Your baby and plagiocephaly

Plagiocephaly (or flat head syndrome) is a condition that describes the asymmetry of the skull. It can be anterior, where it affects the forehead, or posterior, where it affects the back of the head. The most common presentation is a mild flattening to the back of the head on one side in a newborn infant. This arises as the ‘soft’ skull of young babies can be moulded by positioning. For this reason, the condition is often called positional (or deformational) plagiocephaly. It occasionally occurs on both sides of the head, in which case the flat head syndrome is termed brachycephaly because it is shorter cephalocaudally (front to back) than side to side.

Babies are otherwise well with this condition. Plagiocephaly is not associated with any underlying brain abnormality, and the deformity is purely a cosmetic abnormality. The baby’s development should be entirely normal.

Causes

If the baby prefers lying on one side to the other, then this preference will cause a flattening on that side of the head, and the situation will continue to get worse as more and more time is spent on that side. When babies have been born prematurely, their skulls are softer than normal and they have spent the majority of their early life on their back. The incidence in this group is therefore slightly higher. Occasionally a tight neck muscle (the sternocleidomastoid) or delayed motor development can exaggerate the process. Very rarely, and in the most severe cases, the cause is due to premature fusion of a skull suture (craniosynostosis). For these reasons, it is best that a child is assessed early by a multidisciplinary team that contains a physiotherapist, paediatrician and craniofacial surgeon. Occasionally, x-rays are necessary to rule out an underlying problem, and rarely a CT scan may need to be performed. Measurement of the cranial vault asymmetry index and the use of 3D photography provide a robust and objective measure of the degree of severity and the likely natural history.

Natural progression

Very mild asymmetries in the skull shape are normal. Like facial asymmetry, this is within the spectrum of normality. For more severe but still mild asymmetries, the natural progression for this problem is improvement, although the true incidence in adults is hidden by the masking effects of the hair at the back of the head. No robust study has followed a cohort of children with mild abnormalities, who have not undergone any treatment, into adulthood. What we do know is that in the majority of mild cases, things improve to a degree that doesn’t cause children to be teased when they arrive at school or adults to present later on in life. This resolution occurs without any need for surgery or other manipulative intervention.

Treatment

There have been numerous studies looking at the benefits and disadvantages of a variety of treatments for this condition.

Early recognition of the asymmetry is essential. Regular turning and early introduction of ‘tummy time’ reduces the time spent lying on the flat part of the skull. Careful placement of the cot and the toys within it to encourage looking outwards can be beneficial. For instance, if the flat side of the head is the right-hand side and the cot is against a wall, then positioning this side closest to the wall will encourage the baby to look away from the wall. The use of specific pillows can also help in this vein, as any adjunct that helps the baby turn its head away from the flat area will speed up the natural improvement.

Physiotherapy can help address muscle tightness or neuromuscular development and the sooner this is instigated, the faster the resolution. Cranial osteopathy has no proven benefit, while helmet orthoses are still widely debated.

The helmet debate

Are helmets of any use? When should they be started? How long will the treatment course be? These are all questions that have yet to be concluded in scientific literature. What we know from anecdotal evidence, having spoken with patients, is that in some cases, when used appropriately and at the correct age, they seem to be of benefit.

Helmets are expensive devices and need to be used for 23 hours a day. They are hot in the summer and can cause itchy, sweaty, uncomfortable scalps. They rarely cause aggravation of skin problems or problematic patches of skin. We must therefore be sensible about their prescription. Helmet therapy is not routinely available on the NHS.

Usually, a surgeon will assess your child, and if their condition is mild or showing signs of improvement at 6 months, they won’t advise helmet use. If the asymmetry is moderate, severe or not showing signs of improvement, they will want to rule out any underlying cause with x-rays and a physiotherapy assessment before talking about the advantages and disadvantages of helmet therapy.

The earlier the helmet therapy is started, the better. When begun between 4 and 6 months of age, the treatment period is expected to last approximately 3 months. Starting after 6 months extends the treatment period by 1 month for every month delay following this.ⁱ

The benefit of treatment starting after 9 months of age is debatable and almost certainly involves a prolonged treatment protocol of up to 8 months.² A resultant asymmetry less than 1cm is deemed an acceptable result by most study groups and most patients starting treatment under 9 months of age reach a stable 5mm difference.³ Starting treatment after 1 year of age is unlikely to result in huge benefits unless severe in nature.

Main Points

• Plagiocephaly (or flat head syndrome) is a condition that describes the asymmetry of the skull.
• The most common presentation is a mild flattening to the back of the head on one side in a newborn infant.
• If both sides of the head are flattened, meaning that the head is longer from side to side than it is front to back, this is called brachycephaly.
• Plagiocephaly is purely a cosmetic abnormality; it does not affect your baby’s development.
• Plagiocephaly usually occurs if your baby has a preference for laying on one side. Because young babies have soft, malleable skulls, spending too much time on one side can cause a deformity.
• It’s best that a child is assessed early by a multidisciplinary team that contains a physiotherapist, paediatrician and craniofacial surgeon.
• Mild cases of plagiocephaly likely improve on their own without any treatment.
• Early recognition and treatment of plagiocephaly is essential. Treatment will consist of regular turning and encouraging your baby to not spend as much time on one side through careful placement of the cot and the toys within it.
• Helmet therapy, where your baby will wear a helmet for 23 hours a day for several months, is another treatment option. However, they are expensive and not routinely available on the NHS. A surgeon would need to assess the severity of your child’s plagiocephaly, which will usually involve taking x-rays, before recommending helmet therapy.
• If helmet therapy is decided to be a suitable treatment option, it’s best to start it as soon as possible because the treatment period is expected to be longer if started after 6 months.

References

1. 1. What is the optimal time to start helmet therapy in positional plagiocephaly. Kluba S, Kraut W, Reinert S, Krimmel M. PRS (2011) 128 (2), 492-8.
   2. Outcome analysis of cranial moulding therapy in non-synostotic plagiocephaly. Yoo HS, Rah DK, Kim YO. APS (2012) 39, 4, 338-44.
   3. Helmet treatment of deformational plagiocephaly: the relationship between age at initiation and rate of correction. Seruya M, Oh AK, Taylor JH, Sauerhammer TM, Rogers GF. PRS (2013), 131, 1, 555e-61e.