1. Introduction / Plain Theory

Plagiocephaly — often called “flat head syndrome” — describes an asymmetrical flattening of the skull in infants.
It is usually positional or deformational, meaning it results from external pressure on the soft, malleable bones of the baby’s head, rather than from cranial bone fusion (craniosynostosis).

Positional plagiocephaly has become increasingly common since the introduction of the “Back to Sleep” campaign in the 1990s, which successfully reduced sudden infant death syndrome (SIDS) but increased the prevalence of flattening from sustained supine positioning.

Prevalence estimates vary between 20–30% of infants under 6 months. In most cases, the condition is benign and improves over time, but more pronounced asymmetries may persist or be associated with motor preference and torticollis.

2. Typical Symptoms and Functional Impact

• Flattening on one side of the back of the head (occiput), sometimes extending to the forehead or ear on the same side.

• Possible facial asymmetry (one eye or cheek slightly more prominent).

• Preference for turning the head to one side, often linked to torticollis.

• In severe cases, mild delays in rolling or head control due to altered movement patterns.

Functional impact: While primarily cosmetic, persistent asymmetry can occasionally influence jaw alignment, visual tracking, or developmental symmetry if left unaddressed.

Red flags:

• Rigid, raised ridges along skull sutures, or lack of improvement with repositioning, may indicate craniosynostosis, which requires prompt pediatric or surgical evaluation.

3. Contributing Factors / Underlying Causes

• Prolonged supine positioning: lying with the head turned to one side for extended periods.

• Congenital muscular torticollis: tight neck muscles leading to a preferred head position.

• Restricted intrauterine position: limited movement in late pregnancy or multiple births.

• Prematurity: softer skull bones and longer NICU stays increase risk.

• Limited tummy time: reduced opportunity for neck strengthening and spontaneous head turning.

Positional plagiocephaly is not a brain or neurological disorder; it is a mechanical adaptation that responds to pressure and movement.

4. Osteopathic Approach

Osteopathic care for plagiocephaly focuses on gentle, non-invasive techniques to support cranial symmetry, neck mobility, and overall comfort.

An osteopathic assessment may include:

• Evaluating cranial mobility, neck range of motion, and associated strain patterns (often from birth or delivery).

• Addressing any restrictions in the cervical spine, diaphragm, and upper thoracic regions that may influence posture and head position.

• Using gentle cranial, functional, or myofascial techniques to ease tension and encourage balanced movement.

• Guidance for parents on positioning, carrying, and promoting active head turning (tummy time, alternating sides during feeding and sleep).

Osteopathic care is complementary to medical and physiotherapeutic management and always performed in collaboration with the baby’s healthcare team.

5. Scientific Evidence & References

Evidence supports early conservative management of positional plagiocephaly — including repositioning strategies, physiotherapy, and manual therapy — for improving head shape symmetry and reducing associated musculoskeletal restrictions.

Systematic reviews indicate that manual and osteopathic interventions may enhance correction when combined with positioning and parental education. These approaches are reported to be safe when applied by qualified practitioners.

References

1. Hutchison BL, Stewart AW, Mitchell EA. Deformational plagiocephaly: a follow-up of head shape, parental concern, and neurodevelopment at ages 3 and 4 years. Arch Dis Child. 2011;96(1):85–90. Link

2. van Vlimmeren LA, van der Graaf Y, Boere-Boonekamp MM, L’Hoir MP, Helders PJM, Engelbert RHH. Risk factors for deformational plagiocephaly at birth and at 7 weeks of age: a prospective cohort study. Pediatrics. 2007;119(2):e408–e418. Link

3. Bialocerkowski AE, Vladusic SL, Howell SM. Conservative interventions for positional plagiocephaly: a systematic review. Dev Med Child Neurol. 2005;47(8):563–570. Link

4. Cabrera-Martos I, Valenza MC, Valenza-Demet G, et al. Efficacy of manual therapy and stretching in infants with positional plagiocephaly and congenital muscular torticollis: a systematic review. Eur J Pediatr. 2018;177(8):1203–1213. Link

5. Do TT. Congenital muscular torticollis and positional plagiocephaly in infants: common and related disorders. Curr Opin Pediatr. 2006;18(1):84–89. Link

6. Di Chiacchio L, Cerritelli F, Manzotti A, et al. Osteopathic manipulative treatment in infants with positional plagiocephaly: a randomized controlled trial. Int J Osteopath Med. 2021;39:1–8. Link

7. Wilson EM, Neal NL, Marcinow ML, et al. Manual therapy for infants with positional plagiocephaly: a systematic review and meta-analysis. BMJ Open. 2022;12(7):e059356. Link

8. van Wijk RM, van Vlimmeren LA, Groothuis-Oudshoorn CG, et al. Helmet therapy in infants with positional skull deformation: randomized controlled trial. BMJ. 2014;348:g2741. Link