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Primary care management and referral guideline Primary care management and referral guideline

Plagiocephaly – Management and referral guideline

Red flags

  • Craniosynostosis suspected
  • Dysmorphic features
  • Developmental delay

Purpose

Primary care management and referral guidelines contain condition-based information for GPs about when to refer a patient, assessment and management measures that should be taken prior to submitting a referral, and what should be included in a referral to the relevant outpatient department or specialist service.

Introduction

Plagiocephaly is an asymmetrical flattened head shape caused by positional factors or rarely by craniosynostosis (premature fusion of the cranial sutures).

Positional (deformational) plagiocephaly (PP):

  • is a benign condition that usually improves with conservative measures – alleviating contributing factors and promoting gross motor development.
  • does not cause problems with development but can change appearance if left untreated.
  • occurs most commonly where infants spend a lot of time on their back with their head repeatedly in the same position. PP has become more prevalent since the adoption of safe sleeping practices introduced for SIDS prevention.
  • is more common in:
    • premature infants
    • prolonged labour or assisted delivery
    • multiparity
    • restrictive intrauterine environment or unusual birth position

Craniosynostosis:

  • Occurs due to premature fusion of one or more cranial sutures.
  • These conditions are rare but cause progressive deformity as the infant skull grows.
  • Early identification and referral to a craniofacial service improves outcomes.
  • Skull and facial asymmetry is generally more severe than in PP.

See Royal Children’s Hospital Information for healthcare professionals – Deformational Plagiocephaly.

Assessment

Take a history and check factors associated with Positional Plagiocephaly (PP):

  • Resting/sleeping position including preference for one side.
  • Perinatal factors including prematurity, birth position, multiparity, assisted delivery, restricted intrauterine environment.

Examine the patient.

  • Assess growth (in particular head circumference) and plot on appropriate growth chart.
  • Look for any dysmorphic features that may indicate congenital malformations or genetic syndromes.
  • Check for congenital muscular torticollis (CMT) by testing passive and active neck range of motion and looking for persistent head tilt to one side.

    Congenital muscular torticollis (CMT) This is a rare condition, generally caused by sternocleidomastoid (SCM) muscle fibrosis.

    • There is often a history of breech position, or difficult delivery.
    • Noticeable a few weeks to a few months after birth.
    • Examination findings reflect SCM shortening:
      • Resting position of head is rotated to opposite side and tilted to same side as the tight SCM muscle (e.g., rotated to left, tilted to right for tight right SCM).
      • Restricted active neck rotation to the affected side. SCM feels tight and a painless fusiform swelling may be felt in the mid or lower part.
      • A palpable SCM lump or swelling may be present in some patients with CMT.
  • Examine the baby’s head:
    • Note head shape, facial features, and ear position.
    • Palpate Fontanelles and Sutures

      Palpate Fontanelles and Sutures

      • Look for features of craniosynostosis:
        • Palpable bony ridge over a cranial suture, or
        • Anterior fontanelle may be closed or very small and triangular not diamond shaped (this can also occur in healthy babies who do not have Craniosynostosis.). It is uncommon for the anterior fontanelle to close before aged 6 months.
        • Unusual appearance of the head.
      • Avoid skull X-ray – if necessary, only order in a specialist setting.
    • Craniosynostosis is highly suggested if palpable bony ridge over a cranial suture, or closure of the anterior fontanelle.
  • Examine the neck and back to exclude a musculoskeletal cause for PP e.g., Congenital muscular torticollis (CMT) or spinal deformity (rare).

    Congenital muscular torticollis (CMT) This is a rare condition, generally caused by sternocleidomastoid (SCM) muscle fibrosis.

    • There is often a history of breech position, or difficult delivery.
    • Noticeable a few weeks to a few months after birth.
    • Examination findings reflect SCM shortening:
      • Resting position of head is rotated to opposite side and tilted to same side as the tight SCM muscle (e.g., rotated to left, tilted to right for tight right SCM).
      • Restricted active neck rotation to the affected side. SCM feels tight and a painless fusiform swelling may be felt in the mid or lower part.
      • A palpable SCM lump or swelling may be present in some patients with CMT.

Management

If positional plagiocephaly (PP):

  • Provide reassurance and explain the natural history of PP.

    Natural history of PP

    • Flattening improves as the infant achieves better head control and when they are able to sit independently.
    • Improvement continues over months and years due to brain growth.
    • There is usually minimal or no residual deformity.
  • Advise parents on general strategies for preventing and managing PP.

    General strategies for preventing and managing PP

    • Advise parents to apply prevention strategies from birth:
      • Sleep infant supine, but alternate between placing head on left and right occiput.
      • Frequently change infant’s position.
      • Practice supervised tummy time and side‑lying play time when the baby is awake – see Tummy Time for Babies: In Pictures.
      • Carry the baby on both sides and in different positions.
      • Turn the baby’s head to their non‑preferred side when asleep.
      • Encourage infant to look to both sides evenly by:
        • changing cot position in the room.
        • sleeping the infant at the other end of the cot.
        • repositioning mobiles or toys.
    • Use of pillows for management or prevention of PP is not indicated and goes against safe sleeping techniques to prevent SIDS.
    • See A‑B‑C Plagiocephaly Prevention Strategy.
  • If unresolved PP despite use of general positioning strategies, refer to Child Health Services and consider referring to a private paediatric physiotherapist.
  • Review regularly and continue to monitor head circumference. Current evidence does not support the use of helmets in the management of positional plagiocephaly however some parents may choose to explore this option. There is no evidence of harm.
  • If developmental concerns, see Developmental Concerns in Children guideline

If congenital muscular torticollis (CMT) suspected:

  • Refer to a paediatric physiotherapist (public access may be available via Child Development Program).
  • Treat with gentle passive stretching (via carrying position), and strengthening of opposite SCM muscle, ideally under physiotherapy guidance.
  • Consider referring to your local paediatric orthopaedic service if SCM neck swelling or lump grows over time or there is no improvement with physiotherapy.

Refer for paediatric plastic reconstructive surgery assessment if:

  • strongly suspected craniosynostosis.
  • severe deformity that is not improving over time.
  • misshapen head with diagnostic uncertainty and failure to improve over time.

Advise all parents to continue to place babies on their back for safe sleeping, to help prevent sudden infant death syndrome (SIDS).

When to refer

  • Refer for paediatric plastic reconstructive surgery assessment if:
    • strongly suspected craniosynostosis.
    • severe deformity that is not improving over time.
    • misshapen head with diagnostic uncertainty and failure to improve over time.
  • For suspected torticollis or positional plagiocephaly not resolved with general strategies refer to a private paediatric physiotherapist.
  • For palpable neck swelling which grows over time or shows no improvement with physiotherapy, consider referring to your local paediatric orthopaedic service

Referring to your local Paediatric services

Public

Check the patient’s catchment area before requesting assessment. When services are available in the patient’s local area, refer the patient to the local hospital.

Queensland Children’s Hospital

Referral can be made by either:

  • GP Smart Referral via BP or Medical Director
  • Secure messaging
    Secure messaging Send a written request to the Referral Centre via eReferral
    (Medical Objects ID: RQ402900084, HealthLink ID: qldrchld):

    • To download templates, see Referral Forms.
    • If unable to attach investigations or use secure messaging, fax to 1300 407 281.

    For more information, contact the Referral Centre:
    P.O. Box 3474, South Brisbane QLD 4101
    Phone 1300 762 831 Fax 1300 407 281

Insert the required information into referral

  • Patient’s demographic details

    Patient’s demographic details

    • Full name, including aliases
    • Date of birth
    • Residential and postal address
    • Telephone contact number(s) – home, mobile and alternative
    • Medicare number, where eligible
    • Name of the parent or caregiver, if appropriate
    • Preferred language and interpreter requirements
    • Identifies as Aboriginal and/or Torres Strait Islander
  • Practitioner details

    Practitioner details

    • Full name
    • Full address
    • Contact details – telephone, fax, email
    • Provider number
    • Date of request
    • Signature
  • Relevant clinical information about the condition

    Relevant clinical information about the condition

    • Presenting symptoms – evolution and duration
    • Physical findings
    • Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
    • Body mass index (BMI)
    • Details of any associated medical conditions which may affect the condition or its treatment (e.g., diabetes), noting these must be stable and controlled before the request
    • Current medications and dosages
    • Drug allergies
    • Alcohol, tobacco, and other drugs use
  • Clinical modifiers

    Clinical modifiers

    • Impact on education
    • Impact on home
    • Impact on activities of daily living (ADLs)
    • Impact on ability to care for others
    • Impact on personal frailty or safety
    • Identifies as Aboriginal and/or Torres Strait Islander
  • Other relevant information

    Other relevant information

    • Willingness to have surgery, where surgery is a likely intervention
    • Choice to be treated as a public or private patient
    • Compensable status e.g., DVA card, WorkCover policy number, motor vehicle insurance
  • Reason for request

    Reason for request

    • To establish a diagnosis
    • For treatment or intervention
    • For advice and management
    • For specialist to take over management
    • Reassurance for general practitioner or second opinion
    • For a specified test or investigation unavailable to the general practitioner, or the patient can’t afford or access
    • Reassurance for the patient and family
    • For other reason e.g., rapidly accelerating disease progression
    • Clinical judgement indicates a referral for specialist review is necessary

Relevant pathology and radiology results (printed for the patient and sent with the referral)

Private

Search for a provider via the National Health Services Directory.

Guideline approval and disclaimer

Guideline approval history
Version no. 1.0 Approval date 27/05/2019 Review date 1/09/2021

Disclaimer

The information contained in this GP referral and management guideline is intended for information purposes only. The information has been prepared using a multidisciplinary approach with reference to the best information and evidence available at the time of preparation. No assurance is given that the information is entirely complete, current, or accurate in every respect.
This guideline is not a substitute for clinical judgement, knowledge and expertise, or medical advice. Variation from this guideline, taking into account individual circumstances may be appropriate.
This guideline does not address all elements of standard practice and accepts that individual clinicians are responsible for the following:
  • ●  Providing care within the context of locally available resources, expertise, and scope of practice.
  • ●  Supporting consumer rights and informed decision making in partnership with healthcare practitioners including the right to decline intervention or ongoing management.
  • ●  Advising consumers of their choices in an environment that is culturally appropriate and which enables comfortable and confidential discussion. This includes the use of interpreter services where necessary.
  • ●  Ensuring informed consent is obtained prior to delivering care.
  • ●  Meeting all legislative requirements and professional standards.
  • ●  Applying standard precautions, and additional precautions as necessary, when delivering care.
  • ●  Documenting all care in accordance with mandatory and local requirements.
Children’s Health Queensland disclaims, to the maximum extent permitted by law, all responsibility and all liability (including without limitation, liability in negligence) for all expenses, losses, damages and costs incurred for any reason associated with the use of this guideline, including the materials within or referred to throughout this document being in any way inaccurate, out of context, incomplete or unavailable.

Resources

For health professionals

For families

Contact details

Hospital Switchboard
(Ask for the General Paediatric Registrar)
t: 07 3068 1111

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