New guidelines review evidence on PT, helmets for positional plagiocephaly
Sandi K.Lam, M.D., M.B.A., FACS and Thomas G.Luerssen, M.D., FACS, FAAP
Positional plagiocephaly is a common condition encountered by pediatricians and referred
to pediatric subspecialty physicians such as neurosurgeons and plastic surgeons.
About one in four U.S. infants has some degree of positional plagiocephaly. The incidence
has increased since the Academy initiated the Back to Sleep campaign in 1994 to prevent
sudden infant death syndrome.
Due to practice variation in diagnosis and treatment paradigms for this common condition,
the Joint Section on Pediatric Neurosurgery of the American Association of Neurological
Surgeons and the Congress of Neurological Surgeons (CNS) sought to develop evidence-based
management guidelines. A multidisciplinary task force conducted a systematic review
of the literature from 1966 to October 2014 on pediatric plagiocephaly. Nearly 400
abstracts were reviewed yielding 110 articles for full review; 60 were deemed relevant.
The task force made 10 recommendations pertaining to imaging diagnosis, repositioning,
physical therapy and helmet orthoses. The guidelines are published in CNS’ journal
Neurosurgery and have been endorsed by the Academy. They are available at
Definition of positional plagiocephaly
In the guidelines, the term positional plagiocephaly encompasses both positional occipital
plagiocephaly (unilateral flattening of parieto-occipital region, compensatory anterior
shift of the ipsilateral ear, bulging of the ipsilateral forehead) and positional
brachycephaly (symmetric flattening of the occiput, foreshortened anterior-posterior
dimension of the skull, compensatory biparietal widening) and the combination of both
of these deformities.
Positional skull deformities can result from intrauterine constraint or extrauterine
deformation. They can be perpetuated by postnatal sleeping position and exacerbated
by concurrent torticollis or other neuromuscular conditions.
Diagnosis and management
The diagnosis of positional plagiocephaly is made clinically. If it is not clear from
the clinical examination, referral to an expert in cranial deformities is warranted.
Imaging ultimately may be necessary in unusual cases.
CT scan is the gold standard for diagnosis of craniosynostosis and should be used
sparingly in cases when the benefit of the diagnosis is worth the radiation exposure.
MRI has no role in the diagnosis of positional plagiocephaly.
The management of positional skull deformation is nonsurgical and involves ruling
out craniosynostosis and determining the timing and need for intervention such as
physical therapy or helmet orthosis.
Repositioning education is effective in affording some degree of correction in virtually
all infants with positional plagiocephaly. However, most studies suggest that a properly
fitted helmet orthosis corrects asymmetry more rapidly and to a greater degree than
repositioning. This is especially the case if the deformity is severe and if helmet
therapy is applied during the appropriate period of infancy.
There are no standardized criteria regarding the measurement and quantification of
deformity or the most appropriate time window in infancy for treatment of positional
plagiocephaly with a helmet. In general, infants with a more severe presenting deformity
and infants helmeted early in infancy tend to have better reported correction or even
normalization of head shape.
The only randomized data pertaining to helmet orthosis showed no benefit of helmet
therapy in the treatment of mild positional plagiocephaly. However, many have raised
concerns over flawed design and execution of this randomized study. These shortcomings
may contribute to the randomized data conflicting with the majority of the nonrandomized
Torticollis frequently is associated with cranial deformity. In that situation, physical
therapy is an important adjunct in allowing effective repositioning to occur. Positioning
pillows have been used to treat cranial deformity, but it is important to note that
the Academy warns against the use of soft pillows and blankets in the safe sleeping
Weighing all the evidence, it appears that the current commonly accepted management
paradigm of positional plagiocephaly in infants can be justified.
Many groups use conservative therapy such as repositioning and physical therapy for
treatment of mild to moderate deformity in younger infants and reserve helmet therapy
for more severe deformity, especially older infants who have failed to see improvement
with conservative measures.
Evidence in favor of helmet use is annotated by the lack of data regarding the extent
of natural history improvement in positional plagiocephaly, the long-term effects
of helmet therapy and of residual plagiocephaly, and costs associated with helmet
Dr. Lam, an AAP candidate member, and Dr. Luerssen are members of the AAP Section
on Neurological Surgery. Jordan P. Steinberg, M.D., Ph.D., an AAP candidate member,
and Mark M. Urata, M.D., D.D.S., FAAP, representing the AAP Section on Plastic Surgery,
contributed to this article.