Plagiocephaly is a condition in which the head of an infant becomes misshapen. This usually occurs on one side of the back of the head (posterior plagiocephaly). It is easiest to see the flattening by looking down on your child’s head. In addition to a flat head, the child may also have ears that do not line up. This is the result of asymmetric muscle stress on the lower portion of the skull called sternomastoid imbalance. A condition called torticollis, which is a deformity of the same neck muscle called the sternocleidomastoid muscle, also creates this abnormal stress on the lower portion of the skull. This may result in ear asymmetry best seen from above when looking down on the head.
Although rarely associated with craniosynostosis, or a premature closing of the lambdoid sutures of the skull, plagiocephaly is most commonly caused by the position in which the baby spends most of his/her time. Recently, the American Academy of Pediatrics speculate that plagiocephaly is partly caused by newborns and infants sleeping on their backs. However, “The Back-to-Sleep Program” has lead to a large decrease in the number of children that die from Sudden Infant Death Syndrome (SIDS), so it is recommended that parents continue to place their infants to sleep on their backs, but it is best to vary the sleeping position to prevent flattening.
It is important that your child with a flat head be examined by his pediatrician to make sure that he doesn’t have craniosynostosis, a rare but more serious condition that usually requires surgery to correct. Your doctor can usually tell by examining if the flat head is caused by positional plagiocephaly or by closure of a suture. Some clues on examination that would favor a diagnosis of a positional deformity include that your child’s ear on that side of his head will be displaced away from the area of flattening. Children with posterior flattening caused by craniosynostosis will have the ear displaced toward the area of flattening. Also, with positional flattening, the forehead will be prominent or have bossing (meaning it will be bulging outwards) on the same side of the skull that is flattened in the back. If the diagnosis is uncertain, then your doctor may order skull x-rays, a CT scan, or a MRI to see if the sutures are still open.
Children with positional plagiocephaly are usually first treated by keeping them from lying on the flattened side of their head. Sometimes moving the child's crib so that it is facing another direction, or moving his toys or mobile will encourage him to turn his head. You should also try and keep him on his stomach for "tummy time" during the day when he is supervised. This is called a re-positioning program.
Mild deformities will usually correct on their own with these measures. If there is no improvement in a few months then children with positional plagiocephaly may need treatment with a molding helmet or head band such as the Dynamic Orthotic Cranioplasty Band (DOC Band®). DOC Band® is used to help reshape the head. These devices are worn for most of the day to mold the skull’s shape back to normal. The DOC Band® and molding helmets work best if used during your child’s first year of life.
Some children with congenital torticollis, a condition in which the muscles of one side of the neck are tight and keep the head turned to that side, are prone to get a flat head. In addition to the treatments described above, they may also benefit from physical therapy. Premature babies are also more prone to getting a flat head from positional molding of their skull.
It is important to remember that having a flat head caused by a positional deformity is a cosmetic problem and the brain continues to grow normally. Your child will not have any disabilities from this condition and if treatment is begun early, usually before six months of age, the results will be very good, with a normal or near-normal shape. Dr. Chariker has over 10 years of experience treating children with this deformity.
Diagnosis and Treatment
Most often doctors can make the diagnosis of positional plagiocephaly simply by examining the child’s head, without lab tests or x-rays. Regular repositioning of the child's head during sleep is the most common treatment for positional plagiocephaly and may successfully reshape the child's growing skull. Note that true craniosynostosis typically worsens over time.
If there is still some doubt, X-rays or a CT scan of the head will show the doctor if the skull sutures are open or fused. If they are open, the doctor will probably confirm the positional plagiocephaly diagnosis and rule out craniosynostosis. Note that there are characteristic signs detectable on examination that are usually obvious to an experienced practitioner. Therefore X-rays or CT scans are not required for every child.
Treatment for the flattened head, if caused by sleeping position, is usually simple and painless. Your child's doctor will probably recommend alternating both your child's direction in the crib (one night with his head toward the top of the crib, one night toward the bottom) and his head position during sleep (one night with the left side of his head touching the mattress, one night with the right).
Even though your child will probably move his head around throughout the night, alternating sides is still beneficial. There are wedge pillows used to keep babies lying on one side or the other, but Dr. Chariker is not an advocate of this. The AAP does not recommend using any devices that may restrict the movement of an infant’s head.
In addition to alternating sides, you may want to consider moving your baby’s crib to a different area of the room. If there’s something in the room (a window or toy, for example) that is catching his/her attention and causing him to hold his head in a similar position day after day, moving his crib will force him to look at it from another position.
Always be sure your baby gets plenty of time on his stomach during the day, especially while he is awake and you are nearby. Not only does "tummy time" give the back of your baby’s head a rest, it also helps in other ways. Looking around from a new perspective encourages your baby’s learning and discovery of the world. Plus, being on his/her stomach will help him learn to push up on his arms, which helps develop the muscles needed for crawling and sitting up. It also helps to strengthen his neck muscles.
If torticollis is the cause of your baby’s flattened head, a course of physical therapy combined with a home exercise program will usually lead to improvement or resolution. A physical therapist can teach you exercises to do with your child at home. Most exercises will consist of stretching your child's neck to the side opposite the tilt. Eventually, the neck muscles will be elongated and the neck will return to the upright posture. Rarely, surgery is needed to correct the problem. If indicated, Dr. Chariker will release the contracted muscle. Note that the ear asymmetry created by the torticollis may require several years to improve.
For children with severe positional plagiocephaly, Dr. Chariker may prescribe a custom molding helmet or head band. These work best if started between the ages of four and six months, when your child grows the fastest and are usually less helpful after 10 months of age. They work by applying gentle but constant pressure on a baby’s growing skull in an effort to redirect the growth. Remember that these devices are dynamic orthotic devices, but the true dynamic component of this therapy is the brain growth. The helmet remains static while the brain is growing and helping shape the head. The average duration of use is between three to four months. You should never purchase or use any devices like helmets or bands without having your child evaluated by a doctor first.