Subjective
Date of visit
Reason for visit (initial evaluation, follow-up for plagiocephaly)
History of present illness:
Age of infant when plagiocephaly was first noticed
Severity of head shape asymmetry (parental perception)
Any positional preference the infant exhibits (favoring one side)
Past medical history (prematurity, torticollis)
Treatment history (helmeting therapy, positioning techniques)
Parents’ concerns about plagiocephaly and its potential impact
Objective
Infant’s vital signs (temperature, heart rate, respiratory rate)
Physical exam:
Anthropometric measurements (head circumference)
Detailed examination of the head shape (anterior, posterior, and superior views)
Assessment of facial asymmetry (ear position, eye position)
Examination of the neck for torticollis (limited range of motion)
Evaluation of sutures (to rule out craniosynostosis)
Assessment
Plagiocephaly (confirmed based on physical exam findings)
Severity of plagiocephaly (mild, moderate, severe) – can be classified using specific scales
Underlying cause (positional vs. secondary to torticollis or craniosynostosis)
Consideration of differential diagnoses (brachycephaly)
Plan
Treatment recommendations based on severity, age of infant, and cause:
Repositioning techniques: Educating parents on strategies to encourage turning the infant’s head towards the non-flat side during sleep and playtime.
Helmet therapy (cranial orthosis): Molding helmet to be worn for a prescribed period to improve head shape symmetry. This is usually considered for moderate or severe plagiocephaly and is most effective when initiated before 6 months of age.
Physical therapy: For infants with torticollis, a physical therapist can develop a treatment plan to improve neck range of motion.
Surgery (cranial vault remodeling): Rarely needed, only in severe cases and when other interventions fail.
Monitoring plan:
Schedule for follow-up visits to assess response to treatment and head shape improvement
Consider serial measurements of head circumference
Education
Explain plagiocephaly, its causes, and potential long-term effects (mostly cosmetic).
Discuss treatment options, potential benefits and risks/compliance considerations (for helmet therapy).
Reassurance and support for parents regarding the manageability of plagiocephaly.
Provide resources on safe sleep practices and proper head positioning for infants.
Follow-up
Schedule for follow-up appointments as determined by the severity and treatment plan.
Earlier and more frequent follow-up may be needed for infants with moderate or severe plagiocephaly undergoing helmet therapy.
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of plagiocephaly.