What is the recommended treatment for a 5-month-old infant with positional plagiocephaly (flat skull)?

Treatment of Flat Skull in a 5-Month-Old Infant

For a 5-month-old infant with positional plagiocephaly, immediately initiate physical therapy, which is superior to repositioning alone and represents the primary treatment at this age. 1

Immediate Management Steps

Start Physical Therapy Now

• Physical therapy should begin immediately for any infant aged 7 weeks to 6 months with plagiocephaly of any severity, as this achieves better outcomes than repositioning education alone with Level I evidence. 1
• Physical therapy is the primary conservative treatment and demonstrates superior efficacy compared to simple repositioning instructions. 2
• At 5 months of age, your patient is in the optimal window for conservative treatment before considering more aggressive interventions. 1

Avoid Unsafe Positioning Devices

• Do not use positioning pillows despite their potential efficacy, as the American Academy of Pediatrics recommends against them due to safe sleep concerns and SIDS risk. 1, 2
• Focus on supervised repositioning during awake time and physical therapy exercises rather than sleep positioning devices. 1

Assessment of Severity

Clinical Examination Is Sufficient

• Diagnosis can be made through clinical examination alone in most cases without imaging. 1, 2
• If clinical diagnosis is uncertain, use three-dimensional surface imaging or stereophotogrammetry rather than CT scanning to avoid radiation exposure. 1, 2
• Measure diagonal differences across the skull to quantify severity during physical examination. 3

Decision Algorithm for Helmet Therapy

When to Consider Helmet Therapy

Helmet therapy is indicated if moderate to severe deformity persists after 2-3 months of physical therapy and repositioning. 1

• Given your patient is 5 months old, initiate physical therapy now and reassess at 7-8 months of age. 1
• If significant deformity remains at that point, helmet therapy achieves faster and more significant correction than conservative therapy alone in moderate to severe cases. 1, 2
• Earlier helmet initiation (before 6 months) achieves better correction and even normalization compared to later treatment, so don't delay assessment. 2

Exception: Severe Cases at Presentation

• For infants presenting at an advanced age (closer to 6 months) with moderate to severe plagiocephaly, helmet therapy may be recommended even without a prior trial of conservative treatment. 1, 2
• Older infants require longer helmet treatment duration, so earlier intervention is preferable. 2

Critical Pitfalls to Avoid

• Do not delay helmet therapy while waiting for physical therapy to fail in severe cases presenting after 6 months of age. 1
• Do not dismiss the condition as purely cosmetic—untreated plagiocephaly may be associated with delayed intellectual and motor development. 4
• Do not order CT scans unnecessarily, as clinical examination by a specialist is sufficient for diagnosis. 5
• Do not assume all skull flattening is positional—craniosynostosis requires surgical correction and must be excluded. 5

Specialist Referral Considerations

• If you suspect craniosynostosis or need specialist evaluation for treatment planning, refer to a pediatric plastic surgeon as the primary specialist. 5
• Alternative specialists include pediatric neurosurgeons or pediatric otolaryngologists with craniofacial training. 5
• Referral does not require imaging beforehand—the specialist will determine if imaging is needed. 5

Evidence Quality and Natural History

• The physical therapy recommendation carries Level I evidence with high clinical certainty. 1
• Helmet therapy recommendations carry Level II evidence with moderate clinical certainty based on multiple prospective and retrospective comparative studies. 2
• One randomized controlled trial showed no difference between helmet therapy and natural course at 24 months, but this study has been criticized and does not reflect the guideline consensus that helmet therapy achieves faster correction in moderate to severe cases. 6
• Natural history studies show that 80% of children have normal skull shape by age 5 years, but 20% retain mild to moderate deformity, supporting early intervention for significant cases. 7