Plagiocephaly

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Introduction

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.

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.

• 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.

• 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.

Clinically Relevant Anatomy

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

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. As a result, the infant skull is vulnerable to deformation.

Mechanism of Injury / Pathological Process

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. 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).

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)

• Congenital muscular torticollis (CMT) can co-exist with positional plagiocephaly in as many as 30% of cases (see Differential Diagnosis section for more information)

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 craniosynostosis.

Outcome Measures

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

Physiotherapy treatments include:

• caregiver education, including preventative counselling
  • positioning for babies
  • 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
  • there is no evidence supporting the use of cranial remodelling helmets in healthy babies who are typically developing

The following video outlines the concept of Tummy Time.

Differential Diagnosis

Congenital Muscular Torticollis (CMT)

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.

Unilateral Lambdoid Synostosis

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.

Unilateral Coronal Synostosis

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.