Nonsurgical Management of Positional Plagiocephaly in Children

Positioning

• Avoidance of pressure to flattening when supine: Several class III and IV studies suggest that mild to moderate positional plagiocephaly can be effectively treated with positioning and/or physical therapy (15, 53). Positional plagiocephaly may be treated with active positioning of the infant’s head while he or she is sleeping or lying. Objects that attract the infant’s attention can be placed in a way that causes him or her to turn the head in the opposite direction of the flattened occiput, or  a wedge or roll can be placed under the infant to remove forces from the flattened occiput.  
• Most important during first 3–4 months of life: Before 3–4 months of age, infants can be repositioned, but after this age the efficacy of this therapy is gradually reduced due to the infant’s ability to regulate his or her own position. 
• “Tummy time”: Thirty minutes of “tummy time” per day can decrease the deformation (20). 
• Torticollis treated: In infants with associated muscular torticollis, neck stretching exercise can lead to improvement over several weeks (46). These exercises typically include gentle rotation of the infant’s chin to each shoulder and tilting the head so that the infant’s ear approaches the shoulder, for approximately 2 minutes during each diaper change (33). With repositioning therapy, some infants with associated torticollis have improvement of cranial shape along with resolution of torticollis, whereas others do not have improvement in torticollis but have improved cranial shape (11). 

Molding Helmet

• Used to define growth: The goals of cranial molding helmets are to minimize further bossing and to allow the flattened areas to round out (23, 28). 
• Considered when positioning fails: Infants who have persistent, severe positional plagiocephaly by 4-6 months of age or who have failed a trial of positioning can often be treated successfully with molding helmets (16). These are also known as cranial orthotic devices, cranial bands, headbands, helmets, or orthotics (8). 
• Helmet therapy age limit: Helmet therapy is recommended for infants with moderate to severe plagiocephaly presenting at an advanced age (55).
• Mold or topographic scan: An individual mold or topographic scan can be taken of the infant’s head and a corresponding custom passive or active helmet can be made. 
• Passive helmet: Passive helmets allow room for growth in the flattened areas while minimal pressure is applied to the areas with bossing. 
• Active helmet: Active helmets, in contrast to passive helmets, apply compression to the bossed areas with the theory that this allows for more rapid correction. 
• Worn 23 hours per day for at least 3 months: Molding helmets are typically worn for 23 hours per day for at least 3 months with frequent evaluation. Evaluation is typically every 2 weeks for passive designs and weekly for active designs with adjustments made to optimize cranial shape and to minimize skin irritation or breakdown. 
• Rarely used after 1 year of age: As approximately 85% of cranial growth occurs during the first year of life (47), infants rarely have improvement after 1 year of age (reviewed in 49).