Management of Positional Plagiocephaly
Initial Assessment and Diagnosis
- Clinical examination alone is sufficient for diagnosis in most cases, with imaging rarely necessary except when the diagnosis is equivocal, according to the American Academy of Neurosurgery 3, 4
- When uncertainty exists, three-dimensional surface imaging or stereophotogrammetry is preferred over CT scanning, as recommended by the American Academy of Neurosurgery 1, 2
Treatment Algorithm by Age and Severity
- Infants 7 weeks to 6 months with any degree of plagiocephaly should receive physical therapy immediately, which is superior to repositioning alone, with Level I evidence, as recommended by the American Academy of Neurosurgery 1, 2, 4
- Physical therapy achieves better outcomes than repositioning education alone, with high clinical certainty, according to the American Academy of Neurosurgery 1, 4
- The American Academy of Pediatrics recommends avoiding positioning pillows due to safe sleep concerns, as stated by the American Academy of Neurosurgery 1, 2
- Helmet therapy is indicated for moderate to severe deformity that persists despite 2-3 months of physical therapy and repositioning, as recommended by the American Academy of Neurosurgery 1, 5
- Helmet therapy achieves faster and more significant correction than conservative therapy alone in moderate to severe cases, with moderate clinical certainty, according to the American Academy of Neurosurgery 5
- The American Academy of Neurosurgery recommends helmet therapy for infants presenting at an advanced age with moderate to severe plagiocephaly, even without prior conservative treatment 5, 6
Common Pitfalls to Avoid
- The American Academy of Neurosurgery advises against delaying helmet therapy while waiting for physical therapy to fail in severe cases presenting after 6 months, and against dismissing older infants as too old for treatment 1, 6
- The American Academy of Pediatrics recommends not using positioning pillows as primary treatment due to safe sleep concerns, as stated by the American Academy of Neurosurgery 1, 6