Plagiocephaly

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Introduction

Plagiocephaly (also known as flat head syndrome) 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) . This page focuses on non-synostotic plagiocephaly, also known as positional or deformational plagiocephaly.

Clinically Relevant Anatomy

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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

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 of research that linked SIDS with babies put to sleep on their stomachs, and instead to put 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.

While practices are different in other countries, in the UK many babies now spend significant amounts of time on their backs, either on their cot mattress, in a car seat or in a buggy. The external forces from these 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 dangers due to positional plagiocephaly

Congenital Muscular Torticollis can also co-exist with positional plagiocephaly in as many as 30% of cases .

Clinical Presentation

When viewed from above the head will have a parallelogram appearance with a flattened area to one side of their skull 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 Muscular Torticollis.

Alternatively the area of flattening may be even across the back of the head. This is known as brachycephaly

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 .

Outcome Measures

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Differential Diagnosis

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 .

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 caudally .

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 caudally the ipsilateral eyeball to the side of forehead flattening protrudes .

Resources

A Clinician's Guide to Positional Plagiocephaly http://www.bcchildrens.ca/neurosciences-site/Documents/BCCH034PlagiocephalyCliniciansGuideWeb1.pdf