Evaluating and Managing Head Shape

Concern about head shape in the preterm infant is common and often due to cranial deformation. Infants born prematurely are at higher risk than those born at term, though deformation occurs in 18-20% of the latter [Rogers: 2011] [Rogers: 2011] and has become more common since the American Academy of Pediatrics instituted the “Back to Sleep” campaign (which has reduced the incidence of sudden infant death syndrome by 40%). [Task: 2000]
Craniosynostosis, or premature closure of one or more of the cranial sutures, is far less common for both preterm and term infants but can look similar to some types of deformational abnormalities.

Craniosynostosis may be associated with a syndrome or be isolated (nonsyndromic). Syndromic cases are accompanied by the involvement of several organ systems and additional malformations. Head shape is dependent on which sutures are fused. Differentiating craniosynostosis from deformational abnormalities requires taking a thorough history and physical of the infant. The following table describes characteristics that may help to differentiate the two. [Looman: 2012] [Nield: 2007] [Ursitti: 2011]
Table 1: Cranial Deformation vs. Craniosynostosis
Nonsynostonic cranial deformation Craniosynostosis
Head shape at birth commonly
round and symmetrical
Head shape at birth may be abnormal
History of constant supine
positioning with little prone
positioning or “tummy time”
May have family history of craniosynostosis and/or genetic syndromes
Shows preference for one
head position and may
have bald patch on one
side of the back of the head
Head shape may be
parallelogram or brachycephaly
Head shape may be scaphalocephaly, trapezoidal, trigonocephaly, or brachycephaly
May present with torticollis
Ear, forehead, and/or
cheek may be anteriorly shifted
Posterior displacement of the ear
Slight mobility of bones
next to sutures
Bones next to the sutures are immobile
Usually bony ridges found
on palpation of sutures
Bony ridges found near sutures on palpation
Adapted from [Looman: 2012] [Nield: 2007] [Ursitti: 2011]
Cranial deformation takes several forms:
  • Deformational plagiocephaly is the flattening of one side of the posterior skull, creating an oblique or slanted head when viewed from the top. Ipsilateral (along the same side) frontal bossing and asymmetric facial features result, however, the degree of flattening of the occipital skull is more pronounced and results in a parallelogram shape when viewed from above the infant’s head. See Vertex views of lateral and posterior deformational plagiocephaly (Journal of Pediatric Health Care), Table 1 in [Looman: 2012].
  • Deformational brachycephaly is the symmetric flattening of the occipital skull with compensatory bi-parietal widening, giving the appearance of a large head when viewed from the front. Some degree of asymmetry is commonly seen. See photo. These infants may also have a posterior protrusion at the top of the head. When looking at the infant skull from the side, the skull appears to slope downward towards the anterior portion of the head. This is called a “turricephaly” or “tall head.” Images of brachycephaly (Acta Paediatrica), Figure 3 (page 4) in [Ursitti: 2011].
  • Deformational scaphocephaly (also known as dolichocephaly) is an uncommon variant seen in preterm infants who have been positioned on their sides, resulting in flattening of the sides of the head and compensatory increase in the anterior posterior dimension of the cranium. See photo. Preventive measures instituted in NICUs have decreased the incidence of this. Images of scaphocephaly (Acta Paediatrica), Figure 1 (page 3) in [Ursitti: 2011].
Differentiating deformational problems from craniosynostosis may require imaging. Since many infants will have deformational cranial abnormalities, the decision to image the infant using head computerized tomography (CT) may be best left to the specialist, perhaps reducing needless radiation exposure.
Flattening occurs when cranial expansion and growth are consistently resisted in one area of the skull by an external force. [Rogers: 2011] [Rogers: 2011] Limited independent head mobility in very young infants or those with congenital muscular torticollis contribute to the flattening. Growth of the cranium is most rapid in the first few months of life and treatment is most effective in that time frame. Premature infants have more limited head mobility for a longer period of time than full term infants, which may explain their higher frequency of deformational cranial abnormalities.
Anthropomorphic measurements can be obtained and there are age-matched normative values for the CI (cephalic index) which is the maximum width of the head divided by the anteroposterior length. However, the interpretation of normal is culturally based and may not affect the decision to treat. The author, Rogers, suggests the strongest indication to treat is the parent opinion of deformity. [Rogers: 2011] [Rogers: 2011]
Initial treatment considerations include:
  • Mechanical adjustments and exercises that can be done at home. These include positioning the infant’s rounded side of the head against the mattress and changing the crib’s position so the infant would need to look away from the flattened side to see people enter the room. [Laughlin: 2011] Repositioning only works prior to the infant acquiring independent head control, which typically occurs by 4 months of age, corrected. Within 2-3 months, most infants will show improvement. [Task: 2000]
  • Physical therapy to address congenital muscular torticollis (CMT) and positional preferences. A physical therapist can teach parents to address congenital muscular torticollis (CMT) and positional preferences with 3 repetitions of stretches that are performed at each diaper change. [Laughlin: 2011] The stretches usually involve placing one hand on the child’s upper chest while the other gently rates the chin until it touches the shoulder. This is held for 10 seconds and then repeated for the other side. [Laughlin: 2011]
The AAP recommends considering referral to a pediatric neurosurgeon or to a craniofacial specialist if improvement does not improve by 4-6 months of age. Treatments that might then be considered are: [Laughlin: 2011]
  • Sleep orthotic or cradle: these devices position the infant’s occiput on a concave rather than a flat surface. This redistributes the surface pressure on the occiput but maintains the infant in the supine position. This approach only works prior to 3-4 months of age corrected, when infants develop sufficient head control to defeat its purpose.
  • Helmet therapy: This orthotic is typically used for moderate to severe deformational flattening. [Rogers: 2011] [Rogers: 2011] Several principles are important:
    • Helmets are only effective when there is remaining skull growth
    • Younger children correct quicker than older children, consistent with the rate of growth of the cranium
    • Helmets do not apply pressure to the cranium but rather have foam selectively cut away from the area in which growth is desired thereby guiding growth in the path of least resistence. They do not mold or squeeze the cranium.
    • A skilled orthotist is needed to monitor the growth of the infant’s head and the fit of the helmet.
Prevention includes:
  • Preventative counseling by 4 weeks of age: Provide information about tummy time while the infant is awake and being observed (at least 30-60 minutes) and alternating head positon at night during sleep. Too much time in safety seats or swings should be discouraged. [Rogers: 2011]


Plastic Surgery: Provides expertise in evaluation of head shape deformations and management of injuries sustained during the NICU hospitalization. Such injuries can be a result of intravenous infusions, CPAP, other medical equipment, and medical procedures that were necessary during the NICU hospitalization (see all Pediatric Plastic Surgery services providers (3) in our database).
Orthotist: A person skilled in providing supportive equipment for a desired functional outcome. In the case of cranial deformation abnormalities, this individual makes the helmet and monitors its function closely throughout its use on the infant’s head to ensure the best growth and prevent skin sores and discomfort for the infant.
Pediatric Neurosurgery: Provide evaluations, recommendations, and management for severe or persistent cranial deformations see all Pediatric Neurosurgery services providers (1) in our database.



Pediatric Neurosurgery

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Pediatric Plastic Surgery

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Physical Therapy

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Reviewing Author: Faizi A. Siddiqi, MD - 6/2015
Content Last Updated: 6/2015

Page Bibliography

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Evaluation and management of nonsyndromic craniosynostosis.
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