Plagiocephaly

Children’s Hospital Boston’s neurosurgical and plastic surgery teams are recognized as global leaders in diagnosing, understanding and treating plagiocephaly (which is also sometimes called deformational plagiocephaly or positional plagiocephaly). The information on this page is designed to share the basics about this condition so that you and your family know what to expect. 

The term plagiocephaly is derived from Greek for “slanted” (plagio) and “head” (kephale).

Normally:

• an infant’s skull has several plates of bone that are separated by fibrous joints, called sutures
• the sutures will gradually close as the child grows and develops
• when the sutures close, the skull is fully formed as a solid piece of bone 

When a child has plagiocephaly:

• repeated pressure in one area of the skull causes the skull to “flatten out” in that spot
• the head or face may take on a misshapen, flattened or asymmetrical appearance 

Although plagiocephaly affects the external appearance of a baby’s skull, it does not impact her:

• brain development
• vision
• jaw and chewing function
• hearing 

Causes

What causes plagiocephaly?

Studies show 20 to 25 percent of infants who sleep on their back develop plagiocephaly. Many babies with plagiocephaly have muscular torticollis, which causes an abnormal tightening of the neck muscles, causing the head to tilt or turn in one direction. 

A baby may also develop plagiocephaly if:

• his mother’s uterus and/or birth canal are very narrowed or contracted (for example, because of a small pelvis or if the baby is in the breech position)
   
• he is born prematurely. Many premature babies spend extended periods of time in a fixed position while they recover in the neonatal intensive care unit, and their cranial bones are very soft, since these bones do not typically strengthen until the final 10 weeks of pregnancy.

Signs and symptoms

What are the symptoms of plagiocephaly?

A baby with plagiocephaly will have a flattened appearance on one side of the head. This is typically the only symptom of the condition; it is not painful or otherwise disruptive to an infant’s life and day-to-day functioning.

FAQ 

Q: Will my baby be OK?
A: Fortunately, plagiocephaly is a very treatable condition that causes only cosmetic changes in a baby’s skull shape. The condition responds extremely well to non-invasive treatments, like:

• helmeting
• molding cups
• exercises
• changes in sleep position 

Q: Is plagiocephaly common?
A: Yes. Plagiocephaly has always been a common condition, and data shows that it’s become even more common since the American Academy of Pedatrics’ 1992 “Back to Sleep” campaign, which advises parents to place infants to sleep on their backs in order to prevent Sudden Infant Death Syndrome (SIDS).

It is important to note that although the campaign may have indirectly prompted an increase in plagiocephaly cases, it has also caused a significant reduction in the number of babies lost to SIDS.

Q: At what age does plagiocephaly usually develop?
A: Most parents notice the flattening effect when their babies are 6 to 8 weeks old. 

Q: How does the flattening occur?
A: Flattening occurs when the infant’s rapidly growing head attempts to expand, and meets some type of resistance—usually because it’s pressed against a bed or other flat resting surface. This is analogous to how a stationary pumpkin grows flat in a field: Since it cannot grow into the ground, it develops a flat spot.

Q: Why do only some infants who sleep on their backs develop plagiocephaly?
A: Any circumstance in which the baby has a limited ability to reposition his head can cause the flattening. Many infants with plagiocephaly already have the predisposing condition muscular torticollis (an imbalance in the neck muscles), and many babies have other risk factors, such as being part of a multiple birth or having a mother with a small or constricted uterine and birth canal space.

Q: When does the flattening process stop?
A:  Babies with plagiocephaly may continue to experience the flattening process until they gain independent head control, usually around the age of 3 months. A premature or developmentally delayed infant may experience the flattening effect for a longer period, as it may take more time for them to reach this milestone.

Q: Can the flattening be prevented?
A: There are two primary methods parents can use to prevent flattening:

• repositioning the baby by regularly alternating points of contact between her head and the bed or other resting surface, or
• changing the baby’s sleep surface from flat to concave.

It can be difficult to perform this repositioning in some babies, especially those who have a pre-existing health condition, and repositioning usually can’t reverse any flattening that has already occurred. Alternative sleeping surfaces can also be problematic, since most do not expand as the baby’s head grows. 

Children’s has developed a molding cup, called the Plagio Cradle, that is the only device proven effective in both addressing mild flattening in some babies and preventing the flattening process altogether. Read about one baby whose plagiocephaly was successfully treated with the Plagio Cradle device.

Q: Does plagiocephaly cause any medical problems?
A: No. While plagiocephaly causes a visible flattening of the baby’s head, there are no known medical complications linked to the condition. 

Q: What is the main distinction between plagiocephaly and craniosynostosis?
A: Craniosynostosis is the premature fusion of one or more of the sutures in the skull. Unlike plagiocephaly, this condition may limit the size of the surrounding skull, increase intracranial pressure and delay or damage brain growth. A diagnosis of craniosynostosis is made after a clinical evaluation by a craniofacial surgeon and/or a neurosurgeon. X-rays and computed tomography (CT) scans of the head may be performed to confirm the diagnosis, and surgery is usually the recommended treatment.

In plagiocephaly, there is no fusion of the skull sutures. The condition is diagnosed after the craniofacial surgeon or neurosurgeon obtains a medical history and performs a thorough physical exam. X-rays and/or CT scans are usually not necessary, and treatment is non-invasive—typically through positioning changes, exercises and/or corrective helmeting or molding cups.

Q: Is my child going to need surgery?
A: Most likely, no. Unlike other skull malformations like craniosynostosis, plagiocephaly is very treatable using non-surgical methods, such as special exercises, changes to sleep position and corrective devices like helmets. Learn more about these treatments for plagiocephaly.

Q: Will my child need physical therapy?
A: Physical therapy can be very helpful for some infants with plagiocephaly—particularly those who are born with muscular torticollis, an imbalance of the muscles in the neck. Learn more about physical therapy services at Children’s.

Questions to ask your doctor 

You and your family play an essential role in your child’s treatment for plagiocephaly. It’s important that you share your observations and ideas with your child’s treating physician, and that you have all the information you need to fully understand the treatment team’s explanations and recommendations.

You’ve probably thought of many questions to ask about your child’s plagiocephaly. It’s often very helpful to jot down your thoughts and questions ahead of time and bring them with you, along with a notebook, to your child’s appointment. That way, you’ll have all of your questions in front of you when you meet with your child’s treating clinician and can make notes to take home with you.

Some questions to ask your doctor might include: 

• How did you arrive at this diagnosis?
• Are there any other conditions my child might have instead?
• What most likely caused the flattening process?
• Does my child have muscular torticollis or another condition that may have contributed to his plagiocephaly?
• What is the long-term outlook for my child?
• What treatment methods do you recommend at this time—molding cups, corrective helmeting, exercises, changes in sleep position or a combination of treatments?
• What changes do I need to make to my child’s daily routine?
• Will my child benefit from physical therapy at this time?
• What other resources can you point me to for more information?