What is the assessment and management plan for a 6-month-old with mild plagiocephaly (flat head syndrome)?

Assessment and Management of Mild Plagiocephaly in a 6-Month-Old

Regular supervised tummy time while awake is the primary recommended intervention for mild plagiocephaly in a 6-month-old infant, along with varying head position during sleep and minimizing time in car seats or other positioning devices. 1

Assessment

Clinical Evaluation

• Observe head shape for asymmetry, particularly flattening of the occiput (back of head)
• Measure diagonal differences using a caliper to quantify severity
• Rule out craniosynostosis (premature fusion of skull sutures) which would require surgical intervention
• Assess for associated torticollis (neck muscle tightness)
• Evaluate developmental milestones to ensure normal progression

Risk Factors to Identify

• Limited tummy time
• Prolonged time in car seats, swings, or bouncy seats
• Consistent head positioning to one side during sleep
• History of prematurity or multiple birth
• Congenital muscular torticollis

Management Plan

Conservative Interventions (First-Line)

1. Supervised Tummy Time

   • Implement daily supervised tummy time while infant is awake
   • Start with short periods (3-5 minutes) several times daily
   • Gradually increase duration as tolerated
   • Place toys to encourage head turning to both sides

2. Repositioning Techniques

   • Alternate head position during sleep (while maintaining supine/back sleeping)
   • Change crib orientation periodically to encourage infant to look in different directions
   • Avoid excessive time in car seats, swings, and other positioning devices

3. Physical Therapy

   • Consider referral for physical therapy if associated with torticollis
   • Stretching exercises for neck muscles if indicated
   • Guidance on proper positioning techniques

Advanced Interventions (If Needed)

1. Helmet Therapy
   • Consider for moderate to severe cases not improving with repositioning
   • Most effective when started between 4-10 months of age 2
   • Requires 3-6 months of treatment with regular follow-up
   • Research shows higher correction rates with helmet therapy compared to repositioning alone for more severe cases 3

Patient Education

Key Points for Parents

1. Reassurance

   • Mild plagiocephaly is common and typically improves with conservative management
   • No evidence of impact on brain development or neurological function
   • In healthy children, incidence decreases spontaneously from 20% at 8 months to 3% at 24 months 1

2. Safe Sleep Practices

   • Continue placing infant on back to sleep to reduce SIDS risk
   • When awake and supervised, provide regular tummy time
   • If infant can roll both ways (supine to prone and prone to supine), they may remain in the position they assume 1

3. Positioning Strategies

   • Hold infant in upright position when awake
   • Alternate sides when feeding
   • Vary head position during sleep while maintaining supine position
   • Limit time in car seats and other positioning devices to necessary use only

4. Monitoring Progress

   • Expect gradual improvement over weeks to months
   • Follow up as recommended to assess progress
   • Consider helmet therapy if no improvement after 2-3 months of repositioning

Preventive Measures

• Continue supervised tummy time daily
• Vary infant's activities and positions throughout the day
• Alternate arms when holding infant
• Encourage looking in both directions by positioning toys and interaction on both sides

Follow-Up Plan

• Reassess in 4-6 weeks to monitor improvement
• Consider referral to specialist if no improvement after 2-3 months of repositioning therapy
• Document progress with measurements and/or photographs