What is Plagiocephaly?
Definition
Positional plagiocephaly (pronounced "play-jee-oh-seh-fuh-lee") is a cranial deformation consisting of flattening and asymmetrical head shape, typically affecting one side of the infant's head
- Alternative names: Flat head syndrome, deformational plagiocephaly, or non-synostotic plagiocephaly
- Prevalence: Affects up to 50% of infants according to recent studies, with European studies showing 37.8% prevalence in healthy full-term infants at 8-12 weeks of age
Physical characteristics
- Unilateral occipital flattening (flattening on one side of the back of the head)
- Contralateral occipital bulging (bulging on the opposite side)
- In severe cases, may include facial asymmetry and ear misalignment
- Head appears parallelogram-shaped when viewed from above
How Plagiocephaly Develops
- Primary mechanism: External forces continuously applied to the soft, malleable infant skull during early development
- Gravitational effect: When skull flattening occurs, the natural tendency is for the head to turn toward the flattened side due to gravity, creating a self-perpetuating cycle
Timing vulnerability
Most susceptible and easiest to correct during first 4 months of life when:
- Skull bones are softest and most mouldable
- Infant lacks ability to independently change head position
- Brain growth is most rapid
Skull development factors
- Infant skull bones don't fully fuse until several months after birth
- Soft, pliable bones allow easier birth passage and brain growth
- This same softness makes skulls susceptible to positional deformation
Risk Factors and Causes
Primary Risk Factors
- Prolonged supine positioning: Extended time lying on back (though "back to sleep" remains essential for SIDS prevention)
- Congenital muscular torticollis: Tight or imbalanced neck muscles causing positional preference
- Limited mobility: Excessive time in car seats, bouncy chairs, swings, and positioning devices
- Insufficient tummy time: Lack of supervised prone positioning during wake periods
Secondary Risk Factors
- Birth-related factors: Assisted delivery with forceps or vacuum extraction
- Intrauterine positioning: Breech position or limited space in utero (especially with multiples)
- Prematurity: Softer bones and extended time in hospital positioning
- Being firstborn: Often related to tighter uterine space
- Male gender: Higher statistical prevalence
The Critical Golden Period: First 4 Months
- Maximum malleability: Skull is most responsive to both deformational forces and corrective interventions during first 16 weeks
Rapid brain growth
- Brain doubles in size during first year
- Most dramatic growth occurs in first 4 months
- Skull sutures remain most mobile during this period
Motor development window
- Head control typically achieved by 4 months
- Pull-to-sit reflex demonstrates antigravity neck strength
- Independent rolling usually begins around 4-6 months
- Intervention effectiveness: Research consistently shows earlier intervention produces better outcomes with shorter treatment duration
Prevention Strategies for Parents
Positioning and Handling
- Vary sleep positions: Alternate head position nightly (left/right) while maintaining back sleeping for SIDS prevention
- Supervised tummy time:
- Start immediately after hospital discharge
- Begin with 20 seconds at a time, start small with chest-to-chest time
- Build-up to 2-5 minutes over time, several times a day
- Progress to 15-30 minutes daily total by 2 months
- Work toward 60 minutes daily total by 4 months
- Frequent position changes: Every 15-30 minutes during wake periods
- Minimize equipment time: Limit prolonged use of car seats, bouncy chairs, and swings for non-transport purposes
Active Engagement Strategies
- Baby wearing: Use carriers and slings to keep infants upright and off the back of their heads
Interactive positioning
- Alternate feeding positions (switch arms during bottle feeding)
- Vary diaper changing orientations
- Change direction baby faces in crib periodically
- Environmental stimulation: Place toys and interaction sources to encourage head turning to both sides
"Face Time" Positioning
- Supine engagement: Encourage antigravity head control while on back through interactive play
- Pull-to-sit exercises: Gentle exercises that promote neck flexor strength and coordination
- Multi-directional stimulation: Encourage looking and reaching in all directions during supervised play
Treatment Progression and Timeline
Early Detection (6-8 weeks)
- Visual assessment: Parents typically notice flattening by 6-8 weeks of age
- Professional evaluation: Healthcare provider can diagnose through visual observation
- Measurement tools: Anthropometric measurements including cranial vault asymmetry index (CVAI)
Conservative Management (First-line treatment)
- Repositioning therapy: Systematic position changes and environmental modifications
- Physical therapy: Specific exercises targeting neck mobility and strength
- Parental education: Comprehensive guidance on positioning and handling techniques
Manual Therapy Musculoskeletal Interventions
- Paediatric integrative manual therapy by chiropractors, osteopaths or physiotherapists: Specialized techniques tailored for infants, which include craniosacral principles, mobilization of cranial and spinal structures to restore range of motion and to unwind tissue.
Advanced Interventions (Second-line)
- Helmet therapy: Reserved for moderate to severe cases not responding to conservative treatment
- Timing considerations: Most effective when initiated before 12 months, ideally by 6 months
Research Supporting Manual Therapy Benefits
High-Quality Randomized Controlled Trials
Pastor-Pons et al. (2021)
- Study design: 34 infants with moderate-severe plagiocephaly, randomized controlled trial
- Intervention: 10-session paediatric integrative manual therapy plus caregiver education vs. education alone
Key findings
- Cranial vault asymmetry index decreased 3.72% in manual therapy group vs. 0.34% in control group (p = 0.000)
- Significant improvement in cervical rotation (29.7° vs. 6.1°, p = 0.001)
- High parental satisfaction with treatment outcomes
Cabrera-Martos et al. (2016)
- Study design: 46 infants with severe plagiocephaly, randomized controlled pilot study
- Intervention: Manual therapy added to standard treatment (repositioning + helmet) vs. standard treatment alone
Key findings
- Significantly shorter treatment duration (109.84 ± 14.45 days vs. 148.65 ± 11.53 days, p < 0.001)
- Improved motor development scores on Alberta Infant Motor Scale
- All participants achieved minimal asymmetry (Argenta scale 0-1) by discharge
Systematic Review Evidence
2023 Systematic Review (Blanco-Diaz et al.)
- Conclusion: "Physical therapy treatment is considered as the first line of intervention in plagiocephaly with non-synostotic asymmetries and manual therapy is the method that obtains the best results within this intervention"
- Key recommendation: Manual therapy combined with parental counselling produces superior outcomes compared to repositioning alone
2020 Systematic Review (Ellwood et al.)
- Findings: Considerable evidence supports manual therapy over helmet therapy
- Safety profile: Manual therapy approaches demonstrate excellent safety records with no reported adverse events
Specific Manual Therapy Techniques with Evidence
Osteopathic Manipulative Treatment (OMT)
- 12 infants with cranial asymmetry received 4 treatments over 2 weeks
- Significant decreases in cranial vault asymmetry, skull base asymmetry, and trans-cranial vault asymmetry
- Most effective in infants younger than 6.5 months
Craniosacral Therapy
- Focuses on spheno-occipital joint, atlanto-occipital synchondrosis, and sacral mobility
- Biomechanical approach targeting functional joint movement
- Evidence shows reduced treatment duration when added to standard care
Helpful Interventions for Parents
Daily Routine Modifications
- Sleep positioning: Use visual cues (mobile positioning, room lighting) to encourage natural head turning
- Feeding variations: Alternate bottle-feeding arms and breastfeeding positions
- Transport considerations: Minimize non-essential time in car seats and strollers
- Play surface variety: Use different surfaces and elevations for tummy time
Environmental Adaptations
- Crib positioning: Periodically change which end of the crib is the "head" end
- Toy placement: Position interesting objects to encourage turning toward less-favored side
- Caregiver positioning: Vary your position when interacting with baby to promote bilateral head turning
Exercise and Stimulation
- Neck stretches: Gentle, guided range-of-motion exercises (under professional guidance)
- Tummy time progression:
- Start on caregiver's chest for comfort
- Progress to firm surfaces with engaging toys
- Use props like nursing pillows for support initially
- Carrying positions: Vary between forward-facing, side-lying, and upright positions in arms
Red Flags Requiring Professional Evaluation
- Persistent head preference: Consistent turning to one side despite positioning efforts
- Limited neck mobility: Difficulty turning head fully to both sides
- Facial asymmetry: Noticeable differences in ear position, eye alignment, or facial features
- Developmental concerns: Delays in motor milestones or muscle tone abnormalities
Professional Practice Considerations
Assessment Protocol
- Visual evaluation: Systematic observation of head shape from multiple angles
- Anthropometric measurements: CVAI, cranial index, and diagonal diameter differences
- Functional assessment: Cervical range of motion, muscle tone, and motor development
- Parent interview: Birth history, positioning habits, and developmental milestones
Treatment Planning
- Early intervention emphasis: Stress critical importance of first 4 months for optimal outcomes
- Multimodal approach: Combine manual therapy with comprehensive parental education
- Regular monitoring: Track progress using standardized measurements and parental feedback
- Collaborative care: Coordinate with paediatricians and other healthcare providers
Patient Education Priorities
- SIDS safety first: Reinforce that back sleeping remains non-negotiable for safe sleep
- Realistic expectations: Explain that improvement takes time and consistency
- Active participation: Emphasize parents' crucial role in daily positioning and exercises
- Long-term perspective: Discuss natural improvement as child becomes more mobile
CRITICAL: Recognizing Craniosynostosis vs. Positional Plagiocephaly
Craniosynostosis - RED FLAGS Requiring Referral
Definition
Craniosynostosis occurs when one or more sutures close early. Early suture closure can cause the skull to grow in an unusual shape. Sometimes, early suture closure can also restrict overall skull growth which may be harmful to the growing brain inside
Key Differentiating Features
Timing and Progression
- Craniosynostosis: Craniosynostosis is congenital, whereas deformational plagiocephaly usually develops in the neonatal period
- Craniosynostosis: Present from birth, progressively worsens with time
- Positional plagiocephaly: Develops after birth (usually 6-8 weeks), can improve with intervention
Physical Examination Findings
Palpable Ridge
- Craniosynostosis: Persistent ridging at the suture lines in an infant with an abnormally shaped head is suggestive of craniosynostosis
- Craniosynostosis: Hard, bony ridge along affected suture line
- Positional plagiocephaly: No palpable ridging, soft areas over open sutures
Ear Position (Critical Diagnostic Sign)
- Lambdoid craniosynostosis: Ear on flattened side is typically posterior and inferior to the other ear
- Positional plagiocephaly: whereas in plagiocephaly the ear on the flattened side is 'pushed forward'
Head Shape Patterns
- Lambdoid synostosis: In infants with lambdoid synostosis, the posterior bossing is in the parietal area contralateral to the flat part of the head
- Positional plagiocephaly: Deformational plagiocephaly causes frontal bossing ipsilateral to the flat part of the head
Note: These recommendations are based on current research evidence and should be integrated with clinical judgment and individual patient assessment.
