Positional plagiocephaly and sleep position

by Ralph Franciosi, MD, and Anne Harvieux, CICSW

Ralph Franciosi, MD, was medical adviser for the Infant Death Center of Wisconsin and pathologist at Children's Hospital of Wisconsin. He also was a professor of Pathology and Laboratory Medicine at the Medical College of Wisconsin. Anne Harvieux is the program administrator for the Infant Death Center of Wisconsin.

Plagiocephaly is the medical description for flattening of the head. The problem of infants with a misshapen head (flattening of an area of the skull) was first reported from several craniofacial centers in the United States. The medical concern of plagiocephaly is that the flattening was caused by a premature closure of the skull bone sutures (cranial synostosis), which requires surgery to allow for normal brain growth. Because of the concern that the incidence of premature closure of the cranial sutures was occurring imaging studies were performed. There was not an increase in craniosynostosis.

Another cause of head flattening is young infants maintaining the same head position for long periods of time. This is referred to as positional plagiocephaly. Craniofacial centers throughout the United States have reported an increase in the number of infants with positional plagiocephaly since the Back to Sleep Campaign began to reduce the risk of SIDS. In order to rule out the more serious cranial synostosis, many infants are undergoing costly diagnostic work ups.

The increase of skull flattening (positional plagiocephaly) was temporarily associated with the recommendation by the American Academy of Pediatrics to place babies on their back for sleep. This suggested that the deformed skull was related to pressure on an area of the skull related to supine sleep position.

The AAP was concerned that the solution would be the reintroduction of the prone sleep position. This would reverse the 40% decline in the rate of sudden infant death syndrome seen since the supine sleep position was recommended in 1994.

Positional plagiocephaly, due to supine sleep position, should be preventable by alternating pressure points on the skull. Parents can be encouraged to place the infant prone (tummy time) when awake, change the sleep position of the infant's head during supine sleep, and to avoid placing an infant in a car seat carrier, when not traveling, for an extended period of time.

Primary care physicians need to be aware of positional plagiocephaly and take measures to prevent it. At well baby checks, in addition to recording head growth, the shape of the skull can be noted. The parent can be advised about head position during sleep and the preventive measures noted above encouraged. The attention to head shape can detect craniosynostosis earlier.

Primary physicians and others working with parents could help families prevent positional plagiocephaly by encouraging parents to implement the following strategies:

Make sure infants spend time on their stomachs when awake and supervised by a caregiver. This tummy time also will develop a baby's upper body strength and coordination.
Alternate the position of the infant's head. For example, one week, position the head facing right, the next week, left. In addition, periodically alternate the baby's placement in the crib. For example, one week the infant sleeps with his or her feet toward the foot of the crib, the next week, toward the head of the crib. Move the crib so the infant will turn to stimulation, such as a family member entering the room. Limit the use of car seats and carriers to times when actually traveling. Encourage parents to discuss plagiocephaly with the pediatrician.

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