Plagiocephaly in Infants

Overview

• Definition: Plagiocephaly, often referred to as "flat head syndrome," is characterized by an asymmetrical cranial deformation. It includes positional (deformational) plagiocephaly and craniosynostosis.
• Incidence: Positional plagiocephaly is more prevalent, particularly since the "Back to Sleep" campaign for SIDS prevention. Craniosynostosis is less common but clinically significant due to potential neurodevelopmental implications.

Positional Plagiocephaly

• Etiology: Results from prolonged external pressure on one area of the skull, typically due to consistent positioning. This is exacerbated by factors such as:
  • Supine Sleeping Position: Despite its efficacy in SIDS prevention, it increases the risk of positional flattening.
  • Reduced Tummy Time: Limited prone positioning while awake, essential for alleviating cranial pressure and promoting cervical strength.
  • Prematurity: Increased vulnerability due to prolonged NICU stays and a softer calvarium.
  • Multiple Gestations: Intrauterine constraints leading to positional molding.
  • Torticollis: Congenital muscular torticollis causing unilateral head preference.

Craniosynostosis

• Etiology: Arises from the premature fusion of one or more cranial sutures, leading to abnormal cranial and facial morphology.
• Clinical Types:
  • Sagittal Synostosis: Results in scaphocephaly, characterized by a long, narrow skull.
  • Coronal Synostosis: Leads to anterior plagiocephaly or brachycephaly, depending on whether unilateral or bilateral.
  • Metopic Synostosis: Causes trigonocephaly with a prominent midline ridge and hypotelorism.

Clinical Presentation

• Positional Plagiocephaly:
  • Occipital flattening with ipsilateral frontal bossing.
  • Misaligned cranial base and asymmetrical ear positioning.
• Craniosynostosis:
  • Distinct cranial shape alterations depending on the suture involved.
  • Potential for increased intracranial pressure and neurodevelopmental deficits in severe cases.

Diagnosis

• Clinical Evaluation: Physical examination for cranial asymmetry, facial symmetry, and assessment of torticollis.
• Imaging:
  • Positional Plagiocephaly: Primarily a clinical diagnosis; imaging is reserved for atypical cases.
  • Craniosynostosis: CT scans or MRI to confirm suture fusion and evaluate intracranial structures.

Management Strategies

• Positional Plagiocephaly:
  • Repositioning Techniques: Education on alternating head positions during sleep, increased tummy time, and minimizing prolonged supine positioning when awake.
  • Physical Therapy: Particularly for infants with concurrent torticollis to improve neck muscle balance and promote symmetrical head movement.
  • Orthotic Devices: Cranial orthoses (helmet therapy) for moderate to severe cases or those unresponsive to repositioning by 4-6 months. Helmets apply gentle, constant pressure to direct head growth and correct asymmetry.
    • Timing: Optimal use is between 4 and 12 months of age when the skull is most malleable.
    • Duration: Typically worn for 23 hours a day over a period of several months, with periodic adjustments to the helmet to accommodate growth.
• Craniosynostosis:
  • Surgical Intervention: Cranioplasty or endoscopic suturectomy, typically performed within the first year of life to allow for optimal brain growth and cranial reshaping.
  • Post-Operative Care: May include helmet therapy to maintain skull shape post-surgery and multidisciplinary follow-up for developmental assessments.

Prognosis

• Positional Plagiocephaly: Favorable with early and appropriate intervention, with most cases resolving significantly with conservative management.
• Craniosynostosis: Dependent on the type and timing of surgical intervention. Early surgery generally yields good outcomes, although complex cases may require multiple procedures and long-term monitoring.

Research and Development

• Ongoing Investigations: Focus on the genetic basis of craniosynostosis, optimizing surgical techniques, and long-term neurodevelopmental outcomes.
• Innovative Treatments: Advancements in minimally invasive surgical techniques and non-surgical interventions are being explored.

Resources for Practitioners

• Support Networks: Connections with craniofacial specialists, genetic counselors, and multidisciplinary teams for comprehensive care.
• Continuing Education: Access to up-to-date guidelines and emerging research through professional organizations and journals.