Does my child have a “flat” head?
Lloyd Ellis & Anna Noisette
The Royal Children’s Hospital, Melbourne
Objectives of today’s session;
 Types of cranial asymmetry
 Identification of torticollis types
 Prevention
 Monitoring change
 RCH model
 Helmet therapy
 Resources/Questions
 Future?
The Skull
Craniosynotosis
Fused Suture
Name
Description
Sagittal
Scaphocephaly
Boat Skull
Metopic
Trigonocephaly Triangular Skull
Unilateral
Coronal
Bicoronal
Plagiocephaly
Brachycephaly
Lambdoid
Plagiocephaly
Asymmetric
Skull
Short Skull
Asymmetric
Skull
Scaphocephaly
Scaphocephaly
Scaphocephaly
Trigonocephaly
Does my child have a “flat” head?
What causes deformational
Plagiocephaly?
 Prolonged pressure the skull in a particular position
 SIDS protocols “Back to sleep”
 Torticollis – a tightening of the neck muscles
 Macrocephaly
 Child resistant to ‘tummy time’ / muscle weakness
 Lack of education of prevention methods
 Utero constraints eg multiple births, insufficient pelvis
 The expanding brain applies an externally directed
force, with the brain capable of extreme plastic
deformation with no loss of function or intellect if
volume is not reduced
Sleeping Position
• 1992 AAP recommended
infants sleep supine/side to
reduce SIDS risk
• Revised 1996 – no sidelying
sleeping
• Victorian statistics:
1989 513 SIDs deaths/year
2000 140 SIDS deaths/year
Incidence
 SIDS reduced significantly since inception of ‘Back to

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Sleep’ campaign (up to 40%) (Task Force on Sudden Infant
Death Syndrome, 2005; Saeed et al., 2008; Xia et al.,
2008; Losee & Mason, 2005).
Dramatic increase (10-48%) in incidence of plagiocephaly
since “Back to Sleep” campaign (Saeed et al., 2008; Habal
et al., 2004; Persing et al., 2003; Xia et al., 2008).
13-15% singletons have some flattening
Right side more common
1.3% incidence torticollis
Deformity persists in 30% at 2 years
Risk factors:
found repeatedly
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Male
First born
Multiple pregnancy
Prematurity
Oligohydramnios
Supine sleeping
< 5 mins tummy time/day
Delayed motor milestones
Preferred head orientation for sleep at 6 weeks
Positioning to same side for all bottle feeds
Decreased Prone Play
• Decreased awareness
of the importance of
supervised ‘tummy
time’, extended time
on back
• WHY?
• Parental fears
• Infant intolerance
Treatment of Plagiocephaly
 Wait and See!
 If torticollis present, treat with
physiotherapy/gentle stretching
 Counter positioning
• Changing the forces on the head by altering the lying
position
 Cranio-reshaping helmet therapy
• Fitting a custom made helmet which is worn for 23/34
hours a day until improved cosmesis is achieved
Classifications
• Macdonald 1969 gave 3 classifications:
• Sternomastoid tumour group (42.7%)
• palpable mass present
• Muscular torticollis group (30.6%)
• tight SCM but no palpable mass
• Reduced active/passive ROM
• Postural torticollis group (22.1%)
• no palpable mass or tightness
• Full active/passive ROM
Congenital Muscular Torticollis
(CMT)
• CMT usually presenting with
unilateral tightness of the
sternocleidomastoid (SCM)
muscle (Luther, 2002)
• Characterised by lateral flexion
to the affected side and
rotation away from the affected
side
Physiotherapy Rx
• Goals of Physiotherapy:
• increase PROM
• increase AROM
• Improving facial and cranial
symmetry
• Encourage gross motor
development
• Education, Stretching, Counter
positioning techniques including
positions carrying and for play
Counter Positioning
• Parent education
• Active and consistent
repositioning of infant during
play to apply pressure to
prominent part of the skull
• Use of passive devices to
position baby, specially
designed devices
Counter positioning
Positioning, play and
carrying techniques to
encourage movement
to ‘neglected side’ and
lengthen tight muscles
Variety of positions for play
• Supervised ‘tummy
time’ whilst the infant
is awake
• Head shape and motor
development are
affected by sleep and
awake positions of
infant
Prevention is the key !
Key Preventative Strategies
1. Early detection of torticollis & referral to Physiotherapy
2. Encourage prone & side-lying during supervised awake
play periods several times per day
3. Nightly/weekly alternating head positioning during
supine sleeping
4. Avoid prolonged repetitive positioning (e.g. Car seat
carriers, buggies, baby swings & bouncers.
5. Regularly change position of cot in room or toys/mobiles
around cot.
6. Counter positioning / alternating the orientation of infant
in the cot
7. Alternating feeding positions.
(Saeed et al., 2008; Task Force on Sudden Infant Death Syndrome, 2005; Neufeld & Birkett, 1999;
Persing et al., 2003; van Vlimmerman et al., 2008., Canadian Paediatric Society, 2001).
Assessment
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History
Examination
Severity scoring
Measurement
Closure of anterior fontanelle
• Range 4 to 18m
Clinical Severity Score
RCH treatment model
• Research into the effectiveness of conservative
management is just beginning
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3d Capture
Counterpositioning: initial treatment
Follow-up 3d review
Physiotherapy: if torticollis present
Orthotic management: for severe cases in older
infants (from 6/12 old)
To treat or not to treat?
• Cosmetic condition
• Studies have shown that helmets improve the
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head shape
No study has been conducted to see if the
condition self corrects regardless of treatment
Who should we treat ?
Last resort when conservative management fails.
They are not an ‘easy’ option
Significant time and resource costs for health
services and families
Indications for referral to RCH
Deformational Plagiocephaly Clinic
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Failure of early treatment strategies
Severe deformity
Severe torticollis and restriction
Associated medical conditions
• Prematurity
• Developmental delay
Helmet Therapy
• Do not affect the growing brain
• Not the easy option!
• They are a significant cost in time and
resources for families
• For most children they shouldn’t be
required
RCH treatment protocol:
 To qualify a child must:
• Have a deformational score of 6 or greater on the
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assessment sheet or
Score a 3 in a single deformation change
Be at least 6 months old
Have no craniosynostosis
Helmets do not treat torticollis!
How does it work?
Wearing Regime
 Helmet is worn in gradually over 3-7 days (day
time only), then worn 23/24 for duration of
treatment
 Review every 4-6 weeks according to growth
• Repeating 3D photos mid treatment and end of
treatment
The Finished product
The process
• 3D photography using 5
point camera
• Use to manufature
helmet
• Baseline to see shape
improvement
Helmet Therapy
Helmet Therapy
Helmet Therapy
Helmet Therapy
Helmet Therapy
Helmet Therapy
Helmet Therapy
Helmet Therapy
Helmet Therapy
Positional Therapy
Positional Therapy
Positional Therapy
Positional Therapy
7mths
8.5mths
Positional Therapy
8mths
9.5 mths
24mths
12mths
5yrs
Deformational Plagiocephaly - Mild
Deformational Brachycepahley - Mild
Deformational Plagiocephaly – Moderate / Serve
Deformational Plagiocephaly – Moderate / Serve
Deformational Plagiocephaly – Moderate / Serve
Deformational Plagiocephaly – Moderate / Serve
RCH - What are we doing?
• Development of brochure & poster:
- ‘Back to Sleep – Tummy Time to Play
• ‘How to Protect Your Baby’s Head
Shape’
• Available from APA
• Plagiocephaly Fact sheet for parents
– RCH website
• Plagiocephaly Clinic
Future Objectives
Educational material on positional
plagiocephaly to:
• Raise awareness
• Early recognition
• Early management
• Prevention
Further research required in:
• Natural history of plagiocephaly
• Severity rating of plagiocephaly
• Objective outcome measures
Conclusion
• Early detection of deformational
plagiocephaly within 6-10wks and
positional therapies followed there is a
greater degree of avoiding helmet therapy.
Acknowledgements
• Sharon Vladusic, Senior Physiotherapist,
Orthopaedic Department, RCH
• Dr. Susie Gibb, Consultant Paediatrician,
Department of General Paediatrics, RCH
• Angela Serong, Senior Physiotherapist,
RCH
Questions?
References
Canadian Paediatric Society. (2001). CPS Statement Update: Positional
plagiocephaly and sleep positioning: an update to the joint statement on
sudden infant death syndrome. Paediatr Child Health, 6, 788-789.
De Ribaupierre S et al. Posterior plagiocephaly treated with cranial remodeling
orthosis. Swiss med Weekly 2007; 137: 368-72.
Habal, M.B., Castelano, C., Hemkes, N., Scheuerle, J., & Guilford, A. M. (2004).
Clinical Note: In search of causative factors of deformational plagiocephaly.
The Journal of Craniofacial Surgery, 15, 835-841.
Losee, J.E., & Mason, A.C. (2005). Deformational plagiocephaly: diagnosis,
prevention and treatment. Clin Plastic Surg, 32, 53-64
Neufeld, S., & Birkett, S. (1999). Clinical Notebook. Positional plagiocephaly: a
community approach to prevention and treatment. Alta RN, Jan-Feb, 55, 1516.
NHS Quality improvement Evidence note 16: The use of cranial orthosis treatment
for infant deformational plagiocephaly, Scotland, 2007.
Persing, J., James, H., Swanson, J., Kattwinkel, J. (2003). Prevention and
management of positional skull deformities in infants. Pediatrics, 112, 199202.
Saeed, N.R., Wall, S.A., & Dhariwal, D. K. (2008). Management of positional
plagiocephaly. Arch Dis Child, 93, 82-84.
Steinbok P et al. Long term outcome of infants with positional plagiocephaly.
Childs Nervous System 2007: 23: 1275-83.
Task Force on Sudden Infant Death Syndrome. (2005). The changing concept of
sudden infant death syndrome: diagnostic coding shifts, controversies
regarding the sleep environment, and new variables to consider in reducing
risk. Pediatrics, 116, 1245-1255.
Van Vlimmeren LA et al. (2007). Risk Factors for Deformational Plagiocephaly at
birth and 7 weeks of age: A prospective cohort study, Pediatrics ,119; 2:20062012.
Van Vlimmeren LA et al (2008). Effect of Pediatric physical therapy on
deformational plagiocephaly in children with Positional preference. A
randomized controlled trial, Arch Ped Adol Med ,162;8:712-718.
. Xia, JJ et al. (2008). Nonsurgical treatment of deformational plagiocephaly, a
systematic review. Arch Ped Adol Med,162; 8: 719-20.