KidsMD Health Topics

Plagiocephaly

  • Overview

    The term “plagiocephaly” may sound alarming when you first hear it in reference to your child—but the good news is that plagiocephaly (which is also sometimes called deformational plagiocephaly or positional plagiocephaly) is actually a very common, very treatable disorder. While it causes a flattened appearance in a baby’s head or face, plagiocephaly has no known medical repercussions.

    Plagiocephaly develops when an infant’s rapidly growing head attempts to expand, and meets some type of resistance— either prenatally in the mother’s womb, or after delivery because the baby’s head is pressed against a bed or other flat resting surface. This is analogous to how a stationary pumpkin develops a flat spot in a field: Since it cannot grow into the ground, it conforms to that shape. 

    • A baby’s skull is made up of several sections of bone, connected by fibrous joints called sutures, that fuse later in life. During the first few months of a child’s life, the skull itself is soft and malleable.
       
    • Plagiocephaly occurs when an infant’s soft skull becomes flattened in one area, due to repeated pressure on that particular part of the head.
       
    • Many babies develop plagiocephaly by sleeping regularly in one position, or by spending extensive time sitting in the same position in a car seat or swing.
       
    • Plagiocephaly occurs more often in premature infants whose skulls are even more pliable than other babies. These babies may spend a great deal of time lying down as they receive treatment for other medical complications.
       
    • If your child has plagiocephaly, he most likely won’t need surgery. Fortunately, the condition is usually corrected through non-invasive treatments that include special exercises, variations in sleep position and corrective headbands or molding cups.
       
    • Plagiocephaly is different from craniosynostosis, which involve much more serious malformations of the skull bones and require more in-depth treatments.

    How Boston Children's Hospital approaches plagiocephaly

    When you first receive your child's diagnosis, dozens of questions may spring to mind: How serious is plagiocephaly? Will my child need surgery? Is he at risk for neurological problems? How will this impact our family?

    Rest assured: there is no convincing evidence that plagiocephaly has any effect on a child’s brain development, vision or hearing. Even the facial asymmetry caused by the condition seems to improve as a baby grows. The only lasting effect is on the shape of the infant’s head. 

    Here at Children’s Hospital Boston, we have a long and distinguished history of approaching plagiocephaly and various types of brain and skull malformations that affect newborns, infants and older children. Experts in our Departments of Neurosurgery  and Plastic Surgery may work together to diagnose, treat and follow up children and families affected by plagiocephaly and other craniofacial anomalies. We are even able to diagnose some of these problems while babies are still in the womb.

    Children’s clinicians strive to help parents recognize that plagiocephaly is a very treatable condition with entirely cosmetic effects. Experience has taught us that most children with this disorder respond very well to non-surgical, minimally invasive interventions like:

    • customized, corrective helmets and molding cups
    • sleep position changes
    • special exercises

    Our neurosurgical and plastic surgery experts work closely with other specialists across the hospital to develop a customized treatment approach that meets all of your child's physical, emotional and social needs—a care plan that involves you and your family every step of the way. 

    Plagiocephaly:
    Reviewed by John G. Meara, MD, DMD, MBA and Bonnie Padwa, MD, PhD

    © Children’s Hospital Boston, posted in 2011

  • In-Depth

    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 
    Did you know?
    Children’s has developed a molding cup device, called the Plagio Cradle, to treat plagiocephaly. The Plagio Cradle is the only device that is not only beneficial in addressing mild flattening in some babies, but has also been proven effective—through scientific study—in  preventing the flattening process altogether.

    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 Pediatrics’ 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.

    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 in the Treatment tab.

    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?
  • Tests

    How is plagiocephaly diagnosed?

    Children with plagiocephaly typically show a visible flattening of the head.

    A trained clinician can usually diagnose the condition with a thorough physical exam and medical history alone, and does not typically need to order tests, like X-rays or CT scans.

  • Clinicians in the Departments of Neurosurgery and Plastic Surgery at Boston Children's Hospital are world leaders in diagnosing and treating plagiocephaly in newborns, infants and older children. We strive to educate families about the condition, explaining why it is not typically cause for alarm and outlining the best ways to approach it. Usually, we recommend one or more of the following approaches:

    Sleeping and resting position changes
    Your child's clinician can recommend several steps for keeping your baby from increasing pressure on an already flattened area of her head, and making sure she is not spending too much time in one position. Examples may include:

    • giving your baby adequate “tummy time”
    • alternating her head position while she is sleeping on her back
    • ensuring that she spends minimal time on her back while awake 

    Exercises
    Many infants with plagiocephaly—especially those born with muscular torticollis, an imbalance of the neck muscles—will benefit from prescribed neck exercises, often under the guidance of a pediatric physical therapist. Learn more about physical therapy at Children's.

    The Plagio Cradle
    For infants under 3 months old, we prefer using a molding cup known as the Plagio Cradle to address the flattening process. The Plagio Cradle was developed at Children's, and is the only device proven effective not only in addressing existing flattening, but also in preventing flattening in babies who are at particular risk for plagiocephaly (for example, those born very prematurely or with muscular torticollis).

    The Plagio Cradle is placed under a baby's head whenever he is lying on his back. It supports his neck and creates a hollowed space that gradually reshapes his head, allowing it to grow correctly over time. As the child ages, the NOPCO Brace Shop at Children's can make adjustments to the original molding.

    Corrective helmeting
    For infants over 3 months old with a moderate degree of flattening, Children's typically recommends the use of a corrective helmet—this process is called cranial orthosis. The helmet is a lightweight plastic shell with a foam liner. It acts as a brace to redirect the growth of the baby's skull. 

    If measurements taken by a neurosurgical nurse or surgeon indicate that your child may need a helmet, Children's will put you in touch with a company that will create the helmet. We can also give you a list of convenient locations where you can have the helmet made and bring it back for periodic readjustments. 

    Corrective helmets have been in use since 1979 and have an established track record of safely and successfully treating plagiocephaly. A helmet does not squeeze or compress the baby's head; rather, it serves as a passive restraint to growth in areas that are overgrown while allowing uninhibited growth in areas that are flat. Studies have confirmed that this process does not inhibit brain and head growth, but merely redirects the growth to correct the shape of the head. 

    • Because the baby's head is constantly growing, babies usually wear the helmet 21 to 23 hours a day to get the maximal effect.
    • Helmets are most effective in younger infants (4 to 8 months old), who are at the age of fastest cranial growth.
    • The average treatment period with a helmet is usually 3 to 6 months, depending on the age of the infant and the severity of the condition.
    • Careful and frequent monitoring is required. Helmets must be prescribed by a licensed physician with significant craniofacial experience.

    It's also important to note that very few people have perfectly round heads. Only babies who are active when looking around tend to have symmetrical head shapes. Even when treated with a helmet, a child probably won't have a perfectly round head.)

    Coping and support

    When your child has plagiocephaly, your family is likely to have many concerns and questions. In addition to the clinical information offered on this page, Children's has several other resources designed to give your family comfort, support and guidance, including: 

    Our Center for Families, which is dedicated to helping families locate the information and resources they need to better understand their child's particular condition and take part in their care. All patients, families and health professionals are welcome to use the Center's services at no extra cost. The center is open Monday through Friday from 8 a.m. to 7 p.m., and on Saturdays from 9 a.m. to 1 p.m. Please call 617-355-6279 for more information. 

    Children's International Center is a dedicated resource for patients and families from countries outside the United States. The center can provide assistance with everything from reviewing medical records to setting up appointments and locating lodging. Contact the center by phone at 01-617-355-5209 or via e-mail at international.center@childrens.harvard.edu.

    View a comprehensive list of patient and family resources at Children's. 

    Helpful links

    Please note that neither Boston Children's Hospital, the Department of Neurosurgery nor the Department of Plastic Surgery at Children's unreservedly endorses all of the information found at the sites listed below. These links are provided as a resource.


     

  • Research & Innovation

    At Children’s Hospital Boston, our care is informed by our research, and our discoveries in the laboratory strengthen the care we provide at each child's bedside. Children’s scientific research program is one of the largest and most active of any pediatric hospital in the world.

    In particular, our neurosurgery, plastic and oral surgery researchers are making inroads in understanding the causes and development of craniofacial disorders and paving ground for promising new treatments.

    Among our current research projects with promise for treating plagiocephaly and other craniofacial disorders are:

    • John G. Meara, MD, DMD, MBA, Children's plastic surgeon-in-chief, is analyzing the genetic, phenotypic, cognitive and behavioral aspects of craniosynostosis. Read more about his work.
       
    • Bonnie Padwa, MD, PhD, Children's oral surgeon-in-chief, is assessing facial growth patterns in children with several craniofacial anomaly types. Learn more about her research.

    Clinical trials

    Children’s is known for pioneering some of the most effective diagnostic tools, therapies and preventive approaches in pediatric medicine. A significant part of our success comes from our commitment to research—and to advancing the frontiers of mental health care by conducting clinical trials.

    Children’s coordinates hundreds of clinical trials at any given time. Clinical trials are studies that may involve:

    • evaluating the effectiveness of a new drug therapy
    • testing a new diagnostic procedure or device
    • examining a new treatment method for a particular condition
    • taking a closer look at the causes and progression of specific diseases

    While children must meet strict criteria in order to be eligible for a clinical trial, your child may be eligible to take part in a study. Before considering this option, you should be sure to:

    • consult with your child’s treating physician and treatment team
    • gather as much information as possible about the specific course of action outlined in the trial
    • do your own research about the latest breakthroughs relating to your child’s condition

    If your physician recommends that your child participate in a clinical trial, you can feel confident that the plan detailed for that study represents the best and most innovative care available. Taking part in a clinical trial at Children’s is entirely voluntary. Our team will be sure to fully address any questions you may have, and you may remove your child from the medical study at any time.

  • Your Story

    Quincy's story

    Quincy Cunningham was 5 months old when his parents first noticed that the back right side of his head was beginning to look flat. Anthony and Lydia took their first-born son to his pediatrician, who indicated that Quincy appeared to have developed deformational plagiocephaly and referred them to Boston Children's Hospital for treatment.

    Deformational plagiocephaly—a condition in which a baby's head becomes flat on one side—occurs in about 10 percent of otherwise healthy newborns. The flattening can occur at the front (deformational frontal plagiocephaly, or DFP) or the back (deformational posterior plagiocephaly, or DPP) of the head.

    DPP is far more common. It occurs when the back of the head is flat on one side, the ear on that side is more forward, and there is minor flattening of the forehead on the opposite side. A diagnosis of deformational plagiocephaly is usually made through a physical examination, although it sometimes needs to be confirmed by X-rays.

    Babies can be born with deformational plagiocephaly as a result of a tightened womb environment caused by multiple births, a small maternal pelvis or a breech position, but more often than not, the condition develops after birth. Several factors can increase a baby's risk, including torticollis (a congenital condition in which one or more of the neck muscles is extremely tight, causing the head to tilt and/or turn in the same direction), premature birth and back sleeping.

    Plagiocephaly is typically treated based on age. If the condition is identified early, when the child is age 3 months or younger, Children's clinicians recommend using a head cup—a device placed under the child's head whenever he is lying on his back. "

    As a child grows older he becomes more mobile, so the head cup is no longer effective. For children like Quincy, who are already 4 to 5 months old when the plagiocephaly is detected, a molding helmet is recommended. Much like the head cup, the helmet is casted to fit the child's head and is adjusted as he grows. But the helmet is worn nearly 24 hours a day—with the exception of bath time—for a few months.

    "Quincy wore his helmet for about two months," says Anthony. "He was a little unsure about it at first, but after a few days, he got used to it and did great." The Cunninghams saw marked improvement in the shape of their son's head during his time wearing the helmet.

    "As a child gets older, his head is less malleable, so it becomes less likely to achieve a completely rounded shape," says Children's neurosurgeon Joseph Madsen, MD. "Of course, the goal with any plagiocephaly treatment is not perfection, it's improvement."

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