Reassuring Signs in a 4-Month-Old with Positional Plagiocephaly
Clinical examination alone is typically sufficient to diagnose positional plagiocephaly, and reassuring signs include the infant's ability to roll from supine to prone and back, normal developmental milestones, and spontaneous improvement with conservative measures. 1
Key Reassuring Clinical Features
- Normal developmental milestones: Age-appropriate motor skills and development indicate that plagiocephaly is not affecting neurological function 2
- Ability to roll over: At 4 months, many infants begin to roll, which naturally helps redistribute pressure on the skull 1
- Asymmetry without ridges: Absence of ridges along the skull sutures distinguishes positional plagiocephaly from craniosynostosis 1
- Parallelogram-shaped skull: Characteristic asymmetric flattening of one side of the occipital region without fusion of sutures 2
- Ear position shift: Forward displacement of the ear on the affected side without other craniofacial abnormalities 2
- Reversibility with position changes: Head shape improves temporarily when the infant is held upright or placed prone while awake 2
- Response to repositioning: Noticeable improvement with consistent repositioning efforts 1
- No midline shift: Absence of significant facial asymmetry or midline shift 1
Natural History and Expected Improvement
- The incidence of positional plagiocephaly decreases spontaneously from 20% at 8 months to only 3% at 24 months of age in healthy children 1, 2
- Most cases show improvement with conservative management, especially when identified and addressed early 1
- At 4 months of age, the skull is still highly malleable, making this an optimal time for intervention 2
Differentiating from Concerning Signs
Reassurance should be tempered if any of these concerning signs are present:
- Palpable ridges along suture lines (suggests craniosynostosis)
- Progressive worsening despite appropriate interventions
- Associated torticollis that doesn't improve with stretching exercises
- Developmental delays or neurological abnormalities
- Facial asymmetry that progresses or doesn't improve 1
Management Considerations
For a 4-month-old with typical positional plagiocephaly:
- Supervised tummy time: Daily supervised prone positioning while awake promotes motor development and reduces pressure on the flattened area 1, 2
- Repositioning: Alternating head position during sleep and avoiding prolonged time in car seats, swings, or bouncy seats 1, 2
- Physical therapy: If there is associated torticollis or positional preference, physical therapy is superior to repositioning education alone 1, 3
The Congress of Neurological Surgeons guidelines emphasize that clinical examination is usually sufficient for diagnosis, and imaging is rarely necessary except when the clinical diagnosis is equivocal 1.
Remember that parents can be reassured that the incidence of SIDS begins to decline after 4 months of age, and if the infant can roll from supine to prone and back, they can be allowed to remain in the sleep position they assume 1.