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Positional Plagiocephaly | American Association of Neurological Surgeons

Positional plagiocephaly is a condition in which specific areas of an infant’s head develop an abnormally flattened shape and appearance. Occipital plagiocephaly causes a flattening of one side of the back of the head and is often a result of the infant consistently lying on his or her back. A flat area may develop very quickly over several months. Physically, the infant may have one ear that is shifted forward. In more severe cases, the infant may have forehead or cheek protrusion on the flat side of his or her head. There are other types of plagiocephaly, some of which are caused by a serious condition called craniosynostosis. In craniosynostosis, the deformity is caused by premature closure of the fibrous joints between the bones of the infant skull (called cranial sutures). A thorough examination is necessary to confirm or rule out this diagnosis.

A small number of infants have positional plagiocephaly at birth. This is more common in multiple or premature births, but can also be caused by position in the womb. There are no preventive measures that can be taken by expectant mothers or their physicians to avoid this. Newborn infant skulls are very soft and malleable to help ease them through the birth canal, so it is not unusual for newborns to have unusually shaped heads, due to the pressure of birth. This condition usually resolves itself by six weeks of age; however, some infants show a preference for sleeping or sitting with their heads turned consistently in the same position, which may lead to positional plagiocephaly. Infants with torticollis, shortening of the neck muscles on one side of the neck, have difficulty turning their heads to another position. This can be resolved through stretching exercises and only requires surgery in extreme cases.

In 1992, the American Academy of Pediatrics made the recommendation that infants should sleep on their backs to reduce the risk of SIDS (Sudden Infant Death Syndrome), which launched the "Back to Sleep Campaign". Due to SIDS awareness through the Back to Sleep Campaign, the number of SIDS cases has decreased, but there has been a dramatic increase in the number of infants with positional plagiocephaly.

The risk of positional plagiocephaly can be reduced through a few simple measures:

• Provide an infant with plenty of supervised playtime on his or her tummy. This helps build and strengthen neck, shoulder and arm muscles.
• Change the direction the baby is lying in the crib on a regular basis to ensure he or she is not always resting on the same part of the head. For example, have the baby’s feet point toward one end of the crib for a few days, and then change the position so his or her feet point toward the other end of the crib.
• Avoid too much time in car seats, carriers and bouncers while the baby is awake.
• Frequently get "cuddle time" during the day by holding the baby upright over one shoulder.
• When holding, feeding or carrying an infant, make sure that there is no undue pressure placed on the flat side of the head. Change infant’s head position from side to side during feeding time.
• Change the location of the baby’s crib in the room so that he or she has to look in different directions to see the door or the window.
• If there is an element of torticollis (neck stiffness) this will also require treatment for the repositioning therapy to be effective.

Diagnosis is usually made by a pediatrician. At well baby visits, the baby’s head is examined to determine if the shape is symmetrically oval or not. If you have concerns about your baby’s head shape, you should discuss this concern with your pediatrician. If a baby’s head shape is not oval and symmetrical, try to have the baby sleep in different positions (see the next section). If the shape is unusual for this diagnosis, a skull X-ray or CT scan may be ordered. The range of movement of the baby’s neck may also be examined to see if there is any restriction that is contributing to the baby lying in one position more than another.

If this diagnosis is entertained, it may call for a specialist referral to discuss the baby’s head shape further and to distinguish it from premature fusion of the cranial growth plates (sutures). This specialist may be a plastic surgeon, a neurosurgeon or a craniofacial clinic that specializes in baby head shapes. Craniofacial clinics are usually overseen by plastic surgeons and neurosurgeons. If the baby has a tight neck (torticollis), he or she may be referred to a physical therapist that will help with stretching exercises. A tight neck will often resolve with these exercises, but can recur with periods of fast growth.

In the majority of cases, having a flattened area will not affect a child’s brain growth or mental development. Once a child is able to sit and stand, external forces are eliminated and the deformity begins to improve. Although it may not resolve completely, the remaining flattening is usually minor and covered with hair as the child grows. The frontal differences are often minimal and tend to resolve completely over time. However, when unresolved flattening causes facial abnormalities, problems with chewing, eating and vision may occur. In addition, children may have difficulties with socialization due to being self-conscious about their appearance. In some severe cases, surgery may be necessary.

If positional therapy does not work, helmet or band therapy may be recommended. The original molding helmet, introduced in 1979, utilized the basic concept of surrounding the asymmetrical infant head with a symmetrical (normal) mold. This helped the skull resume a normal shape. An alternative technique, Dynamic Orthotic CranioplastySM (DOC Band®), was developed as a more proactive approach in treating positional plagiocephaly. In this technique, the device is specifically designed to apply gentle pressure to the area of the head where growth was not wanted, while leaving space where growth was needed. The band is adjusted on a weekly or biweekly basis.

Today, there are a far wider variety of bands and helmets, many of which take into consideration the concepts of the original molding helmets and the DOC Band®. Every case is different, but all products are custom fit to the infant’s head. For optimal effectiveness, it is recommended that helmet or band therapy begin by five months of age. The length of therapy depends on the individual case, but usually takes between two and six months.

Physical therapy for neck stretching, if torticollis (neck tightness) is present, is also important. Repositioning therapy will not be effective if the torticollis continues to be an issue.

The pediatrician will make the initial diagnosis and usually recommend a course of positional therapy. If this fails to resolve the problem, the parents or guardians will be given a referral to see a specialist, such as a pediatric neurosurgeon. The specialist will review the pediatrician’s referral, perform a thorough evaluation, talk to the parents about the baby’s history and discuss the treatment program. If a cranial remolding helmet is recommended, the family will then be referred to an orthotist for fitting of the helmet. The orthotist may choose to take clinical photographs and a series of measurements with calipers or a scan to assess the shape of the baby’s skull. These pictures and measurements serve as a point of reference throughout the course of treatment. The orthotist will create a duplicate of the baby’s head using a plaster impression or a 3-D scan. The band will be precisely fabricated and customized to the baby’s head to achieve improved symmetry and proportion.

Adjustments to the helmet need to be made every 1-2 weeks because a baby’s head grows very quickly. This involves adjusting the foam lining and/or portions of the outside plastic helmet. A second helmet may be required if the baby grows out of the first helmet prior to completion of treatment.

• Do not purchase helmets without first consulting a physician specialist.
• When treatment starts at the optimum age of 3-6 months, it usually can be completed within 12 weeks.
• Correction is still possible in babies up to age 18 months, but will take longer.
• The baby will wear the helmet/band 23.5 hours per day with the exception of one-half hour set aside for bathing and cleaning.
• Be aware of the cost and the amount covered by insurance before proceeding.
• The baby’s skin should be monitored to make sure there are no deep red areas developing. If there is an area that has too firm contact with the band, the skin may breakdown, causing scarring or other issues.

Angela V. Price, MD, FÂ鶹ÊÓƵ
Assistant Professor, UTSW
Department of Pediatric Neurosurgery
Dallas

The Â鶹ÊÓƵ does not endorse any treatments, procedures, products or physicians referenced in these patient fact sheets. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific neurosurgical advice or assistance should consult his or her neurosurgeon, or locate one in your area through the Â鶹ÊÓƵ’ Find a Board-certified Neurosurgeon online tool.