A 6-month-old male came to clinic for his health supervision visit. He had previously been noted to have right occipital plagiocephaly and the parents had been instructed to change infant positions, increase “tummy-time” and to do stretching exercises of his neck. The family admitted some compliance with the treatment, and were now more concerned about his face as they felt he now was having some facial changes noting his right cheek seemed more prominent. He was otherwise well and developmentally appropriate currently sitting with minimal assistance, easily transferring objects, and saying vowels and consonant sounds. The past medical history showed that he was a first born male, full-term infant.
The pertinent physical exam revealed an interactive infant with normal vital signs and growth parameters. His right occipital area had significant flattening and a slightly vertical peak when viewed from behind the infant. When viewed from above the head had a parallelogram appearance. He had ~8 mm anterior ear displacement. When measuring from the eyebrow to the contralateral occipital protuberance, there was a 10 mm difference between the two sides. There was no obvious ridging of the suture lines, and the anterior fontanelle was 1 cm open. The diagnosis of positional plagiocephaly was made. The infant was referred to a neurosurgeon for possible orthotic treatment with a helmet. The patient’s clinical course showed that the family did comply with the helmet use and after 4 months the infant had significant improvement with only mild posterior flattening and only slight anterior ear displacement still present.
Plagiocephaly can occur at birth due to in utero or intrapartum problems (i.e. prematurity, multiple birth, breech positioning, oligohydramnios, forceps extraction, etc.), but positional plagiocephaly (PP) usually occurs after birth due to mechanical factors. These include positioning of the infants head such that little repositioning occurs (i.e. bottle feeding only on same side, placement in crib on same side, placement always on infant’s back with no prone placement, lying or sitting in crib, infant carrier or other similar object for prolonged time periods, etc.)
Usually PP has a parallelogram skull shape when observed from above caused by flattening of the affected occiput and anterior displacement of the ipsilateral ear and facial structures. This is in contrast to true craniosynostosis (premature closure of the sutures) which is more trapezoidal with flattening of the occipital and frontal areas on the affected side. Although uncommon, lamboid craniosynostosis can also make a parallelogram shape as well.
PP prevention includes infant placement in multiple positions (i.e. upright in arms, cradled in adult arms with head orientation alternating between arms, placement on back for sleep with head orientation alternating at different ends of the crib, prone positioning while awake and attended such as “tummy-time”, etc.) and prolonged placement in one position avoided such as car seats or infant swings. Most infants will have improvement in 2-3 months with repositioning and/or neck exercises. If not, then referral to a neurosurgeon or other similar team proficient in treatment should be considered. Skull radiographs and computed tomography of the head are not recommended, unless a neurosurgeon or other specialist has recommended them for possible surgical evaluation of craniosynostosis.
Treatment for PP includes:
- 1. Repositioning – education of parents to frequently change positions as noted above.
- 2. Neck exercises – torticollis is often present. Neck exercises to increase range of motion can be reviewed here.
- 3. Orthotic skull molding helmets
Skull molding helmets are often recommended for infants older than 6 months, if positioning and exercises have failed to give an adequate response and if the cranial diagonal distances are more than 1.0 cm different between sides (normal difference is 2-4 mm). As most primary care physicians do not have cranial calibers available in their office this measurement is difficult to obtain. One measurement which could be easier to obtain is the anterior superficial helical ear fold to the lateral canthus of the eye indicating anterior displacement of the structures. Normal is < 0.5 cm difference from one side to the other. Helmets have the best results when they are used early (4-6 months) and may have shorter times for results. Reasonable results can be found in infants < 12 months of age but can also be helpful in some children >12 months.
Questions for Further Discussion
1. Why are families and providers concerned about positional plagiocephaly?
2. How common is positional plagiocephaly?
- Symptom/Presentation: Growth Problems
- Age: Infant
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Graham JM Jr, Gomez M, Halberg A, Earl DL, Kreutzman JT, Cui J, Guo X.
Management of deformational plagiocephaly: repositioning versus orthotic therapy. J Pediatr. 2005 Feb;146(2):258-62.
Lipira AB, Gordon S, Darvann TA, Hermann NV, Van Pelt AE, Naidoo SD, Govier D, Kane AA. Helmet versus active repositioning for plagiocephaly: a three-dimensional analysis. Pediatrics. 2010 Oct;126(4):e936-45.
Kluba S, Kraut W, Reinert S, Krimmel M.
What is the optimal time to start helmet therapy in positional plagiocephaly?
Plast Reconstr Surg. 2011 Aug;128(2):492-8.
Laughlin J, Luerssen TG, Dias MS; Committee on Practice and Ambulatory Medicine, Section on Neurological Surgery. Prevention and management of positional skull deformities in infants. Pediatrics. 2011 Dec;128(6):1236-41.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.
19. The health professional works effectively with others as a member or leader of a health care team or other professional group.
23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital