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Plagiocephaly and Craniosynostosis

Checked: 05-07-2024 by Rob Adams Next Review: 04-10-2026

Overview

Please see the Management of Positional Plagiocephaly guideline provided by Bristol Royal Hospital for Children (listed under P). This guideline also has information on recognising Craniosynostosis and appropriate referral pathways.

Plagiocephaly

Positional plagiocephaly is a condition characterised by changes in skull shape and symmetry in infants who are older than 6 weeks of age. It results from mechanical factors which when applied over time in utero, at birth or post- natal, alter the shape of the skull. There has been a significant increase in the incidence since the “Back to Sleep” campaign 1992.

History and physical examination are usually sufficient to make a diagnosis.

Craniosynostosis (premature fusion of sutures)

Clinicians should consider craniosynostosis, the premature fusion of cranial sutures in a child, as a possible diagnosis when reviewing babies with concerns about head shape. This condition has a global prevalence of approximately one in 1695 live births (1).

Although less common than positional plagiocephaly, it is vital to identify these babies as they need rapid referral and may require surgery (see red flag section below).

Differences seen in Craniosynostosis compared to positional Plagiocephaly:

Occipital flattening already at time of birth
Lambdoid suture has palpable ridge
Ear on flattened side is typically posterior and inferior to the other ear (whereas in plagiocephaly the ear on the flattened side is 'pushed forward')
Frontal asymmetry is less

Before Referral

Prevention

Prevention is the key to reducing the incidence and severity of positional plagiocephaly.

When supine positioning for sleep and SIDS are being discussed ('Back to sleep'), also inform parents about the benefit of “tummy time”, when baby is awake, to prevent plagiocephaly.

Education and early intervention

Babies with an odd shape head should be assessed by a GP to confirm the diagnosis.

At first sign of occipital flattening, give appropriate advice about counter positioning and corrective measures:

Provide patient leaflet.
Encourage short periods of supervised “tummy time” whilst the baby is awake and alert, e.g. after each nappy change.
Encourage alternate left and right positioning of the head in the supine sleeping position
Encourage head movement to the opposite side by placement of pictures, toys, mobile on opposite side to the flattening.

Assessment and treatment of co-existing problems

e.g. Torticollis, sternocleidomastoid tumour, developmental delay - see BRHC guideline for advice on referral.

Red Flags

If craniosynostosis is suspected or any odd shape other than typical occipital flattening of positional plagiocephaly then babies should be referred to the Paediatric Rapid Access Clinic (if baby is well) via eRS.

If a baby is unwell with suspected craniosynostosis then refer to the Paediatric Emergency Department.

Referral

There is no indication for imaging prior to referral.

Please see the Management of Positional Plagiocephaly guideline from the BRHC for advice on indication for referral and appropriate referral routes. This guideline includes advice on Craniosynostosis.

Resources

(1) Recognising a child with isolated craniosynostosis | The BMJ - needs membership login for full article

Parent information

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