Diagnosis and management of deformational plagiocephaly

A review

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The increase in the prevalence of nonsynostotic occipital deformational plagiocephaly in infants, which resulted from the American Academy of Pediatrics' 1992 recommendation to have healthy infants sleep supine, has been accompanied by significant controversy in diagnosis and management. The controversy was exacerbated by the 1998 FDA classification of cranial orthotic devices as Class II devices requiring premarket notification, and the subsequent increase in treatment-associated costs.


Two independent reviews of the literature were conducted to clarify the objective evidence available within the context of pediatric craniofacial knowledge.


. Although deformational plagiocephaly is not a life-threatening problem, it is a source of disfigurement for children that may be detrimental to their well-being. Current methods for quantifying the degree of disfigurement have limited interrater reliability, and no prospective randomized controlled trials comparing the efficacy of cranial orthoses to repositioning and physical therapy protocols have been published. Despite this lack of Class I evidence, cranial orthoses are routinely and effectively used to treat persistent severe deformational plagiocephaly. The need for the current FDA regulations has not been supported by clinical experience and reported complications.


This review resulted in the following recommendations: 1) more parental education is needed to minimize the development and progression of deformational plagiocephaly; 2) mild deformity can be treated with repositioning and physical therapy protocols; and 3) severe deformity is likely to be corrected more quickly and effectively with cranial orthosis (when used during the appropriate period of infancy) than with repositioning and physical therapy. The available data do not support the need for FDA classification for cranial orthoses as Class II devices requiring premarket notification. Removal of the regulations, which centralized production of the orthoses to larger companies and markedly increased charges, will probably eliminate much of the controversy and parental anxiety generated by marketing strategies.

Abbreviations used in this paper: AAP = American Academy of Pediatrics; CVA = cranial vault asymmetry; MDI = Mental Developmental Index; OFC = orbitofrontal head circumference; PDI = Psychomotor Developmental Index; SIDS = Sudden Infant Death Syndrome.

Article Information

Address correspondence to: Shenandoah Robinson, M.D., Department of Pediatric Neurosurgery, Rainbow Babies & Children's Hospital, B501, 11100 Euclid Avenue, Cleveland, Ohio 44106. email: Shenandoah.robinson@UHhospitals.org.

© AANS, except where prohibited by US copyright law.




American Academy of Pediatrics Task Force on SIDS: The changing concept of sudden infant death syndrome: diagnostic coding shifts, controversies regarding the sleeping environment, and new variables to consider in reducing risk. Pediatrics 116:124512552005


American Academy of Pediatrics Task Force on Infant Sleep Positioning and SIDS: Changing concepts of sudden infant death syndrome: implications for infant sleeping environment and sleep position. Pediatrics 105:6506562000


American Academy of Pediatrics Task Force on Infant Sleep Positioning and SIDS: Positioning and SIDS. Pediatrics 89:112011261992


Argenta L: Clinical classification of positional plagiocephaly. J Craniofac Surg 15:3683722004


Bhushan VPaneth N: The reliability of neonatal head circumference measurement. J Clin Epidemiol 44:102710351991


Bialocerkowski AVladusic SHowell S: Conservative interventions for positional plagiocephaly: a systematic review. Dev Med Child Neurol 47:5635702005


Boere-Boonekamp Mvan der Linden-Kuiper L: Postional preference: prevalence in infants and follow-up after two years. Pediatrics 107:3393432001


Clarren S: Plagiocephaly and torticollis: etiology, natural history, and helmet treatment. J Pediatr 98:92951981


Collett BBreiger DKing DCunningham MSpeltz M: Neurodevelopmental implications of “deformational” plagiocephaly. J Dev Behav Pediatr 26:3793892005


Cunningham MHeike C: Evaluation of the infant with an abnormal skull shape. Curr Opin Pediatr 19:6456512007


Davis BMoon RSchas HOttolini M: Effects of sleep position on infant motor development. Pediatrics 102:113511401998


de Ribaupierre SVernet ORilliet BCavin BKalina DLeyuraz PF: Posterior positional plagiocephaly treated by cranial remodelling orthosis. Swiss Med Wkly 137:3683722007


de Chalain TPark S: Torticollis associated with positional plagiocephaly: a growing epidemic. J Craniofac Surg 16:4114182005


Ellenbogen RGruss JCunningham M: Update on craniofacial surgery: the differential diagnosis of lambdoid synostosis/posterior plagiocephaly. Clin Neurosurg 47:3033182000


Fowler EBecker DPilgram TNoetzel MEpstein JKane A: Neurologic findings in infants with deformational plagiocephaly. J Child Neurol 23:7427472008


Govaert BMichels AColla Cvan der Hulst R: Molding therapy of positional plagiocephaly: subjective outcome and quality of life. J Craniofac Surg 19:56582008


Graham JM JrGomet MHalberg AEarl DKreutzman JCui J: Management of deformational plagiocephaly: repositioning versus orthotic therapy. J Pediatr 146:2582622005


Hellbusch JHellbusch LBruneteau R: Active counter-positioning of deformational occipital plagiocephaly. Nebr Med J 86:3443491995


Hutchison BHutchison LThompson JMitchell E: Plagiocephaly and brachycephaly in the first two years of life: a prospective cohort study. Pediatrics 114:9709802004


Jalaluddin MMoss DShaffon D: Occipital plagiocephaly: the treatment of choice. Neurosurgy 49:5452001. (Abstract)


Jantz JBlosser CFruechting L: A motor milestone change noted with a change in sleep position. Arch Pediatr Adolesc Med 151:5655681997


Johnson TSEngstrom JLGelhar DK: Intra- and interexaminer reliability of anthropometric measurements of term infants. J Pediatr Gastroenterol Nutr 24:4975051997


Kelly KLittlefield TPomatto JManwaring KBeals S: Cranial growth unrestricted during treatment of deformational plagiocephaly. Pediatr Neurosurg 30:1931991999


Kordestani RPatel SBard DGurwitch RPanchal J: Neurodevelopmental delays in children with deformational plagiocephaly. Plast Reconstr Surg 117:2072182006


Lee RTeichgraeber JBaumgartner JWaller AEnglish PLasky R: Long-term treatment effectiveness of molding helmet therapy in the correction of posterior deformational plagiocephaly: a five-year follow-up. Cleft Palate Craniofac J 45:2402452008


Lee WRichards KRedhed JPapay F: A pneumatic orthotic cranial molding helmet for correcting positional plagiocephaly. J Craniofac Surg 17:1391442006


Littlefield TRBeals SPManwaring KHPomatto JKJoganic EFGolden KA: Treatment of craniofacial asymmetry with dynamic orthotic cranioplasty. J Craniofac Surg 9:11171998


Littlefield TKelly KPomatto JBeals S: Multiple-birth infants at higher risk for development of deformational plagiocephaly. Pediatrics 103:5655701999


Littlefield TPomatto JKelly K: Dynamic orthotic cranioplasty: treatment of the older infant. Report of four cases. Neurosurg Focus 9:3E52000


Liu YKadlub Nda Silva Freitas RPersing JDuncan CShin C: The misdiagnosis of craniosynostosis as deformational plagiocephaly. J Craniofac Surg 19:1321362008


Losee JMason ADudas JHua LMooney M: Nonsynostotic occipital plagiocephaly: factors impacting onset, treatment, and outcomes. Plast Reconstr Surg 119:186618732007


Loveday Bde Chalain T: Active counterpositioning or orthotic device to treat positional plagiocephaly. J Craniofac Surg 12:3083132001


Majnemer ABarr R: Influence of supine sleep positioning on early motor milestone acquisition. Dev Med Child Neurol 47:3703762005


McGarry ADixon MTGrieg RJHamilton DRSexton SSmart H: Head shape measurement standards and cranial orthoses in the treatment of infants with deformational plagiocephaly: a systematic review. Dev Med Child Neurol [epub ahead of print]2008


McKinney CCunningham MHolt VLerous BStarr J: Characteristics of 2733 cases diagnosed with deformational plagiocephaly and changes in risk factors over time. Cleft Palate Craniofac J 45:2082162008


Miller RClarren S: Long-term developmental outcomes in patients with deformational plagiocephaly. Pediatrics 105:152000


Mortenson OSteinbok P: Quantifying positional plagiocephaly: reliability and validity of anthropometric measurements. J Craniofac Surg 17:4134192006


Moss S: Nonsurgical, nonorthotic treatment of occipital plagiocephaly: what is the natural history of the misshapen neonatal head?. J Neurosurg 87:5 Suppl6676701997


Mulliken JVander Woude DHansen MLaBrie RScott R: Analysis of posterior plagiocephaly: deformational versus synostotic. Plast Recontr Surg 103:3713891999


National Health Service (QIS): The Use of Cranial Orthosis Treatment for Infant Deformational Plagiocephaly Edinburgh, UKNational Health Service Quality Improvement Scotland2007. (http://www.nhshealthquality.org/nhsqis/files/Infant%20plagiocephaly%20final%20May%202007.pdf) [Accessed 12 January 2009]


O'Broin EAllcutt DEarley M: Posterior plagiocephaly: proactive conservative management. Br J Plast Surg 52:18231999


Paine R: Neurologic conditions in the neonatal period. Pediat Clin North Am 8:5776101961


Panchal JAmirsheybani HGurwitch RCook VFrancel PNeas B: Neurodevelopment in children with single-suture craniosynostosis and plagiocephaly without synostosis. Plast Reconstr Surg 108:11492114982001


Peitsch WKeefer CLaBrie RMulliken J: Incidence of cranial asymmetry in healthy newborns. Pediatrics 110:182002


Persing JJames HSwanson JKattwinkel J: Prevention and management of positional skull deformities in infants. Pediatrics 112:1992022003


Plank LGiavedoni BLombardo JGeil MReisner A: Comparison of infant head shape changes in deformational plagiocephaly following treatment with a cranial molding orthosis using a noninvasive laser shape digitizer. J Craniofac Surg 17:108410912006


Pollack ILosken HFasick P: Diagnosis and management of posterior plagiocephaly. Pediatrics 99:1801851997


Regelsberger JDelling GTsokos MHelmke KKammler GKranzlein H: High-frequency ultrasound confirmation of positional plagiocephaly. J Neurosurg 105:5 Suppl4134172006


Rekate H: Occipital plagiocephaly: a critical review of the literature. J Neurosurg 89:5 Suppl24301998


Rogers GFMiller JMulliken JB: Comparison of a modifiable cranial cup versus repositioning and cervical stretching for the early correction of deformational posterior plagiocephaly. Plast Reconstr Surg 121:9419472008


Saeed NWall SDhariwal D: Management of positional plagiocephaly. Arch Dis Child 93:82842008


Scruton D: Position as a cause of deformity in children with cerebral palsy (1976). Dev Med Child Neurol 50:4042008


Siatkowski RFortney ANazir SCannon SPanchal JFancel P: Visual field defects in deformational posterior plagiocephaly. J AAPOS 9:2742782005


Sim JWright C: The Kappa statistic in reliability studies: use, interpretation, and sample size requirements. Phys Ther 85:2572682005


Spermon JSpermon-Marijen RScholten-Peeters W: Clinical classification of deformational plagiocephaly according to Argenta: a reliability study. J Craniofac Surg 19:6646682008


Stallings MRappo PLanzkowsky S: Comment on Persing J, James H, Swanson J, et al: Prevention and management of positional skull deformities in infants. Pediatrics 113:4224242004


Steinbok PLam DSingh SMortenson PSinghal A: Longterm outcome of infants with positional occipital plagiocephaly. Childs Nerv Syst 23:127512832007


Stellwagen LHubbard EChambers CJones K: Torticollis, facial asymmetry, and plagiocephaly in normal newborns. Arch Dis Child 93:8278312008


Sze RParisi MSidhu MPaladin ANgo AVSeidel K: Ultrasound screening of the lambdoid suture in the child with posterior plagiocephaly. Pediatr Radiol 33:6306362003


Teichgraeber JSeymour-Dempsey KBaumgartner JXia JWaller AGateno J: Molding helmet therapy in the treatment of brachycephaly and plagiocephaly. J Craniofac Surg 15:1181232004


van Vlimmeren Lvan der Graaf YBoere-Boonekamp ML'Hoir MHelders PEnglebert R: Risk factors for deformational plagiocephaly at birth and at 7 weeks of age: a prospective cohort study. Pediatrics 119:4084182008


Vles JColla CWeber JBeuls EWilmink JKingma H: Helmet versus nonhelmet treatment in nonsynostotic positional posterior plagiocephaly. J Craniofac Surg 11:5725742000


World Health Organization Multicentre Growth Reference Study Group: Reliability of anthropometric measurements in the WHO Multicentre Growth Reference Study. Acta Paediatr Suppl 450:38462006


Zonenshayn MKronberg ESouweidane M: Cranial index of symmetry: an objective semiautomated measure of plagiocephaly. J Neurosurg 100:5 Suppl5375402004




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