Flat Head - Asymmetric Head - Positional Plagiocephaly

Positional Plagiocephaly

Changes in head shape caused by head position, often from consistently lying on one side

Positional plagiocephaly, also known as flat head syndrome or an asymmetric skull shape, is a condition in which a baby's head develops a noticeably asymmetrical appearance. In some cases the asymmetry can be severe; for example, one ear may be in front of the other, or one side of the forehead or cheekbone may be more prominent. There are several causes, but most cases occur when a baby is consistently laid on the same side. Other major causes include a compressed position in the womb or neck muscle problems that limit neck movement.

Causes of Positional Plagiocephaly

Some babies are born with positional plagiocephaly. This is more common in multiple pregnancies or premature births and may be related to the baby's position in the womb. Unfortunately, there is usually no preventive step that mothers or doctors can take before birth. Newborn skulls are very soft and moldable so babies can pass through the birth canal; for this reason, unusual head shapes after birth can be normal and usually improve within the first six weeks. However, if a baby keeps the head in the same position, positional plagiocephaly may develop. Babies with torticollis, a shortening or tightness of neck muscles on one side, may have difficulty turning the head to the other side. This usually improves with stretching exercises and only rarely requires surgery.

The most important cause of skull shape deformity is the baby's lying position. In 1992, the American Academy of Pediatrics recommended that babies sleep on their backs to reduce the risk of sudden infant death syndrome (SIDS), which led to the "Back to Sleep" campaign. This reduced sudden infant deaths, but it also led to more babies with head shape problems. Consistently lying in one position is the main factor in the development of this deformity.

Although the positional type described above is the most common type of plagiocephaly, a more serious and rare condition called craniosynostosis can also cause head asymmetry. Craniosynostosis occurs when the zipper-like joints between the baby's skull bones, called cranial sutures, close too early. A detailed examination is needed to confirm or rule out this diagnosis. You can get detailed information about craniosynostosis here .

The risk of positional plagiocephaly can be reduced with a few simple measures:

• Provide supervised playtime that helps your baby develop and strengthen the neck, shoulder and arm muscles, and place your baby on the tummy during these times. NEVER LEAVE A BABY WHO CANNOT YET ROLL OVER OR HOLD UP THE HEAD ON THE TUMMY WHEN YOU ARE NOT WATCHING!
• Regularly change the direction your baby faces while lying down, so the same part of the head is not always under pressure. You do not need to keep watch throughout sleep. You can support the position with pillows, but make sure the baby cannot roll face down.
• Avoid letting your baby spend too much awake time in car seats, carriers and bouncers. Try to reduce the time the back of the head rests against a surface.
• During the day, hold your baby upright on your shoulder and practice frequent "cuddle time."
• When holding, feeding or carrying your baby, make sure extra pressure is not placed on the flat side of the head. During feeding, change the baby's head position from one side to the other.
• Change the baby's sleeping location in the room so they need to look in different directions to see the door or window.
• If torticollis (neck stiffness) is present, it also needs to be treated for repositioning therapy to be effective.

Testing and Diagnosis

The diagnosis is usually made by a pediatrician. During baby visits, the doctor examines whether the baby's head has a symmetrical oval shape. If you are concerned about your baby's head shape, you should discuss it with your pediatrician. If the head is not oval and symmetrical, try placing the baby to sleep in different positions. If the shape is unusual for this diagnosis, a brain CT scan may be requested. Your baby's neck range of motion may also be examined to see whether any limitation is causing the baby to lie more on one side.

If this diagnosis is being considered, referral to a specialist may be needed to discuss your baby's head shape in more detail and to distinguish it from early fusion of the cranial growth plates (sutures). This specialist is usually a pediatric neurosurgeon. If your baby has neck stiffness (torticollis), you may be referred to a physiotherapist who can help with stretching exercises. A tight neck usually improves with these exercises, but it may reappear during periods of rapid growth.

Treatment Options

In most cases, having a flattened or asymmetric area does not affect brain growth or mental development. When a child can sit upright independently, external pressure decreases and the deformity begins to improve. Even if it does not resolve completely, the remaining flattening is usually mild and covered by hair as the child grows. Frontal differences are usually minimal and tend to improve over time. However, if unresolved flattening causes facial asymmetry, problems with chewing, eating or vision may occur. Later, when children become aware of their appearance, they may dislike the way they look, have difficulty in social life or experience peer bullying.

If torticollis (neck stiffness) is present, additional evaluation and precautions are important. The repositioning suggestions above may not be effective unless torticollis is also treated.

If the repositioning therapy described above does not work, helmet or band therapy may be recommended. The original helmet treatment, introduced in 1979, was based on surrounding the asymmetric baby head with a symmetrical (normal) mold. This helps the skull return toward a normal shape. Dynamic Orthotic Cranioplasty was later developed as a more proactive approach to positional plagiocephaly. It can be thought of as an advanced type of helmet therapy. In this method, the device is designed to apply gentle pressure where growth is not desired while leaving room where growth is needed. The band is adjusted weekly or every two weeks.

For the most effective results, helmet or band therapy is recommended to start around five months of age. Treatment duration depends on the individual case, but usually lasts two to six months.

HELMET TREATMENT

The pediatrician usually makes the initial diagnosis and recommends the repositioning therapy described above. If this does not solve the problem, you may be asked to see a pediatric neurosurgeon. The specialist will review the pediatrician's referral, perform a detailed assessment, talk with the parents about the baby's history and discuss the treatment plan.

If a helmet is recommended, the family is referred to an orthotist for ordering and using the helmet. The orthotist may take a series of measurements using clinical photographs or a scanning device to assess the baby's skull shape. These images and measurements serve as reference points throughout treatment. The orthotist creates a virtual copy of the baby's head and shapes the helmet to fit the baby precisely.

Because a baby's head grows quickly, helmet adjustments should be made every 1-2 weeks. This involves adjusting the foam liner and/or the outer plastic parts of the helmet.