Overview of Plagiocephaly and Treatment Options

What Is Plagiocephaly (“Flat Head”)?

“Flat Head” is a simplified term for Positional Deformational Plagiocephaly (pronounced Play-gee-oh-sef-ali), which is a cranial deformation.

In 1992, the “Back to Sleep” campaign was released by the American Academy of Pediatrics in an attempt to reduce the likelihood of SIDS (Sudden Infant Death Syndrome). Although this campaign succeeded in a 70 percent reduction of SIDS by placing infants on their back while sleeping, it increased the number of infants diagnosed with cranial asymmetrical deformities. The rise of cranial asymmetry is attributed to the long period of sleeping time in which infants are positioned on their back and the head is continuously resting on a flat surface. The growth rate of the cranium is at its highest in the first few months of life, and any prolonged contact in a single area will result in deformation. It is this restriction of growth in a fixed area that is the single greatest cause of cranial asymmetry in infants today. 

The different types of cranial asymmetry are as follows:

Plagiocephaly: a flattening on one side of the back of the head with a bulging in the forehead of the same side as the flattening

Brachycephaly: a symmetrical flattening on the back of the head. This flattening causes the head to appear wide above the ears and short from front to back. From a side view, the back of the head appears taller than the front

Brachycephaly with Asymmetry: is a combination of Plagiocephaly and Brachycephaly. This means the head shape has both a flattened back and bulging of the forehead on the same side, as well as a wide appearance above the ears and a side view with the back of the head seeming taller than the front.

Scaphocephaly: head shape that is long from front to back and very narrow from side to side

Possible Causes for the Asymmetries:

There are a multitude of reasons as to why infants may develop cranial asymmetries. Some may occur prior to birth, others occurring during or after birth.  While the causes, or risk factors, may differ from muscle tightness/weakness of the neck on one side(torticollis), position in the womb, prematurity, developmental delay, or other external reasons, the one common denominator is that of restricting the growth in a fixed area. 

Pre-Birth:

Multiple births (twins or more)

First born Child

Breech births

Infants of the male sex 

During / After birth:

Long Labor

Time in Neo-natal Intensive Care Unit (NICU)

Poor muscle tone

Spine abnormalities

Torticollis (neck muscle tightness/weakness)

Positioning

Torticollis: a tightening of the neck muscles, resulting in a tipping forward of the head on the tightened side and rotating towards the opposite side. This favored position may lead to an asymmetry as the skull continues to grow.

Prevention and Treatment:

Studies show that 18 to 28 percent of infants are diagnosed with Plagiocephaly. However, there are preventative methods and products, such as the cradle, which can reduce the susceptibility for an infant’s skull to develop a cranial asymmetry.

Repositioning: An infant’s skull is incredibly flexible in its growing stages prior to cranial maturity. This makes it vulnerable to risks of flattening while placed against any surface for long periods of time.

To avoid this, some medical experts recommend a technique called “repositioning,” which simply means alternating the infant’s position to evenly distribute the gravitational pressures on a growing skull.

Suggested means of repositioning include encouraging infants to respond to toys and stimuli equally on both right and left sides. If flattening becomes apparent on a certain area of the infant’s head, parents should encourage a position in which the flattened portion of their child’s head is not in contact with any surface. Also recommended is to have an infant spend time on their stomach, which must be supervised for safety reasons.

While repositioning is often considered the most conservative means of treatment for any cranial asymmetry for children less than 6 months old, the effectiveness of these methods have not been well demonstrated in study. If repositioning is considered, then parents, and their pediatricians, must pay close attention to any changes, so not to delay the intervention of proven treatments.

Cradling: The PlagioCradle is a conservative and effective means of preventing and/or treating cranial asymmetry. The cradle is recommended for use with children that are zero to three months of age, and must be immediately discontinued once the child has aged past three months, or exhibits the ability to roll over.

The cradle provides infants with a contoured sleep surface which supports the base of the child’s head, enabling symmetrical cranial growth. Used within the first three months of a newborns life, this cradle serves as a preventative tool against the possibility of needing to treat the asymmetry with more aggressive means, such as a corrective helmet. As this orthotic device is only distributed by licensed physicians, a prescription may be provided upon parental request.

Course of Cradling Care:

Prevention and/or treatment, using the PlagioCradle, consists of the following steps once the prescription has been written:

In order to determine whether cranial asymmetry is present, or if the child is at risk of developing asymmetry, an initial evaluation by a trained and licensed specialist must be performed.

Primary evaluation, fitting & cranial scan appointment- the orthotist will provide information concerning repositioning methods, cranial asymmetries and the cradle. Measurements and a 3D scan will be taken of the infant’s head using infant-safe lasers and cameras.
Follow-up appointments as necessary throughout the treatment period
Concluding appointment for discharge and final scan
 

Helmeting: If your child's treatment/prevention plan has not started before three months of age, it is possible that helmeting will need to be prescribed. A corrective helmet is constructed from layers of closed-cell foam covered by a light-weight plastic shell. The different layers of removable foam enable the orthotist to remove the foam as the child’s head continues to grow and mature. The design of the helmet makes contact with the bulging areas of the child’s head, while enabling the flattened areas to grow in a normal, rounded fashion. This corrective helmet is typically prescribed for children who are three to 18 months of age diagnosed with any form of cranial asymmetry.  At Boston Brace, we manufacture a cranial remolding helmet known as the Boston Band.

The normal prescription time for use of the helmet varies as it depends on the age and degree of the cranial asymmetry in each child. The usual wear time is 23 hours a day for a duration of three to four months. After the initial meeting with the orthotist, a treatment plan specific to the child and their diagnosis will be created.

The course of corrective treatment with the helmet consists of the following steps in chronological order:

1.  Primary evaluation (typically an hour long) and cranial scan
2.  Secondary appointment after one to two weeks from the original visit for fitting.
3.  Follow up appointment every two to four weeks throughout the treatment period
4.  Concluding appointment for discharge and final scan