Positional plagiocephaly is a common skull deformity seen in infants.  Typically the infant is diagnosed between 3-6 months with it.  Plagiocephaly is a flattening of the skull bones most often due to the infant’s position on the back of his/her head to prevent Sudden Infant Death Syndrome, (SIDS).  Other reasons that account for the flattening of the head include prolonged time in a bouncy seat or car seat, anything that can put pressure on the back of the head.  Many times the infants also have a history of keeping the head turned to one side more so than the other.  On exam, these infants that tend to prefer to keep their head to one side are found to have Torticollis which is tightening of the neck muscle. 

Torticollis is typically there since birth and as the infant grows the head and neck movement has some restriction on turning to one side and there is a preference to keep the head tilted to one side more than the other.  For these reasons, the head becomes flatter due to the decreased range of motion of the head and neck.   Positional plagiocephaly and torticollis is more common in multiple births due to their positions in utero.

Positional plagiocephaly and torticollis are both conditions that will not affect the infants’ cognitive development, growth or development.  These conditions are very treatable.  One of the first treatment recommendations that we tell our patients is first to increase the time off of the back of the infant’s head as much as possible while awake.  Tummy time can be fun for the infant as well as the caregiver.  Placing colorful soft toys on the floor within the infants reach may make tummy time easier.  The car seat should only be used for transporting the infant in the car.  Limit the amount of time in a bouncy seat or swing.  Repositioning is another way to get the infant off of the flat part of the head, by alternating side sleeping positions.  When he or she is in the crib, try to reposition the crib or an object he or she likes to look at to get the infant to turn their head to the other side.  When infants reach certain developmental milestones such as rolling over between 4-5 months of age, or starting to sit on their own between 6-8 months, then they will be repositioning themselves lessening the amount of time on the back of their heads.

Torticollis is a condition of a tight neck muscle and if this is not treated, it will make the decrease the success of improving the positional plagiocephaly.  Many times, infants will need an evaluation by a pediatric physical therapist, (PT).  The PT can treat the infant as well as teach the parents neck stretching exercises to do at home.  Typically, the neck stretching exercises should be done at least 4-6 times a day, during diaper changes to help loosen the neck muscle.  The neck stretching exercises should continue up until 12-15 months to prevent the torticollis from returning. 

There are different types of plagiocephaly as well as different degrees of plagiocephaly which are important to consider when evaluating an infant.  If the infant is diagnosed with mild to moderate plagiocephaly and the infant is less than 10-11 months, the treatment is repositioning, tummy time, and the least amount of time on the back of the head as possible.  If the infant is diagnosed with moderate to severe plagiocephaly, the same treatment is recommended unless they are approaching 9-10 months.  In this case, if the tummy time and repositioning has not improved the head shape, then a cranial molding helmet may be recommended.  A cranial molding helmet is a thermoplastic band that is made for each infant if needed.  The cranial molding helmet is worn up to 23 hours a day for approximately 2 ½- 3 months.  The infant is fitted for the helmet, and follows up with the Neurosurgeon and/or APN after he or she has been wearing the helmet for 4-6 weeks, and at regularly scheduled intervals. The infant will continue to follow up with the facility where the helmet was made, for re-adjustments during the treatment.

Neck-Stretching Exercises for Torticollis
Neck-stretching exercises have been recommended for your child because he or she has tightnes sin his or her neck muscles that is limiting neck movement. these excercises should be performed with each diaper change, or at least 5 times a day, until your child's nec has a normal range of motion. Exercise 1. The first excercise is designed to improve rotation of your child's head to the right and left. Place on hand on your child's chest. Place the other hand on the side your child's face. Gently but firmly turn the head so that the chin moves toward the shoulder. Turn the head only to the point of resistance, hold for 10 seconds, and release. Switch hands and repeat the same steps, turning the head to the shoulder in the opposite direction.	Exercise 2. The second exercise is designed to improve bending of your child's head to the side. Place one hand on your child's upper chest and shoulder area so that his or her body does not move. Hold the top of your child's head with the other hand. Gently but firmly tilt the head to the side, pressing the ear toward the shoulder. Press only to the point of resistance, hold 10 seconds, and release. Switch hands and repeat the same steps, tilting the opposite ear to the shoulder. During the exercise that move the tight area of your child's neck, your child will fuss and squirm. However, consistent use of these exercises gradually will improve yoru child's neck mobility.

This information is designed for general guildlines only. Your physician may modify these guidlines for your child. If you have specific questions about these instructions or concerns regarding your child's care, contact Advanced Neurosurgery Associates. Produced by Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, and Cranial Technologies, Phoenix Arizona Text and figures © 2001, Barrow Neurological Institute This handout may be reproduced without permission for the purpose of parent-education.

 

Positioning Protocol

Frequent changes in your child's position are recommended. Examples are listed below to help improve your child's neck mobility to prevent or to improve an abnormal head shape. If your child's head shape fails to improve by 3 to 4 months of age, contact your doctor.

Alternate the end of the crib in which you place your baby to sleep. Alternate the end of the changing table in which you place your child's head. If you stand or sit at the end of your baby for diaper changes, position yourself slightly off to the side and alternate sides to encourage your baby to move his or her head. Place toys on the side of the stroller, swing, crib or infant seat where nect rotations is most limited. Alternate the hip or arm with which you carry your baby. You may notice some fussing and irritability at first because your baby will have to turn in the direction of the neck restriction, but the fussiness will decrease with time. Peform both sets of neck-stretching exercises (see Neck Stretching Exercises for Torticollis protocol) at each diaper change, as perscribed by your doctor. Attempt to interact with your child on the side where neck movement is limited. A cushioned head support may be necessary to support your baby's neck when he or she is in the car seat. Infants tend to scrunch up and turn to the side of lease resistance. Provided supervised "tummy time" daily while your baby is awake. Initially, babies often cry and resist this position. Start with just a minute or two of tummy time and gradually increase it as your baby learns to tolerate it. Tummy time will help improve your child's muscle and strength and development.

This information is designed for general guildlines only. Your physician may modify these guidlines
for your child. If you have specific questions about these instructions or concerns regarding your child's care,
contact Advanced Neurosurgery Associates.

Produced by Barrow Neurological Institute, St. Joseph's Hospital and Medical Center,
Phoenix, Arizona, and Cranial Technologies, Phoenix Arizona
© 2001, Barrow Neurological Institute

This handout may be reproduced without permission for the purpose of parent-education.