Plagiocephaly: Difference between revisions

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== Introduction ==
[[File:Plagiocephaly.jpg|Example of plagiocephaly in infant.
Credit: [https://commons.wikimedia.org/wiki/File:Плагиоцефалия.jpg#file Medical advises, Плагиоцефалия,] [https://creativecommons.org/licenses/by-sa/3.0/legalcode CC BY-SA 3.0].
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[[File:Plagiocephaly.jpg|center|frame|Example of plagiocephaly in infant.
Positional plagiocephaly is increasingly common in infants. Positional plagiocephaly is an asymmetric deformation of the skull. It has a number of potential causes, including: first birth, assisted labour, multiple births (e.g. twins, triplets etc), prematurity, [[Congenital torticollis|congenital muscular torticollis]], position of the head and lying in the same position for prolonged periods.<ref name=":4">Jung BK, Yun IS. Diagnosis and treatment of positional plagiocephaly. Archives of craniofacial surgery. 2020 Apr;21(2):80.</ref><ref name=":2">Childerens health qld gov. Plagiocephaly Available:https://www.childrens.health.qld.gov.au/fact-sheet-plagiocephaly/ (accessed 8.10.2021)</ref>
Credit: [https://commons.wikimedia.org/wiki/File:Плагиоцефалия.jpg#file Medical advises, Плагиоцефалия,] [https://creativecommons.org/licenses/by-sa/3.0/legalcode CC BY-SA 3.0].
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== Introduction ==
There are two types of plagiocephaly: 1. ''plagiocephaly followed by craniosynostosis'' (a birth defect in which the bones in a baby's skull fuse prematurely) and 2. ''positional plagiocephaly without craniosynostosis''.<ref name=":4" /><ref>Unnithan AK, De Jesus O. [https://www.statpearls.com/ArticleLibrary/viewarticle/126820 Plagiocephaly]. InStatPearls [Internet] 2022 May 1. StatPearls Publishing.</ref>


'''Plagiocephaly''' is a term used to describe an assymetry in the shape of the skull. It can be '''synostotic''' (caused by premature closure of the skull sutures) or '''non-synostotic''' (caused by the effect of sustained external forces on the soft infant skull) <ref>Ghizoni E, Denadai R, Raposo-Amaral CA, Joachim AF, Tedeschi H and Raposo-Amaral CE. Diagnosis of infant synostotic and non-synostotic cranial deformities: a review for pediatricians. Rev Paul Pediatr 2016;34(4):495-502 </ref>. This page focuses on non-synostotic plagiocephaly, also known as positional or deformational plagiocephaly or referred to as flat head syndrome.
* When plagiocephaly occurs with craniosynostosis, the skull deforms due to premature fusion of the sutures in the skull. This condition often requires surgical management and helmet therapy may be used.<ref name=":4" />


== Clinically Relevant Anatomy<br> ==
* In plagiocephaly without craniosynostosis, the sutures between the bones are normal, so skull growth is not affected. However, the shape can be altered - most commonly the head is flattened on one side of the posterior aspect.<ref name=":4" />  


{{#ev:youtube|G1XhXvrWmAE|300}}<ref>Dr. J. Baby Skull. Available from https://www.youtube.com/watch?v=G1XhXvrWmAE&t= [Accessed 14/6/2018]</ref>
== Clinically Relevant Anatomy  ==
The 2 minute video below explains the skull and fontanels of a newborn.{{#ev:youtube|G1XhXvrWmAE|300}}<ref>Dr. J. Baby Skull. Available from https://www.youtube.com/watch?v=G1XhXvrWmAE&t= [Accessed 14/6/2018]</ref>


The skull covers and protects the brain and consists of several bony plates connected together by fibrous material called sutures. Sutures allow movement of the bones necessary to accommodate brain growth and allow moulding of the head during birth <ref>University of Rochester Medical Centre. Anatomy of the newborn skull. https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=90&contentid=p01840 (accessed 13 June 2018).</ref> and as a result the infant skull is vulnerable to deformation.   
The skull covers and protects the brain. It consists of several bony plates connected together by fibrous material called sutures. Sutures allow movement of the bones necessary to accommodate brain growth and allow moulding of the head during birth.<ref>University of Rochester Medical Centre. Anatomy of the newborn skull. https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=90&contentid=p01840 (accessed 13 June 2018).</ref> As a result, the infant skull is vulnerable to deformation.   


== Mechanism of Injury / Pathological Process  ==
== Mechanism of Injury / Pathological Process  ==


Positional plagiocephaly is caused by pressure on the developing infant skull from an external force. This can occur in the womb, but more commonly develops post-natally. The "Back to sleep" campaign was launched in 1991 in the UK to reduce the risk of sudden infant death syndrome (SIDS). The campaign sought to educate parents and health care professionals about research that linked SIDS to babies put to sleep on their stomachs, and advise putting them on their back to sleep. According to The Lullaby Trust the incidence of SIDS has significantly dropped in the UK since the campaign was launched <ref>The Lullaby Trust. The Lullaby Trust celebrates 25th anniversary of Back to Sleep campaign<nowiki/>https://www.lullabytrust.org.uk/the-lullaby-trust-celebrates-25th-anniversary-of-back-to-sleep-campaign/ (Accessed 14 June 2018)</ref>.  
It is not uncommon for newborns to have "unusually" shaped heads - depending on the cause, most of these cases resolve within around six weeks of birth.<ref name=":3">RCHM Plagiocephaly – misshapen head Available:https://www.rch.org.au/kidsinfo/fact_sheets/Plagiocephaly_misshapen_head/ (accessed 8.10.2021)</ref> Reasons for a change in head shape include the baby's position in the uterus and "moulding" of head during labour, including if the delivery is assisted (i.e. ventouse, forceps).<ref name=":3" /> 


Whilst practices may be different in other countries, in the UK many babies may spend significant amounts of time on their backs, either in their cot, in a car seat or in a buggy. The external forces from these firm surfaces can cause positional plagiocephaly. '''However it is still recommended to put babies on their backs to sleep as the importance of a reduced SIDS risk outweighs any potential dangers due to positional plagiocephaly''' <ref name=":1">Great Ormond Street Hospital for Children. Positional Plagiocephaly. https://www.gosh.nhs.uk/conditions-and-treatments/conditions-we-treat-index-page-group/positional-plagiocephaly (Accessed 14 June 2018)</ref>.
''Positional plagiocephaly'' is caused by pressure on the developing infant skull from an external force. This can occur in the womb (particularly with first birth, multiple births), but more commonly develops postnatally.


[[Congenital torticollis|Congenital Muscular Torticollis]] can also co-exist with positional plagiocephaly in as many as 30% of cases <ref>Ellenbogen RG, Abdulrauf SI, Sekhar LN Principles of Neurological Surgery. Philedelphia: Elsevier, 2018.</ref>. This is when a tight sternocleidomastoid muscle causes a restriction in cervical range of movement and predisposes one side of the posterior occiput to flattening. 
* Babies in many areas spend significant amounts of time on their backs (in a cot, car seat, buggy etc) - the external forces from these firm surfaces can cause positional plagiocephaly
** please note that "Back to Sleep" approaches are recommended to reduce the risk of sudden infant death syndrome (SIDS)<ref name=":1">Great Ormond Street Hospital for Children. Positional Plagiocephaly. https://www.gosh.nhs.uk/conditions-and-treatments/conditions-we-treat-index-page-group/positional-plagiocephaly (Accessed 14 June 2018)</ref>  


== Clinical Presentation  ==
* [[Congenital torticollis|Congenital muscular torticollis (CMT)]] can co-exist with positional plagiocephaly in as many as 30% of cases<ref>Ellenbogen RG, Abdulrauf SI, Sekhar LN Principles of Neurological Surgery. Philedelphia: Elsevier, 2018.</ref> (see Differential Diagnosis section for more information) 
 
When viewed from above the head will have a parallelogram-shaped appearance with a flattened area to one side of their occiput posteriorly and a convexity to the forehead contralaterally. The ear on the contralateral side to the flattening may be displaced anteriorly. A head tilt may indicate an associated [[Congenital torticollis|Congenital Muscular Torticollis]].
 
Alternatively the area of flattening may be even across the back of the head. This is known as '''brachycephaly.'''


== Diagnostic Procedures  ==
== Diagnostic Procedures  ==
Positional plagiocephaly is diagnosed from the child's history and clinical presentation and does not usually require any imaging, however a skull x-ray may be required to rule out craniosytosis <ref>Reece A, Cohn A. Clinical Cases in Pediatrics: A trainee handbook. London: JP Medical Ltd, 2014.</ref>, which is premature fusing of the skull sutures.
Positional plagiocephaly is diagnosed from the child's history and clinical presentation and does not usually require any imaging. However, a skull x-ray may be required to rule out craniosynostosis.<ref>Reece A, Cohn A. Clinical Cases in Pediatrics: A trainee handbook. London: JP Medical Ltd, 2014.</ref>


== Outcome Measures  ==
== Outcome Measures  ==
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As diagnosis is largely based on observation, it is helpful to record observations from different views. This can be supplemented with photography. Clinically, where no equipment is available it may be useful for parents/ carers to take photographs periodically to identify change.  
As diagnosis is largely based on observation, it is helpful to record observations from different views. This can be supplemented with photography. Clinically, where no equipment is available it may be useful for parents/ carers to take photographs periodically to identify change.  


A study investigating head shape measurement standards <ref>McGarryA, Greig RJ, Hamilton DRL, Sexton S, Smart H. Head shape measurement standards and cranial orthoses in the treatment of infants with deformational plagiocephaly. Dev Med Child Neurol 2008;50(8):568-576.
== Physiotherapy Management / Interventions ==
</ref> described various other methods of measuring outcomes using:
Physiotherapy treatments include:<ref>Eskay K. Torticollis and Plagiocephaly Course. Plus, 2023.</ref><ref>Hohendahl L, Hohendahl J, Lemhöfer C, Best N. The Effect of Pediatric Physiotherapy on Positional Plagiocephaly: A Retrospective Trial. Physikalische Medizin, Rehabilitationsmedizin, Kurortmedizin. 2022 Sep 8.</ref><ref>Di Chiara A, La Rosa E, Ramieri V, Vellone V, Cascone P. Treatment of deformational plagiocephaly with physiotherapy. Journal of Craniofacial Surgery. 2019 Oct 1;30(7):2008-13.</ref>
* Anthropometric calliper measures
* Ezeform moulding ring of cranium and analysis software
* X-rays
* An observational categorical system
* A Heads‐Up band (a newly developed measuring technique) 
* A strip of thermoplastic material positioned around the infant’s head, transferred to paper and traced with measurements taken from tracings.
* Two‐dimensional head tracings taken using artist’s flexi curve placed around the infant’s head. 
* Cosmetic outcome score (0–10) assigned by parents


== Management / Interventions  ==
* caregiver education, including preventative counselling
'''Education and advice''' to parents/carers are the most important aspect of management, as they will be involved with every aspect of the child's daily care.  
** positioning for babies<ref>Burmeister S, Kayne AN, Yazdanyar AR, Hagstrom JN, Burmeister DB. Plagiocephaly Perception and Prevention: A Need to Intervene Early to Educate Parents. The Open Journal of Occupational Therapy. 2021;9(3):1-1.</ref>
* During sleep, the "Back to sleep" advice should be followed: Baby should be placed on their back to sleep on a firm mattress and without the use of pillows or aids.
** avoid baby being in containers all day (e.g. rockers, hammocks etc)
* During waking hours, advice should be given regarding:
** avoid baby lying on back all day (but always sleep on back)
** encourage early tummy time
* aggressive repositioning - i.e. position the infant to decrease the pressure on the flattened area of the head
** during feeding reduce pressure on the affected occiput; switch sides if there is a rotation preference
** place a blanket roll under the shoulder and hip to help offload the flattened area of the head
** sometimes transport the baby in a front carrier or an upright stroller to offload the back of the head
* developmental facilitation
** positioning in side-lying/propping
** strengthen symmetrically in the midline
* helmet therapy
** less than one in ten babies with plagiocephaly have a severe and persistent deformity, and they may need to be treated with helmet therapy<ref name=":3" /><ref>Watt A, Alabdulkarim A, Lee J, Gilardino M. Practical Review of the Cost of Diagnosis and Management of Positional Plagiocephaly. Plastic and Reconstructive Surgery Global Open. 2022 May;10(5).</ref>
** there is no evidence supporting the use of cranial remodelling helmets in healthy babies who are typically developing<ref name=":2" />


** Altering of positions for play e.g. supported side lying, tummy time.
The following video outlines the concept of Tummy Time.{{#ev:youtube|M3rCtW9DMD4|300}}<ref>Pathways. Five essential Tummy Time moves. Available from: https://www.youtube.com/watch?v=M3rCtW9DMD4 [accessed 14/6/2018]</ref>
** Encouragement of play and daily activities promoting visual tracking and cervical movement to side of flattening.
** Placement of their cot to facilitate desired direction of head turning.
** Limited time spent in car seats
** Consideration of the use of infant carriers
'''Reassurance''' to parents/ carers that positional plagiocephaly is not thought to be directly linked to any brain abnormalities, that it is thought to be a mainly cosmetic issue <ref name=":1" />.
 
A '''stretching programme''' if associated [[Congenital torticollis|Congenital Muscular Torticollis]].
 
'''Cranial moulding helmet therapy''' or bands aim to restrict skull growth in non-desireable directions, leading to "filling-out" of areas of flattening.  Their use is controversial and it is unclear if their use is superior to adherence to conservative advice and positioning methods detailed above <ref name=":1" />. A RCT carried out in the Netherlands in 2004 compared the improvement in head shape in children that received helmet therapy for positional plagiocephaly or brachycephaly with children that did not receive helmet therapy and concluded that given the near-equal outcomes and the significant cost and prevalence of side effects associated with helmet therapy, helmet use should be discouraged <ref>Van Wijk RM, Van Vlimmeren LA, Groothuis-Oudshoorn CGM, Van der Ploeg CPB, IJzerman MJ, Boere-Boonekamp MM. Helmet therapy in infants with positional skull deformation: randomised controlled trial. BMJ 2014;348
</ref>
 
{{#ev:youtube|M3rCtW9DMD4|300}}<ref>Pathways. Five essential Tummy Time moves. Available from: https://www.youtube.com/watch?v=M3rCtW9DMD4 [accessed 14/6/2018]</ref>
== Differential Diagnosis  ==
== Differential Diagnosis  ==


==== [[Congenital torticollis|Congenital Muscular Torticollis (CMT)]] ====
==== Congenital Muscular Torticollis (CMT) ====
A shortened sternocleidomastoid muscle can cause flattening of the occiput on the contralateral side e.g. a child with a left sided CMT presents with a right sided positional plagiocephaly. Active and passive neck movements should be checked to rule out CMT as the cause of the plagiocephaly. Early physiotherapy input is required to restore the range of movement in the neck and improve the plagiocephaly <ref name=":0">BC Children's Hospital. A Clinician's Guide to Positional Plagiocephaly<nowiki/>http://www.bcchildrens.ca/neurosciences-site/Documents/BCCH034PlagiocephalyCliniciansGuideWeb1.pdf (accessed 14 June 2018)</ref>.
A shortened sternocleidomastoid muscle causes [[Congenital torticollis|congenital muscular torticollis (CMT)]], which can flatten the occiput on the contralateral side. A child with left-sided CMT has right-sided positional plagiocephaly. Active and passive neck movements and head tilt need to be assessed to determine if CMT is causing the plagiocephaly. Early physiotherapy input is required to restore neck range of motion and improve the plagiocephaly.<ref name=":0">BC Children's Hospital. A Clinician's Guide to Positional Plagiocephaly<nowiki/>http://www.bcchildrens.ca/neurosciences-site/Documents/BCCH034PlagiocephalyCliniciansGuideWeb1.pdf (accessed 14 June 2018)</ref>


==== Unilateral Lambdoid Synostosis ====
==== Unilateral Lambdoid Synostosis ====
This is rare, but caused by the premature fusion of one lambdoid suture. It is identified by retraction of the '''ipsilateral''' ear and forehead and a trapezoid shape of the head when viewed fromabove <ref name=":0" />.
A rare condition where there is premature fusion of one lambdoid suture, which results in plagiocephaly. It is identified by retraction of the '''ipsilateral''' ear and forehead and a trapezoid shape of the head when viewed from above.<ref name=":0" />


==== Unilateral Coronal Synostosis ====
==== Unilateral Coronal Synostosis ====
Premature fusion of a coronal suture resulting in forehead assymetry and diagnosed by examining orbital symmetry. Looking from the front the ipsilateral will be higher and wider and when viewed from above the ipsilateral eyeball to the side of forehead flattening protrudes <ref name=":0" />.
Premature fusion of a coronal suture, which causes assymetry of the forehead. It is diagnosed by examining orbital symmetry. Looking from the front, the ipsilateral orbit will be higher and wider than the contralateral orbit; when viewed from above, the eyeball on the side of the forehead flattening will protrude.<ref name=":0" />  
 
== Resources  ==
* [http://www.bcchildrens.ca/neurosciences-site/Documents/BCCH034PlagiocephalyCliniciansGuideWeb1.pdf A Clinician's Guide to Positional Plagiocephaly]
* [https://www.gosh.nhs.uk/conditions-and-treatments/conditions-we-treat-index-page-group/positional-plagiocephaly Positional Plagiocephaly]
* [http://apcp.csp.org.uk/documents/parent-leaflet-head-turning-preference-plagiocephaly-2011 Parent/ Carer Information leaflet]


== References  ==
== References  ==
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[[Category:Paediatrics]]
[[Category:Musculoskeletal/Orthopaedics]]
[[Category:Musculoskeletal/Orthopaedics]]
[[Category:Condition]]
[[Category:Conditions]]
[[Category:Primary Contact]]
[[Category:Primary Contact]]
[[Category:Paediatrics - Conditions]]
[[Category:Congenital Conditions]]
[[Category:Course Pages]]

Latest revision as of 08:03, 2 April 2023

Introduction[edit | edit source]

Positional plagiocephaly is increasingly common in infants. Positional plagiocephaly is an asymmetric deformation of the skull. It has a number of potential causes, including: first birth, assisted labour, multiple births (e.g. twins, triplets etc), prematurity, congenital muscular torticollis, position of the head and lying in the same position for prolonged periods.[1][2]

There are two types of plagiocephaly: 1. plagiocephaly followed by craniosynostosis (a birth defect in which the bones in a baby's skull fuse prematurely) and 2. positional plagiocephaly without craniosynostosis.[1][3]

  • When plagiocephaly occurs with craniosynostosis, the skull deforms due to premature fusion of the sutures in the skull. This condition often requires surgical management and helmet therapy may be used.[1]
  • In plagiocephaly without craniosynostosis, the sutures between the bones are normal, so skull growth is not affected. However, the shape can be altered - most commonly the head is flattened on one side of the posterior aspect.[1]

Clinically Relevant Anatomy[edit | edit source]

The 2 minute video below explains the skull and fontanels of a newborn.

[4]

The skull covers and protects the brain. It consists of several bony plates connected together by fibrous material called sutures. Sutures allow movement of the bones necessary to accommodate brain growth and allow moulding of the head during birth.[5] As a result, the infant skull is vulnerable to deformation.

Mechanism of Injury / Pathological Process[edit | edit source]

It is not uncommon for newborns to have "unusually" shaped heads - depending on the cause, most of these cases resolve within around six weeks of birth.[6] Reasons for a change in head shape include the baby's position in the uterus and "moulding" of head during labour, including if the delivery is assisted (i.e. ventouse, forceps).[6]

Positional plagiocephaly is caused by pressure on the developing infant skull from an external force. This can occur in the womb (particularly with first birth, multiple births), but more commonly develops postnatally.

  • Babies in many areas spend significant amounts of time on their backs (in a cot, car seat, buggy etc) - the external forces from these firm surfaces can cause positional plagiocephaly
    • please note that "Back to Sleep" approaches are recommended to reduce the risk of sudden infant death syndrome (SIDS)[7]

Diagnostic Procedures[edit | edit source]

Positional plagiocephaly is diagnosed from the child's history and clinical presentation and does not usually require any imaging. However, a skull x-ray may be required to rule out craniosynostosis.[9]

Outcome Measures[edit | edit source]

As diagnosis is largely based on observation, it is helpful to record observations from different views. This can be supplemented with photography. Clinically, where no equipment is available it may be useful for parents/ carers to take photographs periodically to identify change.

Physiotherapy Management / Interventions[edit | edit source]

Physiotherapy treatments include:[10][11][12]

  • caregiver education, including preventative counselling
    • positioning for babies[13]
    • avoid baby being in containers all day (e.g. rockers, hammocks etc)
    • avoid baby lying on back all day (but always sleep on back)
    • encourage early tummy time
  • aggressive repositioning - i.e. position the infant to decrease the pressure on the flattened area of the head
    • during feeding reduce pressure on the affected occiput; switch sides if there is a rotation preference
    • place a blanket roll under the shoulder and hip to help offload the flattened area of the head
    • sometimes transport the baby in a front carrier or an upright stroller to offload the back of the head
  • developmental facilitation
    • positioning in side-lying/propping
    • strengthen symmetrically in the midline
  • helmet therapy
    • less than one in ten babies with plagiocephaly have a severe and persistent deformity, and they may need to be treated with helmet therapy[6][14]
    • there is no evidence supporting the use of cranial remodelling helmets in healthy babies who are typically developing[2]

The following video outlines the concept of Tummy Time.

[15]

Differential Diagnosis[edit | edit source]

Congenital Muscular Torticollis (CMT)[edit | edit source]

A shortened sternocleidomastoid muscle causes congenital muscular torticollis (CMT), which can flatten the occiput on the contralateral side. A child with left-sided CMT has right-sided positional plagiocephaly. Active and passive neck movements and head tilt need to be assessed to determine if CMT is causing the plagiocephaly. Early physiotherapy input is required to restore neck range of motion and improve the plagiocephaly.[16]

Unilateral Lambdoid Synostosis[edit | edit source]

A rare condition where there is premature fusion of one lambdoid suture, which results in plagiocephaly. It is identified by retraction of the ipsilateral ear and forehead and a trapezoid shape of the head when viewed from above.[16]

Unilateral Coronal Synostosis[edit | edit source]

Premature fusion of a coronal suture, which causes assymetry of the forehead. It is diagnosed by examining orbital symmetry. Looking from the front, the ipsilateral orbit will be higher and wider than the contralateral orbit; when viewed from above, the eyeball on the side of the forehead flattening will protrude.[16]

References[edit | edit source]

  1. 1.0 1.1 1.2 1.3 Jung BK, Yun IS. Diagnosis and treatment of positional plagiocephaly. Archives of craniofacial surgery. 2020 Apr;21(2):80.
  2. 2.0 2.1 Childerens health qld gov. Plagiocephaly Available:https://www.childrens.health.qld.gov.au/fact-sheet-plagiocephaly/ (accessed 8.10.2021)
  3. Unnithan AK, De Jesus O. Plagiocephaly. InStatPearls [Internet] 2022 May 1. StatPearls Publishing.
  4. Dr. J. Baby Skull. Available from https://www.youtube.com/watch?v=G1XhXvrWmAE&t= [Accessed 14/6/2018]
  5. University of Rochester Medical Centre. Anatomy of the newborn skull. https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=90&contentid=p01840 (accessed 13 June 2018).
  6. 6.0 6.1 6.2 RCHM Plagiocephaly – misshapen head Available:https://www.rch.org.au/kidsinfo/fact_sheets/Plagiocephaly_misshapen_head/ (accessed 8.10.2021)
  7. Great Ormond Street Hospital for Children. Positional Plagiocephaly. https://www.gosh.nhs.uk/conditions-and-treatments/conditions-we-treat-index-page-group/positional-plagiocephaly (Accessed 14 June 2018)
  8. Ellenbogen RG, Abdulrauf SI, Sekhar LN Principles of Neurological Surgery. Philedelphia: Elsevier, 2018.
  9. Reece A, Cohn A. Clinical Cases in Pediatrics: A trainee handbook. London: JP Medical Ltd, 2014.
  10. Eskay K. Torticollis and Plagiocephaly Course. Plus, 2023.
  11. Hohendahl L, Hohendahl J, Lemhöfer C, Best N. The Effect of Pediatric Physiotherapy on Positional Plagiocephaly: A Retrospective Trial. Physikalische Medizin, Rehabilitationsmedizin, Kurortmedizin. 2022 Sep 8.
  12. Di Chiara A, La Rosa E, Ramieri V, Vellone V, Cascone P. Treatment of deformational plagiocephaly with physiotherapy. Journal of Craniofacial Surgery. 2019 Oct 1;30(7):2008-13.
  13. Burmeister S, Kayne AN, Yazdanyar AR, Hagstrom JN, Burmeister DB. Plagiocephaly Perception and Prevention: A Need to Intervene Early to Educate Parents. The Open Journal of Occupational Therapy. 2021;9(3):1-1.
  14. Watt A, Alabdulkarim A, Lee J, Gilardino M. Practical Review of the Cost of Diagnosis and Management of Positional Plagiocephaly. Plastic and Reconstructive Surgery Global Open. 2022 May;10(5).
  15. Pathways. Five essential Tummy Time moves. Available from: https://www.youtube.com/watch?v=M3rCtW9DMD4 [accessed 14/6/2018]
  16. 16.0 16.1 16.2 BC Children's Hospital. A Clinician's Guide to Positional Plagiocephalyhttp://www.bcchildrens.ca/neurosciences-site/Documents/BCCH034PlagiocephalyCliniciansGuideWeb1.pdf (accessed 14 June 2018)