Guideline sources The following summarized guidelines for the evaluation and management of plagiocephaly are prepared by our editorial team based on guidelines from the Congress of Neurological Surgeons (CNS 2016) and the Canadian Paediatric Society (CPS 2011). 1 2 3 4 5 Guidelines 1. Screening and diagnosis Diagnosis: diagnose plagiocephaly on the basis of clinical examination. A 2. Diagnostic investigations Clinical evaluation: obtain evaluation for craniosynostosis, congenital torticollis and cervical spine abnormalities as part of the examination of a patient with plagiocephaly. B https://web.pathway.md/diseases/recIQUieuMaFfIeIe 1/3 6/29/23, 11:12 PM Plagiocephaly Pathway Diagnostic imaging: Obtain imaging only if the clinical diagnosis is equivocal, using the following modalities: A skull X-ray B ultrasound of the suspect suture B 3D surface imaging or stereophotogrammetry - in case of plagiocephaly without synostosis B CT - in case of nondiagnostic results from radiography or ultrasound. A 3. Nonpharmacologic interventions Physical therapy: Offer physical therapy over repositioning education alone to reduce the prevalence of infantile positional plagiocephaly in infants 7 weeks of age. B Offer physical therapy over using a positioning pillow in infants with positional plagiocephaly to ensure a safe sleeping environment and comply with AAP recommendations. B Repositioning: As per CNS 2016 guidelines, consider offering repositioning in infants with deformational plagiocephaly, recognizing that it is inferior to physical C and helmet therapies. C As per CPS 2011 guidelines, offer repositioning therapy plus physiotherapy as needed as the interventions of choice in most patients with mild or moderate positional plagiocephaly. B Helmet therapy: As per CNS 2016 guidelines: Offer helmet therapy in infants with persistent moderate-to-severe plagiocephaly after a course of conservative treatment (repositioning and/or physical therapy). B Offer helmet therapy in infants with moderate-to-severe plagiocephaly presenting at an advanced age. B As per CPS 2011 guidelines: Consider offering helmet therapy in patients with severe asymmetry. Recognize that helmet therapy influences the rate of improvement of asymmetry but not its final outcome. C Insufficient evidence to recommend helmet therapy in patients with mild or moderate asymmetry. I 4. Preventative measures Positioning: Advise positioning of the head to encourage lying on each side in the supine position for the prevention of plagiocephaly. Recognize that more effort may be required for the child with a strong positional preference to lie more on one side of the head. B Advise prone positioning during awake time (tummy time) for 10-15 minutes at least TID for the prevention of plagiocephaly. B https://web.pathway.md/diseases/recIQUieuMaFfIeIe 2/3 6/29/23, 11:12 PM Plagiocephaly Pathway Clinical findings Symptoms Past medical history Changes in skull shape Congenital muscular torticollis Neurological exam Head and neck exam Torticollis Cranial vault asymmetry Ear displacement Frontal bossing Head flattening Observed cranial index (from > 76% to < 90%) Occipital bossing Parietal bossing Parietal widening Skull bossing References 1. Tamber MS, Nikas D, Beier A et al. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline on the Role of Cranial Molding Orthosis Helmet) Therapy for Patients With Positional Plagiocephaly. Neurosurgery. 2016 Nov;79 5 E632 E633. Open 2. Mazzola C, Baird LC, Bauer DF et al. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline for the Diagnosis of Patients With Positional Plagiocephaly: The Role of Imaging. Neurosurgery. 2016 Nov;79 5 E625 E626. Open 3. Klimo P Jr, Lingo PR, Baird LC et al. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline on the Management of Patients With Positional Plagiocephaly: The Role of Repositioning. Neurosurgery. 2016 Nov;79 5 E627 E629. Open 4. Carl Cummings. Positional plagiocephaly. Paediatr Child Health. 2011 Oct. Open 5. Baird LC, Klimo P Jr, Flannery AM et al. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline for the Management of Patients With Positional Plagiocephaly: The Role of Physical Therapy. Neurosurgery. 2016 Nov;79 5 E630 E631. Open https://web.pathway.md/diseases/recIQUieuMaFfIeIe 3/3