Objective. The management of infants with posterior plagiocephaly has been controversial both because of widely differing estimates in the literature of the relative frequencies of true lambdoidal synostosis vs positional molding and because of divergent approaches to treating this problem in different institutions. Based on our experience, we hypothesized that the vast majority of children with posterior plagiocephaly did not have true synostosis and that the cosmetic impairment in such patients could be effectively treated with nonsurgical modalities.

Methods. Between 1992 and 1995, we prospectively applied in 71 infants a consistent management philosophy for these malformations that has incorporated a detailed evaluation of sutural anatomy as the basis for a physiologic approach to treatment. This approach has been directed at distinguishing true synostosis from deformational plagiocephaly and at avoiding surgery for patients with deformational abnormalities by using a combination of nonsurgical modalities to restore normal cranial growth dynamics. All children first underwent skull radiographs to determine whether the lambdoidal sutures were patent. In equivocal cases, computed tomography was also performed. Patients without true synostosis were enrolled on a course of positional therapy. In patients that did not improve after 2 to 3 months, a custom-fitted orthoplastic molding helmet was applied to facilitate passive skull recontouring.

Results. Forty children had patent sutures based on skull radiographs, and 29 others, in whom the radiographs were equivocal, had open sutures based on computed tomography, thus establishing the diagnosis of deformational plagiocephaly in 69. Predisposing factors for this deformity included a strong positioning preference during early infancy (n = 67), torticollis (n = 10), prematurity (n = 6), and developmental delay (n = 2). Only two patients had true lambdoidal synostosis; in each case, this was associated with synostosis of the posterior sagittal suture and was managed effectively with cranial reconstructive surgery. Thirty-five patients with deformational plagiocephaly had a dramatic improvement in their cranial contour with positional therapy alone; 34 patients failed to improve and were treated with molding helmets. All but five children, each of whom was more than 6 months old at initial intervention (P < .025), developed a normal or nearly normal head shape with these measures.

Conclusion. The vast majority of children with posterior plagiocephaly do not have true synostosis and can be effectively managed by nonsurgical means. The impact of positional preference on the development of this process is discussed.

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