Home Exercises for Mild to Moderate Positional Plagiocephaly in a 4-Month-Old
For a 4-month-old with mild to moderate positional plagiocephaly, formal physical therapy is superior to repositioning education alone and should be the primary treatment approach. 1
Treatment Algorithm
First-Line: Physical Therapy Program
Physical therapy is recommended over repositioning education alone based on Level I evidence (high clinical certainty) from the Congress of Neurological Surgeons. 1, 2 This superiority has been demonstrated in randomized controlled trials for infants 7 weeks of age or older. 1
Core Physical Therapy Components
Repositioning techniques that parents can implement at home include:
- Alternating head position during sleep: Place the infant's head to the right side one day, left side the next day, to prevent prolonged pressure on the flattened area 2, 3
- Supervised tummy time while awake: This is essential both for preventing worsening and facilitating motor development 2, 3
- Holding the infant upright when awake: Minimize time spent with the back of the head against surfaces 2
Active exercises typically prescribed by physical therapists include:
- Neck stretching exercises: Particularly important if there is any torticollis or positional preference that contributes to the plagiocephaly 3, 4
- Exercises to encourage head turning: Toward the non-preferred side to reduce asymmetric positioning 3
What NOT to Do
Avoid positioning pillows or soft devices in the sleeping environment. 1, 2 Even though positioning pillows may have comparable efficacy to physical therapy exercises, the American Academy of Pediatrics explicitly warns against their use due to increased SIDS risk. 1, 2 The Congress of Neurological Surgeons recommends physical therapy over positioning devices to ensure safe sleeping environments. 1
Clinical Context and Timing
At 4 months of age, this infant is in an optimal window for conservative treatment. 2 The natural history of positional plagiocephaly shows spontaneous improvement, with incidence decreasing from 20% at 8 months to 3% at 24 months. 2 However, active intervention with physical therapy accelerates and maximizes this improvement. 1
Continue back-sleeping for SIDS prevention despite plagiocephaly risk. 2 The benefits of supine sleeping vastly outweigh the cosmetic concerns of plagiocephaly. 2
When to Escalate Treatment
Helmet therapy should be reserved for persistent moderate to severe plagiocephaly after a trial of conservative treatment (repositioning and physical therapy). 1, 5 Most studies demonstrate that helmets correct asymmetry more rapidly and to a greater degree than repositioning alone, but this is typically unnecessary for mild to moderate cases responding to physical therapy. 1, 2
Common Pitfalls
- Relying solely on repositioning education: This is less effective than a structured physical therapy program with active exercises 1, 2
- Delaying specialist referral: If improvement is not seen with home exercises within 4-6 weeks, formal physical therapy evaluation should be obtained 4
- Using positioning devices during sleep: This contradicts safe sleep guidelines despite potential efficacy 1, 2