To whom should a pediatric patient with plagiocephaly be referred for evaluation and treatment?

Referral for Plagiocephaly

Infants with plagiocephaly should be referred to a pediatric plastic surgeon, as this is the preferred specialist for skull deformities including deformational plagiocephaly and craniosynostosis. 1

Primary Referral Pathway

Refer to pediatric plastic surgery for all infants with:

• Deformational plagiocephaly (positional skull flattening) 1
• Suspected craniosynostosis (premature suture fusion) 1
• Any skull shape abnormality requiring specialist evaluation 1

The American Academy of Pediatrics guidelines explicitly state that infants with congenital malformations of the skull, including deformational plagiocephaly or craniosynostosis, should be referred to a pediatric plastic surgeon. 1

Alternative Specialist Options

While pediatric plastic surgery is preferred, other acceptable specialists include: 1

• Pediatric neurosurgeon (particularly if craniosynostosis is strongly suspected) 1
• Pediatric otolaryngologist with craniofacial training 1
• General plastic surgeon with pediatric craniofacial experience 1

When Imaging is NOT Required Before Referral

Do not obtain imaging before referral - clinical examination alone is sufficient for initial specialist evaluation. 1 The Congress of Neurological Surgeons guidelines emphasize that imaging is rarely necessary and should be reserved for equivocal clinical examinations. 1 Most infants with plagiocephaly can be adequately diagnosed through detailed clinical examination by the specialist. 1

Timing of Referral

Refer early - ideally between 4-10 months of age when conservative treatments (repositioning, helmet therapy) are most effective. 2 However, treatment can still be beneficial beyond 12 months of age, as research demonstrates similar correction intervals in older infants compared to younger ones. 2

Critical Pitfalls to Avoid

• Never delay referral waiting for "spontaneous improvement" in moderate to severe cases - early intervention optimizes outcomes 2
• Do not order CT scans before referral - this exposes infants to unnecessary radiation when clinical examination by a specialist is sufficient 1
• Do not assume all plagiocephaly is positional - craniosynostosis requires surgical correction and must be distinguished from benign positional plagiocephaly 1
• Screen for developmental delays - plagiocephaly is associated with motor delays in multiple studies, particularly in children ≤24 months, and may warrant concurrent physiotherapy referral 3
• Assess for torticollis - approximately 19% of plagiocephaly patients require physiotherapy for associated torticollis 4

What the Specialist Will Determine

The pediatric plastic surgeon will:

• Definitively distinguish positional plagiocephaly from craniosynostosis through clinical examination 1
• Order imaging only if clinical examination is equivocal (skull x-rays or ultrasound preferred over CT) 1
• Recommend treatment: repositioning, physiotherapy, helmet therapy (for moderate-severe cases), or surgery (if craniosynostosis confirmed) 1, 2, 4