REMEDY : BNSSG referral pathways & Joint Formulary

Home > BNSSG ICB > Development Area >

Plagiocephaly and Craniosynostosis - DRAFT

Checked: 05-07-2024 by Rob Adams Next Review: not set yet



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.

Please see the clinical guidance on Plagiocephaly provided by Bristol Royal Hospital for Children, for further details.

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. 

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 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 immediately to general paediatrics via eRS marked urgent.


There is no indication for imaging prior to referral.

Please see the clinical guidance on Plagiocephaly from the BRHC for advice on indication for referral and appropriate referral routes.


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

Parent information

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.