Plagiocephaly: Getting a-head of the problem

Definitions!

  • Plagiocephaly: Flat, slanting/oblique head
  • Craniosynostosis: Premature fusion of one or more cranial sutures
  • Positional (aka deformational) plagiocephaly: Flattened shape and appearance of cranium due to extrinsic forces acting on an intrinsically normal skull
Source: UpToDate

Note that the remainder of this blog post will largely focus on positional plagiocephaly. 


Diagnosing plagiocephaly… from above!

  • Look down at the patient from above. 
  • Identify the side of flattening. 
  • Identify if and which ear is anteriorly positioned. 
Source: UpToDate

Note that with positional plagiocephaly, the flattened side corresponds with the anterior positioning of the ipsilateral ear. As such, in positional plagiocephaly, the head shape is a parallelogram. 


DDx

Positional plagiocephaly should be differentiated from other conditions that result in plagiocephaly, including congenital muscular torticollis (CMT), positional torticollis, unilateral lambdoid synostosis, and unilateral coronal synostosis. 

CMT: 

  • Postural deformity of neck
  • Head tilt to one side with chin rotated to the opposite side
  • Reduced cervical range of motion
  • Palpable SCM tightness or mass

Positional plagiocephaly vs Craniosynostosis

  • Consider the pathophysiology of craniosynostosis: the premature synostosis (i.e. union/fusion) of at least one cranial suture leads to compensatory skull growth in parallel to the affected suture (e.g., fusion of sagittal suture results in skull elongation, aka scaphocephaly—see figure above)

Craniosynostosis is associated with multiple genetic syndromes, including Crouzon syndrome, Apert syndrome, Pfeiffer syndrome, and Carpenter syndrome. 


Interventions for positional plagiocephaly

Position and handling: 

  • Increased tummy time
  • Supervised time with supported sitting up or cuddling upright
  • Adjusting infants head position during feeds, holding, carrying

Environmental adaptations: 

  • Place infant at a different end of the crib each time going to sleep
  • Infants prefer to face the room to look around
  • Place crib-safe toys or mirrors on desired side of infant
  • Limit time in car seats, swings, and other infant devices

Helmet or band therapy (cranial orthosis):

  • Helmet: surrounds the asymmetrical head with a symmetrical mold
  • Band: more proactive, applies gentle pressure to area where head growth not wanted, leaving space for area of desired growth
    • Adjusted weekly or bi-weekly

Physical Therapy:


Blog post based on Med-Peds Forum talk by Julia Ding, PGY4