What Kind of Stretching Exercises are Recommended for Positional Plagiocephaly?

Patient Presentation
A 4-month-old female came to clinic for her health supervision visit. Her mother was concerned about a flat spot on the back of her head. Her mother said that the infant was always placed on her back to sleep, at the same end of the crib and that over time “she always seems to want to put her head in the same direction.” Her mother stated that she did not spend much time on her stomach and spent a fair amount of time in a car seat sleeping. She did not roll over yet. The past medical history showed a normal head shape at 2 weeks of age. She was full term without problems. The family history was negative for neurological problems or early deaths.

The pertinent physical exam showed a smiley female who would make spontaneous vowel sounds and transfer objects with her hands. Her head circumference was 25% and her length and weight were 75-90%. All were tracking appropriately. She had a right occipital flatness with her right ear slightly anteriorly displaced with no facial asymetry. Her anterior fontanelle was open. No obvious torticollis was observed. The rest of her examination including a neurological examination were normal. The diagnosis of positional plagiocephaly was made. The mother was instructed to decrease the amount of time in the car seat, increase the amount of time on her abdomen, and place her on her back but with her head on the opposite side of the crib. The mother wanted to see a “specialist” and a consultation with a pediatric neurosurgeon was made. The mother noted some improvement at the neurosurgeon’s visit and was reassured by normal skull radiographs. At followup by neurosurgery and her 6 month health supervision visit, the positional plagiocephaly had resolved.

Case Image

Figure 89 – 10-04-10 – AP and lateral radiographs of the skull demonstrates flattening and indentation of the occipital portion of the skull. The cranial sutures are all patent.

Positional plagiocephaly (PP) is an asymmetric head shape caused by external pressure on the occiput or other area of the head. The prevalence has increased since the 1992 recommendations began in 1992 for placing infants on their back for sleeping to decrease the risk of sudden infant death syndrome. Overall the rates vary from 0.3%-48% for infants < 1 year old.

Children are at higher risk for PP at 7 weeks if they are:

  • Male
  • First-born birth order
  • Having a preference for sleeping position
  • Head placed in same end of crib
  • Bottle feeding only
  • Same side feeding position
  • Low amount of time placed on abdomen (a.k.a. “tummy time”)
  • Slow motor milestone achievement

In another study, mothers of infants with positional plagiocephaly at 6 weeks thought the infants were less active, and they themselves had lower educational attainment and were less likely to have attended pre- or ante-natal parenting classes.

Craniosynostosis is caused by the premature fusion of 1 or more cranial sutures with abnormal head shape occurring. It usually occurs because of abnormal ossification called primary craniosynostosis. It can also occur because of abnormal brain growth called secondary craniosynostosis. Overall the incidence of craniosynostosis is 0.04-0.1%. with sagittal (50-58%) and coronal (20-29%) sutures being the most commonly affected.

Learning Point
The skull is maximally deformable around 2-4 weeks so parents should be educated to place the child on their back for sleeping but to alternate positions of the occiput. Parents should also be instructed to do tummy time with their infant when awake and when they are observing the infant. The child should not be left unattended on their abdomen. Decreasing the amount of time in car seats or other similar seating also helps to prevent PP (e.g. “if the child is not riding in the car, then they should not be in the seat.”). These same maneuvers also helps treat PP, along with placing the rounded side of the head down on the mattress when sleeping, and changing the position of the crib so the child looks out while lying on the rounded head side. Neck stretching with each diaper change (about 2 minutes) should be recommended. These exercises can be done as follows:

“One hand is placed on the child’s upper chest, and the other hand rotates the child’s head gently so that the chin touches the shoulder. This is held for approximately 10 seconds. The head is then rotated toward the opposite side and held for the same count. This will stretch out the sternocleidomastoid. Next, the head is tilted so that the infant’s ear touches his or her shoulder. Again, the position is held for a count of 10 and repeated for the opposite side. This second exercise stretches the trapezius muscle.” Three repetitions per diaper change are recommended.

If there is no improvement, referral to a pediatric neurosurgeon or other specialist trained to treat such conditions is recommended to determine if the correct diagnosis is made (or this is craniosynostosis instead) and if other treatment such as cranial molding or surgery is necessary. A physical therapist may also assist in managing torticollis if still present after initial treatment.

Children aged 4-12 months responds best to cranial molding if necessary because of the great malleability of the infant skull. Treatment is usually for 2-3 months for best results. Treatment for craniosynosis is almost always surgery but PP may also require surgery if it is severe and resistant to more conservative treatment.

Questions for Further Discussion
1. Describe the physical examination for determining possible positional plagiocephaly or craniosynostosis.
2. What are the risks for craniosynostosis?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Uncommon Infant and Newborn Problems and Head and Brain Malformations.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Persing J, James H, Swanson J, Kattwinkel J; American Academy of Pediatrics Committee on Practice and Ambulatory Medicine, Section on Plastic Surgery and Section on Neurological Surgery.
Prevention and management of positional skull deformities in infants. Pediatrics. 2003 Jul;112(1 Pt 1):199-202.

Hutchison BL, Thompson JM, Mitchell EA. Determinants of nonsynostotic plagiocephaly: a case-control study. Pediatrics. 2003 Oct;112(4):e316.

van Vlimmeren LA, van der Graaf Y, Boere-Boonekamp MM, L’Hoir MP, Helders PJ, Engelbert RH. Risk factors for deformational plagiocephaly at birth and at 7 weeks of age: a prospective cohort study. Pediatrics. 2007 Feb;119(2):e408-18.

Sheth RD, Iskandar BJ, Heger IM, Roy S. Craniosynostosis. eMedicine.
Available from the Internet at http://emedicine.medscape.com/article/1175957-overview (rev. 7/23/2010, cited 9/7/10).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.


    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital