How to manage positional plagiocephaly?

From the Guidelines

Positional plagiocephaly can be effectively managed through supervised, awake tummy time, which is recommended on a daily basis to promote motor development, facilitate development of the upper body muscles, and minimize the risk of positional plagiocephaly. This approach is supported by the American Academy of Pediatrics (AAP) and is based on the understanding that positional plagiocephaly can be associated with a supine sleeping position, lack of varied head positioning during sleep, and insufficient time spent in awake, supervised tummy time 1.

Key Management Strategies

• Implement regular repositioning of the infant's head during sleep to ensure equal time with the head turned to both sides
• Practice supervised "tummy time" for 15-20 minutes, 3-4 times daily when the baby is awake to strengthen neck muscles and reduce pressure on the flattened area
• Change the crib orientation periodically to encourage the infant to turn their head in different directions to look at interesting objects or caregivers
• Limit time spent in car seats, swings, and bouncy chairs when not traveling
• Consider cranial orthotic devices (helmets) for moderate to severe cases diagnosed between 4-6 months of age, typically worn 23 hours daily for 2-6 months
• Physical therapy exercises can help if torticollis (neck muscle tightness) is contributing to the condition

Importance of Early Intervention

Early intervention is crucial, as the skull becomes less moldable after 12 months of age, making treatment less effective 1. By starting supervised, awake tummy time as early as possible and maintaining a consistent routine, parents can help minimize the risk of positional plagiocephaly and promote healthy development in their infants.

Additional Considerations

• Children with developmental delay and/or neurologic injury have increased rates of positional plagiocephaly, although a causal relationship has not been demonstrated 1
• In healthy normal children, the incidence of positional plagiocephaly decreases spontaneously from 20% at 8 months to 3% at 24 months of age 1

From the Research

Management of Positional Plagiocephaly

The management of positional plagiocephaly can be approached through various methods, including conservative treatments and surgical interventions.

• Conservative treatments are recommended for positional plagiocephaly not accompanied by craniosynostosis 2.
• These treatments involve a variety of approaches, such as:
  • Change of positions
  • Physiotherapy
  • Massage therapy
  • Helmet therapy

Effectiveness of Conservative Treatments

Research has shown that physical therapy treatment is considered 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 3.

• In cases of moderate or severe plagiocephaly, helmet therapy can be an effective second-line intervention.
• Counseling of parents or caregivers and early treatment are essential for optimal therapeutic outcomes.

Diagnosis and Treatment Protocol

A management protocol for positional plagiocephaly involves classifying infants into three categories of deformity (mild, moderate, severe) according to measurements on digital photographs 4.

• Diagnosis and treatment follow two phases: a pediatric phase (up to 5 months of age) and a neurosurgical phase (from 5 months onwards).
• Infants are referred to neurosurgical consultation only after being treated with postural changes and physiotherapy and only after reaching the age of 5 months.

Pathogenesis, Diagnosis, and Management

Positional plagiocephaly is a deformation resulting from intrauterine constraint or postnatal positioning leading to asymmetrical cranial growth 5.

• Education on recognition of positional plagiocephaly, prevention strategies, and treatment options is essential for primary care physicians and parents.
• In milder cases, the deformation can be managed by stretching exercises and regular prone positioning, while in more severe cases, molding helmets may be needed.

Treatment with Cranial Remodeling Orthosis

A prospective study of 260 children treated by dynamic orthotic cranioplasty for posterior positional plagiocephaly showed that the treatment was effective, well tolerated, and had zero morbidity 6.

• The ideal period for initiating this therapy is between the ages of 4 and 6 months.
• The remodelling helmet is a convincing option that can be recommended in infants with posterior positional plagiocephaly whose skull deformity is not satisfactorily corrected by physiotherapy.