When to Intervene with Plagiocephaly
Intervene immediately with physical therapy for infants 7 weeks of age or older with any degree of positional plagiocephaly, and reserve helmet therapy for those with persistent moderate to severe deformity after conservative treatment or those presenting late with moderate to severe asymmetry. 1
Initial Assessment and Diagnosis
Clinical examination alone is sufficient for diagnosis in most cases—imaging is rarely necessary except when the diagnosis is equivocal. 1 When uncertainty exists, use three-dimensional surface imaging or stereophotogrammetry rather than CT scanning. 1
The key clinical features to identify include:
- Occipital flattening (unilateral or bilateral)
- Contralateral forehead flattening
- Ear displacement (posteroinferior on the affected side)
- Brow asymmetry (lowering on the contralateral side) 2
Treatment Algorithm by Age and Severity
Infants Under 7 Weeks
- Begin with repositioning education and frequent head turning 1, 3
- This age group can achieve significant improvement with positioning alone 3
Infants 7 Weeks to 6 Months with Any Degree of Plagiocephaly
Physical therapy is superior to repositioning alone and should be initiated immediately. 1 This carries Level I evidence (high clinical certainty). 1
- Physical therapy achieves better outcomes than repositioning education alone 1
- Avoid positioning pillows despite comparable efficacy due to safe sleep concerns per AAP recommendations 1
- Continue conservative treatment for 2-3 months before considering helmet therapy 4
Moderate to Severe Plagiocephaly After Failed Conservative Treatment
Helmet therapy is indicated when moderate to severe deformity persists despite 2-3 months of physical therapy and repositioning. 1, 3, 4
The evidence demonstrates:
- Helmet therapy achieves faster and more significant correction than conservative therapy alone in moderate to severe cases 1
- Treatment duration is significantly shorter when started before 6 months (14 weeks) versus after 6 months (18 weeks) 5
- Infants treated before 6 months achieve normal Cranial Vault Asymmetry Index values (<3.5%), while those treated after 6 months do not reach normal values (4.5%) 5
Infants Presenting Late (After 6 Months) with Moderate to Severe Deformity
Helmet therapy is recommended for infants presenting at advanced age with moderate to severe plagiocephaly, even without prior conservative treatment. 1, 6 This represents the second major indication for helmet therapy.
Critical timing considerations:
- Optimal starting age for helmet therapy is 5-6 months of life 5
- Delaying treatment significantly worsens outcomes 5
- Infants older than 12 months can still achieve improvement, though the previously held upper age limit may be inaccurate 7
- Treatment remains effective up to 18 months of age, though earlier intervention yields superior results 7
Common Pitfalls to Avoid
Do not delay helmet therapy while waiting for physical therapy to fail in severe cases presenting after 6 months. The often-practiced regimen of sequential therapy (physiotherapy first, then helmet) should be replaced by combined therapy in severe cases. 5
Do not dismiss older infants (>12 months) as too old for treatment. Recent evidence shows these patients can achieve improvement within similar treatment intervals as younger infants, though outcomes may not reach complete normalization. 7
Do not use positioning pillows as primary treatment despite comparable efficacy to physical therapy, as they violate safe sleep guidelines. 1, 6
Severity Stratification
The Argenta classification system provides validated progressive severity stratification:
- Type II, III, IV, and V deformities require progressively longer treatment times (53%, 75%, and 81% longer respectively for Types III-V versus Type II) 7
- This confirms that higher Argenta types represent genuinely more severe deformities requiring more intensive intervention 7
- Overall correction rate to Type I plagiocephaly is 81.6% with helmet therapy regardless of initial severity 7
Evidence Quality Note
These recommendations carry Level I evidence (high clinical certainty) for physical therapy superiority over repositioning, and Level II evidence (moderate clinical certainty) for helmet therapy indications. 1, 6 The helmet therapy recommendations are based on one prospective randomized controlled trial, five prospective comparative studies, and nine retrospective comparative studies. 1, 6