature infants and by quantifying both the growth acceleration and the ventilatory pressures involved.
Why might prolonged high-pressure ventilation reshape a growing skull? The authors point to several plausible mechanisms that remain to be tested. Positive end-expiratory pressure, the pressure maintained in the airways at the end of each breath to keep the lungs open, is known from decades of neonatal physiology research to influence cerebral hemodynamics. Studies dating back to the late 1980s documented changes in cerebral blood flow velocity when positive end-expiratory pressure was adjusted in preterm infants, and more recent work has shown that ventilation mode changes can affect cerebral oxygen saturation. Sustained elevations in intracranial venous pressure or altered pulsatile forces transmitted through the dura could, in theory, alter the mechanical signaling environment of cranial sutures, which are exquisitely sensitive to tension and compression during development. Chronic hypoxia and the inflammatory milieu of severe BPD may add further systemic influences on osteoblast activity in the skull vault.
The clinical implications are potentially significant for both monitoring and intervention. Head circumference is routinely measured in neonatal follow-up care, but an accelerating head growth curve in a ventilator-dependent infant might currently be attributed to catch-up growth or, in some cases, mistaken for hydrocephalus. The new findings suggest that clinicians caring for infants with severe BPD on prolonged high-pressure support should consider cranial imaging when head growth accelerates disproportionately, since early identification of suture fusion can inform decisions about surgical release. Traditional management of single-suture craniosynostosis, as reviewed in the neurosurgical literature, ranges from observation to endoscopic strip craniectomy or open cranial vault remodeling, and the optimal approach for these medically fragile infants with thickened, abnormally remodeling skulls is entirely uncharted territory.
The authors are careful about the limits of their evidence. Ten patients from a single center, identified retrospectively, cannot establish causation, and the study lacked a comparison group of ventilated infants without severe BPD or of preterm infants managed with lower ventilatory pressures. The researchers explicitly call for prospective studies to define ventilatory exposure thresholds, clarify the underlying mechanisms, and determine the neurologic and surgical implications of this phenotype. Data availability is constrained by privacy protections inherent to such a small, reidentifiable cohort, though deidentified data may be shared upon reasonable request with institutional review board approval. The study protocol was approved by the Orlando Health Institutional Review Board, and the authors declare no competing interests.
Even with those caveats, the report opens an unexpected window onto how the environment of intensive care may leave structural marks on the developing body. The skull of an extremely premature infant is a dynamic, pliable structure whose sutures normally remain open for years to allow brain growth; the idea that months of positive-pressure breathing could accelerate bone deposition and suture fusion adds intensive care itself to the list of forces that sculpt cranial development. For the growing population of technology-dependent children who survive extreme prematurity, the findings underscore the need for long-term craniofacial surveillance and for research that treats the ventilator not merely as a life-sustaining tool but as a physiological exposure with consequences that may extend to the skeleton. As the authors conclude, only carefully designed prospective studies can determine whether this novel phenotype represents a true complication of modern neonatal intensive care and what it will mean for the neurodevelopmental and surgical futures of the children it affects.
Subject of Research: Atypical secondary craniosynostosis in ventilator-dependent premature infants with severe bronchopulmonary dysplasia
Article Title: Are premature infants with severe bronchopulmonary dysplasia at increased risk for atypical craniosynostosis?
Article References: Martin, S. G., Matrone, C., Stephens, M., Queliz Pena, T., Schreck, M., Guerrero, R. A., Zimmerman, A., Elbabaa, S. K., Jafrani, R., & Golden, B. (2026). Are premature infants with severe bronchopulmonary dysplasia at increased risk for atypical craniosynostosis?. Journal of Perinatology. https://doi.org/10.1038/s41372-026-02907-3
Image Credits: AI Generated
DOI: 10.1038/s41372-026-02907-3
Keywords: craniosynostosis, bronchopulmonary dysplasia, premature infants, mechanical ventilation, positive end-expiratory pressure, tracheostomy, head circumference, calvarial thickening, neonatology, craniofacial surgery, Journal of Perinatology, retrospective study
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Harold Sullivan. (September 26, 2026). High-Pressure Ventilation Linked to Atypical Skull Suture Fusion in Preterm Infants. Scienmag. https://scienmag.com/high-pressure-ventilation-linked-to-atypical-skull-suture-fusion-in-preterm-infants/
Harold Sullivan. “High-Pressure Ventilation Linked to Atypical Skull Suture Fusion in Preterm Infants.” Scienmag, 26 September 2026, https://scienmag.com/high-pressure-ventilation-linked-to-atypical-skull-suture-fusion-in-preterm-infants/. Accessed 26 September 2026.
Harold Sullivan. “High-Pressure Ventilation Linked to Atypical Skull Suture Fusion in Preterm Infants.” Scienmag. September 26, 2026. https://scienmag.com/high-pressure-ventilation-linked-to-atypical-skull-suture-fusion-in-preterm-infants/
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Tags: atypical skull fusion patterns in preemiesbronchopulmonary dysplasiacalvarial thickeningcraniofacial surgerycraniosynostosiscraniosynostosis in premature infantsextreme prematurity and cranial sutureshead circumferencehigh-pressure ventilation effects in neonatesimpact of mechanical ventilation on skull developmentJournal of Perinatologymechanical ventilationneonatal craniofacial abnormalitiesneonatal intensive care and skull growth monitoringneonatal skull deformitiesneonatal skull deformities linked to ventilator useneonatologypositive end-expiratory pressurepremature infantspremature infants with skull vault thickeningpreterm infant cranial suture fusionretrospective studytracheostomytracheostomy and skull deformities
