Plagiocephaly: Symptoms, Types, Causes and Treatment

Plagiocephaly, often recognized as a flattening or asymmetry of a baby's head, has become increasingly common in recent decades. While many cases are benign and correctable, understanding the nuances of its symptoms, types, causes, and treatment options is crucial for parents and healthcare providers alike. This article provides a comprehensive, evidence-based exploration of plagiocephaly, offering clarity on its identification and management.

Symptoms of Plagiocephaly

Plagiocephaly can present with a range of symptoms, making early recognition important for timely intervention. Parents and caregivers may first notice subtle changes in a baby's head shape or facial features, but not all signs are immediately obvious.

Below is a summary of the most common symptoms associated with plagiocephaly:

Symptom	Description	Distinction	Source
Head Flattening	Noticeable flattening on one part of the skull	Posterior or frontal	1 3 9
Facial Asymmetry	Misalignment of facial features (ears, eyes, jaw)	More marked in synostotic	1 7 8
Ear Displacement	One ear pushed forward compared to the other	Often ipsilateral	1 9
Forehead Bulging	Prominence of the forehead on one side	Common in frontal types	1 7
Torticollis	Tight neck muscle, head tilt/preference	Often co-occurs	1 6 12

Table 1: Key Symptoms

Head Shape Changes

The most recognizable sign of plagiocephaly is a flattening of part of the baby's head. This is most often seen at the back (posterior plagiocephaly), but can also affect the forehead (frontal plagiocephaly). In some cases, the flattening is accompanied by a bulging of the opposite side, giving the skull a parallelogram-like shape 1 3 9.

Facial Asymmetry and Related Features

Beyond the skull itself, plagiocephaly can cause subtle or more pronounced facial asymmetry. This may include:

• The eyes appearing at different levels
• The jaw or chin pointing slightly off-center
• The nasal root deviating to one side

These features are more pronounced in synostotic (suture-fused) forms of plagiocephaly, where bone growth is restricted 1 7 8.

Ear and Forehead Position

One ear may appear pushed forward, and the forehead on the same side may bulge out. These anatomical shifts are valuable clues for clinicians trying to distinguish between types of plagiocephaly 1 9.

Torticollis

A significant number of infants with plagiocephaly also have torticollis, a condition in which a neck muscle is tight, causing the head to tilt or rotate to one side. This can both contribute to and result from head shape asymmetry 1 6 12.

Types of Plagiocephaly

Understanding the different types of plagiocephaly is essential for accurate diagnosis and effective management. The main distinction is between deformational (positional) and synostotic (suture-fused) forms.

Type	Cause/Mechanism	Common Features	Source
Deformational	External pressure on a flexible skull	Parallelogram shape, resolves with time	2 3 5 6 9
Synostotic	Premature fusion of skull sutures	Severe asymmetry, facial distortion	1 4 7 8 9
Frontal	Asymmetry affecting the forehead region	Bulging forehead, retruded maxilla	1 7 8
Posterior	Flatting of the back of the head	Ear misalignment, occipital flattening	3 9

Table 2: Plagiocephaly Types

Deformational (Positional) Plagiocephaly

The most common type, deformational plagiocephaly, results from sustained external pressure on a baby's soft skull. This form is often associated with babies sleeping on their backs, as recommended to prevent sudden infant death syndrome (SIDS) 2 3 5 6 9. Deformational plagiocephaly usually improves with time and conservative interventions.

Synostotic Plagiocephaly

Synostotic plagiocephaly is less common and results from the premature fusion of one or more cranial sutures (craniosynostosis). This restricts normal skull growth and can lead to more severe asymmetries and facial distortions. Surgical intervention is often required 1 4 7 8 9.

Frontal vs. Posterior Plagiocephaly

• Frontal plagiocephaly affects the forehead and is often a result of coronal suture abnormalities or external forces on the front of the head 1 7 8.
• Posterior plagiocephaly involves flattening at the back of the head and is most commonly seen in deformational cases 3 9.

Causes of Plagiocephaly

The causes of plagiocephaly are multifactorial, ranging from environmental influences to biological and mechanical factors.

Cause	Description	Risk Factors/Associations	Source
Supine Sleep	Sleeping on the back, pressure on skull	SIDS prevention, modern parenting	3 5 9 11
Limited Neck Mobility	Torticollis or positional preference	Neck muscle tightness	1 5 6 12
First-born Status	Less uterine space, more pressure	First pregnancy	5
Lack of Tummy Time	Reduced time off the back of the head	Low activity, less prone play	2 5 12
Craniosynostosis	Premature suture fusion (genetic/unknown cause)	Syndromes, isolated cases	1 4 7 8 9

Table 3: Causes of Plagiocephaly

Positional and Mechanical Causes

The most prevalent cause of plagiocephaly in modern societies is the recommendation for infants to sleep on their backs to reduce the risk of SIDS. While effective in saving lives, this position can increase pressure on the same spot on the skull, especially if the baby has a head-turning preference or limited mobility 3 5 9 11.

Limited tummy time and reduced overall activity also contribute to the risk, as the baby spends prolonged periods with their head resting on a flat surface 2 5 12.

Biological and Developmental Factors

Some infants are more predisposed to plagiocephaly due to conditions like torticollis, where neck muscles are tight or shortened, limiting head rotation and mobility 1 5 6 12.

First-born babies may be at higher risk due to the tighter confines of the uterus, leading to increased pressure on the skull before birth 5.

Craniosynostosis

A less common but significant cause is craniosynostosis—the premature fusion of skull sutures. This condition can be isolated or part of a syndrome and leads to more pronounced and persistent head shape changes 1 4 7 8 9.

Treatment of Plagiocephaly

Treatment strategies for plagiocephaly depend on the underlying cause, severity, and age of the child. Most cases of deformational plagiocephaly respond well to conservative measures, while synostotic forms often require surgical intervention.

Treatment	Approach/Tool	Effectiveness	Source
Repositioning	Changing head position, tummy time	Effective for mild cases	2 5 11 12 13
Physical Therapy	Neck exercises, stretching for torticollis	More effective than repositioning	2 12 13 14
Helmet Therapy	Custom-molded helmet to reshape skull	Faster correction, mixed long-term impact	2 6 12 13
Surgery	Correction of fused sutures (synostotic)	Necessary for synostosis	4 7 8 9
Parental Guidance	Education, reassurance, monitoring	Essential for all cases	11 12

Table 4: Plagiocephaly Treatments

Conservative Management: Repositioning and Tummy Time

For most infants with deformational plagiocephaly, simple strategies such as repositioning the head during sleep and increasing supervised tummy time during awake periods are highly effective. These methods help relieve pressure on the flattened area and encourage symmetrical skull growth 2 5 11 12 13.

Physical Therapy

Physical therapy is particularly beneficial for infants with associated torticollis or significant positional preference. Guided stretching and exercises improve neck mobility and can lead to faster and more complete resolution of skull asymmetry compared to repositioning alone 2 12 13 14. Evidence suggests that physical therapy is superior to repositioning education for treating positional plagiocephaly, especially when torticollis is present 14.

Helmet Therapy (Cranial Orthosis)

In cases where conservative measures are insufficient, or in moderate to severe cases, helmet therapy may be considered. Custom-molded helmets help guide the growth of the skull into a more symmetrical shape. While helmet therapy can accelerate improvement, current evidence does not demonstrate a significant advantage in long-term outcomes compared to conservative care for most cases. Drawbacks include cost, inconvenience, and potential for skin irritation 2 6 12 13.

Surgical Intervention

Surgery is reserved for synostotic plagiocephaly, where one or more cranial sutures have fused prematurely. The goal is to correct skull shape, relieve pressure on the brain, and prevent further complications. Early and accurate diagnosis is critical, as surgical timing and approach can affect long-term outcomes 4 7 8 9.

Parental Education and Support

Regardless of the treatment pathway, parental guidance, education, and reassurance are vital. Most cases of deformational plagiocephaly have a favorable course, and helping parents understand the condition and the effectiveness of conservative measures can alleviate anxiety and promote adherence to intervention strategies 11 12.

Conclusion

Plagiocephaly is a complex yet common condition affecting infants, with a range of causes and varying degrees of severity. Early recognition and intervention are key to optimal outcomes.

Key takeaways from this article:

• Plagiocephaly presents with head shape changes, facial asymmetry, and sometimes torticollis.
• The condition is most often deformational (positional) but can also be synostotic (suture-fused).
• Common causes include supine sleep, limited neck mobility, and lack of tummy time; craniosynostosis is a less common but serious cause.
• Treatment ranges from repositioning and physical therapy to helmet therapy and, rarely, surgery.
• Parental education and reassurance are critical for successful management and reducing anxiety.

With proper understanding and timely intervention, most infants with plagiocephaly can achieve healthy, symmetrical cranial development.