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University of Toronto Medical Journal
202
the flattened side to be positioned anteriorly and the forehead
and hemiface to protrude relative to the opposite side. The
skull takes on a classic parallelogram appearance when viewed
from above. This presentation differs from that of craniosyn-
ostosis, an uncommon condition that results in premature
fusion of the sutures of the skull (Figure 1). Unlike craniosyn-
ostosis, positional plagiocephaly is primarily a cosmetic problem
with no adverse effect on either brain growth or normal motor
development.
The frequency of reported PP has increased dramatically since
the early 1990’s with incidence reported to be between 8% to
48% of healthy newborns.
1,2,3
There are several contributing fac-
tors leading to the development of PP. The most significant
factor contributing to the development of PP is a child’s pref-
erence to look in one direction when placed on his/her back
to sleep. Congenital muscular torticollis, although less common
than positional preference, can also contribute to the develop-
Abstract
There has been a dramatic increase in the incidence of
infant positional plagiocephaly (PP) within the last 8
years, most likely associated with the supine sleep recom-
mendations for the prevention of Sudden Infant Death
Syndrome (SIDS). Although not a medical condition,
skull and facial deformity associated with PP causes a
great deal of anxiety among parents, resulting in signifi-
cant use of medical time and resources. Fortunately, PP
is preventable and responds favourably to conservative
management. A multi-disciplinary group at the The
Hospital for Sick Children (i.e. health promotion specialist,
physical therapists, craniofacial surgeon) developed a multi-
level educational initiative to reduce the incidence of PP.
This education program is unique because of its preventative
approach targeting new parents and caregivers as well as
infant health care practitioners (IHCP) such as pediatricians,
family physicians and public health nurses. Resources
include 1) a poster entitled “Why time on his tummy is good
for his head”; 2) a parent pamphlet entitled “You can pre-
vent baby flathead” and 3) an IHCP guide entitled “A
Clinician’s Guide to Positional Plagiocephaly”. This infor-
mation is relevant to paediatric health care professionals and
professionals involved in health promotion and prevention at
paediatric health facilities.
Defining the Problem
Positional plagiocephaly (PP) is a deformation of the skull
resulting from extrinsic forces acting on an intrinsically normal
skull. Typically the cranial vault is shifted causing the ear on
Rehabilitation Medicine
Positional Plagiocephaly among Infants: Identification, Management
and Prevention
Rita Damignani, M.Sc.,B.Sc.PT*
Karen Klar, B.Sc.PT**
Christopher Forrest, M.D., M.S., FRCS(C)**
Supported by the Hospital for Sick Children Foundation and the Centre for Health Information and Promotion (CHIP).
*Academic & Clinical Specialist/Physical Therapy, Department of Rehabilitation
Services, Hospital for Sick Children, Toronto, Ontario
**Physical Therapist, Plastic Surgery, Department of Rehabilitation Services, Hospital
for Sick Children, Toronto, Ontario
***Medical Director, Craniofacial Program, Head, Division of Plastic Surgery, Centre
for Craniofacial Care & Research, Plastic and Reconstructive Surgery, Hospital for Sick
Children, Toronto, Ontario
Figure 1. Illustration of parallelogram-shape skull associated with positional
plagiocephaly (left diagram) versus trapezoid-shape skull associated with cranial
synostosis (right diagram).
ment of PP when the sternocleidomastoid muscle is tight.
Limited rotation toward the affected side makes it difficult to
achieve an equal distribution of forces on the infant’s cranium
resulting in secondary skull asymmetry. Referral to physical
therapy to address the tight muscle is indicated in these
patients.
In 1992, a study published by the American Academy of
Pediatrics demonstrated an association between infant sleeping
position and Sudden Infant Death Syndrome (SIDS), prompt-
ing the subsequent “Back to Sleep Campaign”.
4
This initiative
recommended that infants be placed on their backs to sleep. In
the ensuing years, there has been a dramatic increase in the inci-
dence of infants with deformation changes of the cranium and
face as noted by multiple craniofacial centers across North
America.
1,5,6
Positional preference is exacerbated by the fact
that infants under the age of 3 months are positioned on their
backs for the majority of the time. Recently, the Canadian
Paediatric Society has amended its infant positioning message
to include the recommendation that infants be repositioned
periodically and placed in prone during playtime. Despite this
amendment, the incidence of PP continues to rise.
A Multi-disciplinary Prevention Initiative
The escalating incidence of PP resulted in the establishment of
a multi-disciplinary prevention initiative at The Hospital for
Sick Children. The objective of the task force, which was com-
prised of a multi-disciplinary team (physical therapists, health
promotion specialist, craniofacial surgeon) was to reduce the
incidence of positional skull deformities in infants and thereby
reduce the demand on medical resources. The rationale for a
multi-level educational initiative was based on the following:
• positional plagiocephaly is preventable
• although information regarding plagiocephaly is available (i.e.
websites), there is no information addressing prevention
• easily identifiable target groups of parents and infant health
care providers (IHCP) (i.e. paediatricians and family physi-
cians, public health nurses, midwives etc.) exist; these indi-
viduals could be targeted both pre- and post-natally.
Key Messages
There were 4 key messages that were considered pertinent to
the group’s mission:
volume 81, number 3, May 2004 203
Figure 2. Photograph of parent pamphlet entitled, “You Can Prevent Baby
Flathead.”
Figure 3. Photograph of poster entitled, “Why time on his tummy is good for
his head.”
Figure 4. Photograph of clinician’s guidebook entitled, “A Clinician’s Guide to
Positional Plagiocephaly: Everything you need to understand, prevent, identify
and treat ‘Baby Flathead’.”
University of Toronto Medical Journal
204
4-6 Months: Infants are beginning to roll and move independently
at this age, therefore counter-positioning may be less effective at
reversing skull flattening. Other aspects of conservative manage-
ment, such as reducing the amount of awake time infants spend
on their backs and increasing tummy time are, however, very ben-
eficial at this time. If severe skull flattening persists, a skull-mold-
ing helmet can be used. Using the molding helmet at this age is
most successful because the infant’s skull is still very flexible and
malleable.
7-12 Months: The degree of skull flattening usually plateaus by
this age because infants are usually rolling and sitting independently
and therefore spending less time on their backs. Counter-posi-
tioning to reverse skull flattening is less effective at this time. With
normal growth and development the shape of the skull will con-
tinue to improve until approximately 12-14 months of age when
the majority of the skull growth has occurred. As the child
approaches one year of age, the skull is more resistant to molding.
Helmets, therefore, are not a reasonable option to begin treatment
when the child is beyond 12 months of age.
Summary
Positional plagiocephaly is a widespread problem that in most
cases can be prevented, easily diagnosed and successfully managed
by the paediatrician or other primary health care clinician.
Prevention, however, should be the first line of defense in address-
ing this problem. Parental guilt and anxiety related to the devel-
opment of their infant’s skull asymmetry is significant and if left
to progress can result in utilization of a great deal of health care
resources. There has been a trend for infant healthcare profes-
sionals to advise parents that cranial dysmorphism will resolve over
time. This may occur in milder cases of PP, but if not appropri-
ately managed infants can have some degree of permanent resid-
ual deformity. The PP educational tools were developed to be
widely utilized by IHCP’s and to be promoted in health care facil-
ities across Ontario. For more information regarding these
resources contact:
The Centre for Health Information and Promotion (CHIP)
The Hospital for Sick Children
555 University Ave., Toronto, ON M5G 1X8
Tel: (416) 813-5819 Fax: (416) 813-6715
Or visit www.sickkids.ca/plasticsurgery under Craniofacial
Program to download these resources.
References
1. Kane AA, Mitchell LE, Craven KP and March JL. (1996). Observations on
a Recent Increase in Plagiocephaly Without Synostosis. Pediatrics. 97: 877-885.
2. Bruneteau RJ and Mulliken JB. (1992). Frontal plagiocephaly: synostotic, com-
pensational, or deformational. Plast Reconstr Surg. 89: 21-31.
3. Boere-Boonekamp MM and van der Linden-Kuiper LT. (2001). Positional
Preference: Prevalence in Infants and Follow-up after Two Years. Pediatrics.
107: 339-343.
4. American Academy of Pediatrics Task Force on Infant Positioning and SIDS.
(1992). Pediatrics. 89: 1120-1126.
5. Turk AE, McCarthy JG, Thorne CHM and Wisoff JH. (1996). The “Back to
Sleep Campaign” and Deformational Plagiocephaly: Is There Cause for
Concern? J Craniofac Surg. 7: 12-18.
6. Argenta L, David L, Wilson J and Bell, W. (1996). An Increase in Infant
Cranial Deformity with Supine Sleeping Position. J Craniofac Surg. 7: 5-11.
1) Infants should be positioned on their backs to sleep as rec-
ommended by the Canadian Paediatric Society and the
“Back to Sleep Campaign”
2) Parents must be made aware of the importance of using the
prone position for supervised infant play, starting at a very
early age
3) Parents/caregivers should be aware of an increased risk of
developing positional plagiocephaly that occurs as the result
of an infant demonstrating a preference to look to one side
when positioned on their back
4) Positional plagiocephaly is preventable through pre- and
postnatal education that specifically addresses newborn and
infant positioning strategies
Educational Resources
With the support of the Foundation and the Centre for Health
Information and Promotion (CHIP) the following educational
resources were developed:
A) Parent Pamphlet (Figure 2)
The parent pamphlet is designed as a useful reference for par-
ents and caregivers of infants. It reinforces why ‘tummy time’
is so important while the infant is awake. It explains what posi-
tional preference is and gives helpful suggestions on position-
ing and handling strategies to prevent positional preference.
The pamphlet informs parents that infants can also develop
skull asymmetry from spending long periods of time in a car
seat or reclining seat (a frequently seen problem), particularly
within the first few months of life. It also advises parents and
caregivers on how to counter-position the infant if positional
skull flattening has been confirmed by an IHCP.
B) Poster (Figure 3)
The poster is designed to catch the eye of parents/caregivers in
physician’s offices, pre- and post-natal classes and other appro-
priate public places. The poster reinforces the supine sleep
position but addresses the issue of positional skull deformities
among infants. Its major focus is to reinforce the benefits of
supervised ‘tummy time’ when the infant is awake.
C) Clinician’s Guide Book (Figure 4)
The guidebook is written for all health professionals who see
newborns and infants in their practice. It contains all the infor-
mation needed to understand, prevent, identify early, and treat
positional plagiocephaly. It enables IHCPs to educate parents
on strategies to decrease the likelihood of positional skull defor-
mities. It also clearly defines when to refer for medical paedi-
atric expertise. The general guidelines for managing PP, as
summarized in the clinician’s guidebook, are as follows:
0-4 Months: Conservative treatment is most effective within
the first 4 months of life. Counter-positioning can be used to
reverse early skull flattening. The brochure for parents, You Can
Prevent Baby Flathead, contains important treatment strategies and is
a helpful resource to share with parents during this time.