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Positional Cranial Deformation

Frank Vicari, MD and Mizuho Morrison, DO

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When do kids need to be referred for cranial deformities? What conservative measures and practical tips can you tell your parents of newborns? What is the treatment algorithm for conservative versus helmet therapy? We discuss all of these things and more on cranial deformities with expert and leading author Dr.Frank Vicari.



  • Most cases of positional cranial deformity will resolve with conservative therapy only.

  • The parallelogram-shaped head is very common for positional molding and uncommon for synostosis.

  • Patients that are more likely to fail conservative therapy are those who are older, have more severe deformity, or have associated medical conditions such as developmental delay.

  • To reduce the risk of positional cranial deformity, tummy time should start the day the child leaves the hospital and pediatricians should be teaching the parents how to implement tummy time.



  • Since the Back to Sleep campaign was initiated in 1992, the rate of Sudden Infant Death Syndrome(SIDS) has decreased by 40%.

  • At the same time, the incidence of children with positional cranial deformities increase by 600%.

  • Dr. Vicari was the senior author of a recent paper adding some good evidence in regards to how this condition should be managed.

Steinberg JP, et al. Effectiveness of conservative therapy and helmet therapy for positional cranial deformation. Plast Reconstr Surg. 2015 Mar;135(3):833-42. [PMID: 25415272]



What is your take on the increase in positional cranial deformities?

  • It was not simply the Back to Sleep campaign that led to an increase in cranial deformities. Other social changes and parenting conveniences have been factors.

    • Children spend more time in car seats, swings and otherwise on their backs. Car seats are now not only in the car but also can attach to a stroller or swing. Between this and sleeping on their backs a child may be supine for 20 hours a day.

    • The increase in multiple births related to in-vitro fertilization has also been a factor. Less room in utero for positioning is a set-up for positional deformities.


How do we make the diagnosis of positional cranial deformity?

  • Have the child sit on the caregiver’s knee facing inward and look down from the top. Putting your fingers in the child’s ears will also help. From above, a child’s skull should be a rectangle with rounded sides about three quarters as wide as it is long (0.78:1).

  • If there is a positional cranial deformity you should see a parallelogram. In other words, if it is flat on the back- right and bulging on the back- left you should expect to see opposite changes up front to a lesser degree. It would be a little flatter on the front- left and bulging on the front- right. There will also be an offset of the ears with the right ear more anterior than the left. The parallelogram shape is very common for positional molding and uncommon for synostosis.


Plagiocephaly final.tif

Image 1: Schematic representation of plagiocephaly related to craniosynostosis forming a trapazoid (left), normal cranium forming a rectangle (middle) and positional plagiocephaly forming a parallelogram (right). Note anterior and posterior displacement of ears in the plagiocephaly (parallellogram) patient, whereas the ears are not displaced in the normal and synostosis examples.


  • With brachycephaly, the child is short front- to- back and wide from ear- to- ear. If the cephalic ratio is more than two standard deviations from normal you should refer these patients.


*Editors note: The cephalic ratio is the width of the cranium divided by the length. Later in the interview Dr. Vicari will also refer to another metric of cranial deformity called the “diagonal difference”, which is generated from the difference between two diameters of the skull measured 30 degrees lateral of the middle of the anterior aspect of the skull.


Normal ranges for the cephalic ratio by age and gender can be found here:

Wilbrand JF, et al. Clinical classification of infant nonsynostotic cranial deformity. J Pediatr. 2012 Dec;161(6):1120-5 [PMID: 22727872]

  • In comparison to positional molding, synostosis tends to be an “upper third problem”. In other words, you may see a flatness of a forehead or a deformation in an orbit, but the cheek and the mandible should be in a normal position. This is not true with positional molding. In positional molding, if that forehead is flat you should also expect to see that the malar eminence is a also flat.


What was your study? What was the goal of your study?  What were some of your major findings?

  • The goal is to put together evidence for therapy in positional cranial deformities from our group that see 800 to 1000 patients a year.

  • The study is a retrospective study of almost 5000 kids looking at our treatment program.

  • The program is a team approach with a craniofacial surgeon, a physical therapist, an occupational therapist, an orthotist and, either nurse clinician, advance practice person or physician assistant.

    • The typical child would come in between 4 to 6 months  of age when the parents or pediatricians have a concern. Their head shape is evaluated and they patient is sent home with exercises to complete at home, with or without physical therapy.

    • The protocol is designed to change behavior of the parents and the child together, including teaching them to do tummy time. The parent is also taught how to pick up the child in a way that the child has to do a little work. The goal is to get the back muscles, which attach along the back of the skull, which do the work of reshaping the skull, to be engaged.

    • The family does these interventions at home for about 2-3 months and then are re-assessed. This re-assessment includes the STAR scanner (a laser-guided, three-dimensional imaging system) measurements of the cephalic ratio, diagonal difference, and a number of other measurements. The goal in diagonal difference is to get the number less than 6mm and the cephalic ration within two standard deviations.

      • If things are going well the interventions are continued.

      • If they are not improving they are moved into the helmet group.


What should pediatricians do based on this study?

  • What this study shows us is that conservative therapy was successful more than 70% of the time. This suggests a trial of conservative therapy is reasonable and providers will not be missing a critical window for helmet therapy.

*Editors note: In addition to a high success rate in those who received conservative therapy initially, those who crossed over from conservative therapy to helmet therapy had a 96.1% success rate, which was not statistically significantly different than the 94.4% success rate in those who were initially treated with helmet therapy.


  • If the deformity is mild, establish a home program, and then decide whether or not you need to add physical therapy.

  • If the deformity is moderate or worse, they should be referred.

  • This study also identifies risk factors for failure of conservative therapy: age, severity of condition, and associated conditions. Patients with conditions like developmental delay, central motor weakness, or hypotonia may need helmet therapy sooner.


*Editors note: In this study, the patients who failed conservative therapy:

  • Were older at the start of therapy (5.7 versus 5.1 months)

  • Had greater deformity with increased cranial ratio (0.94 versus 0.91 and diagonal difference (10.3 versus 9.0)

  • Were more likely to have torticollis (46 percent versus 39 percent)

  • Were more likely to have developmental delay (14 percent versus 8 percent)

  • Were more likely to be born by cesarean delivery (38 percent versus 22 percent)

  • Had lower compliance (84 percent versus 87 percent)


What other advice to you have for pediatricians?

  • Tummy time begins the day you get home from the hospital. Pediatricians should be giving families instructions on how to implement tummy time.

    • The baby's chest will fit easily in the palm of your hand. You can support the baby's chest in the palm of your hand and lay the baby across your knees or you can have the baby's chin in your thumb and index finger, the baby's chest in your hand, the rest of the body laying across your knees as you're sitting on the chair.

  • Minimize the time patients are in devices that support the upper torso, such as Exersaucers and bouncy seats.

  • If you are seeing a decreased range of motion to the neck, then physical therapy should be started.


When is it too late to refer?

  • The decision is based on age and severity, and what else is going on in the child's life.

  • What we've been working on in the last three years is what we call a “critical age”.

  • The question is one of volume. How much volume needs to be filled and how much volume we expect the child’s head to grow. Given the age and gender, we can predict how much volume the child’s head will grow in a given amount of time. If we know the predicted increase in volume is more than the amount needed to fill the space, we have room for conservative therapy.

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Goodness Gracious, Great Bowels of Fire! Full episode audio for MD edition 201:44 min - 95 MB - M4AHippo Peds RAP June 2015 Summary 497 KB - PDF