Positional Head Deformity

1. See Also
   1. Craniosynostosis
2. Definition
   1. Head deformity in infant related to fixed position
3. Epidemiology: Incidence in U.S.
   1. 1992: 1 per 300 healthy infants
   2. 1999: 1 per 60 healthy infants
   3. Increase due to back positioning for SIDS prevention
4. Pathophysiology
   1. External pressure from prolonged fixes head positioning
   2. Infant susceptible due to rapidly developing skull
5. Risk factors
   1. Prematurity
   2. Hypotonic muscle disorders
   3. Congenital Torticollis
   4. Intrauterine Constraint (Twins, Oligohydramnios)
6. Signs
   1. Forehead protrudes on side of occiput flattening
   2. Ear on flattened side moves anterior to other ear
   3. Eyes appear to have unequal positioning
   4. Bald spot may be present on flattened side
   5. Viewed from above, head shape is a parallelogram
7. Differential Diagnosis: Synostotic Plagiocephaly
   1. Critical to differentiate from positional deformity
   2. Findings that suggest Synostotic Plagiocephaly
      1. Lambdoid Suture with palpable ridge
      2. Ear on flattened side more posterior than other side
      3. Forehead does not protrude
      4. No signs of external pressure (e.g. bald spot)
8. Radiology: Indicated for unclear or refractory cases
   1. Skull XRay or CT Head with 3D Reconstruction
      1. Check Sutures for Synostotic Plagiocephaly
   2. Ultrasound also effective in lambdoid Suture evaluation
      1. Sze (2003) Pediatr Radiol 33(9):630-6
9. Management
   1. General
      1. Teach prevention at Well Child Visits (see below)
      2. Evaluate head shape for deformity at Well Child Visit
      3. Identify mild deformity early (e.g. 2 month check)
   2. Step 1: Physical therapy to relieve Torticollis
      1. Parent education
      2. Sternocleidomastoid stretches
   3. Step 2: If no improvement at 4-8 weeks
      1. Check for Synostotic Plagiocephaly (See XRay above)
      2. Custom molded head orthosis (skull-molding helmet)
         1. Vles (2000) J Craniofac Surg 11(6):572-4
   4. Step 3: Refer if refractory or possible synostosis
      1. Craniofacial surgery or
      2. Pediatric neurosurgery
10. Complications
    1. Cosmetic deformity: Facial asymmetry (10% of cases)
    2. Persistent occipital flattening (33% of cases)
    3. Developmental delay in some persistent cases
       1. Mild delay: 8-20% of persistent deformity cases
       2. Significant delay: 9-13% of persistent cases
       3. Panchal (2001) Plast Reconstr Surg 108(6):1492-8
11. Prevention: Education at Well Child Visits
    1. Regular supervised play in prone position
    2. Approach infant for feeding from alternating sides
    3. Avoid prolonged sitting in Car Seat or swing
12. References
    1. Biggs (2003) Am Fam Physician 67(9):1953-56
    2. Persing (2003) Pediatrics 112:199-202
    3. Pollack (1997) Pediatrics 99:180-5