Preventing deformational plagiocephaly through parent guidance: a randomized, controlled trial


Deformational plagiocephaly (DP) occurs frequently in otherwise healthy infants. Many infants with DP undergo physiotherapy or helmet therapy, and ample treatment-related research is available. However, the possibility of preventing DP has been left with little attention. We sought to evaluate the effectiveness of intervention in the newborn’s environment, positioning, and handling on the prevalence of DP at 3 months and to investigate the causal relationship between DP and cervical imbalance. We carried out a randomized controlled trial, with healthy newborns randomized into two groups at birth. All families received standard positioning instructions to prevent SIDS. Additionally, the intervention group received detailed instructions regarding the infant’s environment, positioning, and handling, with the goal of creating a nonrestrictive environment that promotes spontaneous physical movement and symmetrical motor development. Two- and three-dimensional photogrammetry served to assess cranial shape and goniometry to measure cervical motion. At 3 months, the prevalence of DP was lower in the intervention group in both 2D (11 vs 31 %) and 3D analyses (15 vs 33 %), and the asymmetry was milder in the intervention group. Infants with DP at follow-up had also developed more torticollis.

Conclusion: An early educational intervention reduces the prevalence and severity of DP at 3 months.

What is Known:
Deformational plagiocephaly, often with associated torticollis, is common in healthy infants.
Parental education is frequently recommended for preventing deformational plagiocephaly, although information regarding the effectiveness of preventive strategies is scarce.
What is New:
Early parent guidance effectively reduces the prevalence and severity of DP and improves the cervical range of motion at three months.
Educating both parents and professionals about proper infant positioning on a national scale could help minimize public healthcare costs.

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Fig. 1
Fig. 2
Fig. 3



Anterior cranial asymmetry index


Cephalic index


Congenital muscular torticollis


Deformational plagiocephaly


Endocanthion left


Endocanthion right




Oblique cranial length ratio from 2D image


Oblique cranial length ratio from 3D image


Posterior cranial asymmetry index


Tragion left


Tragion right


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The authors are grateful to all the families who participated in the study. The research was funded by a grant from the Alma and K. A. Snellman Foundation.

Author contributions

HA wrote the first draft of the manuscript and performed the data analysis. HA and AMV were responsible for the recruitment, background data collection, physical examination, and the management and development of the trial. AMV, VH, TH, and PP designed the study and obtained funding. AMV and PP supervised the study. HA and VV processed and analyzed the images. VV wrote the software used to align and analyze the 3D images. All authors interpreted the data, contributed to writing and revising the manuscript, and take full responsibility for the integrity of the data and the accuracy of the data analysis.

Conflicts of interest

The authors declare no conflicts of interest.

Author information



Corresponding author

Correspondence to Henri Aarnivala.

Additional information

Communicated by Beat Steinmann



Instructions for parents of infants in the intervention group—Preventing deformational plagiocephaly

The purpose of this study is to assess the impact of early intervention in the environment, positioning, and handling of infants on the development of deformational plagiocephaly. For the sake of study reliability, it is important to follow these instructions as carefully as possible.

A one-sided head position while asleep or awake, frequent and prolonged use of bouncers and car seats, as well as one-sidedness while feeding and handling the baby may increase the baby’s risk for posterior cranial deformation or cause an imbalance in or restrict the baby’s neck mobility. These guidelines are intended to help you minimize the risk of these conditions affecting your baby.

Sleeping: To reduce the risk of sudden infant death syndrome, it is important that your baby sleeps in the supine position. You should alternate the position of the head evenly between left and right. If your baby chooses to sleep on one side, you should pay attention to switching the side regularly and evenly. The bed/cot should have enough space to allow your baby to turn freely and should be placed in such a way that your baby receives stimuli (light, sound, etc.) equally from all directions. Consider, for example, the side of the room opposite the window/-s with your baby’s feet or head towards the window(s).

Feeding: When breastfeeding, alternating breasts also naturally alternates your baby’s position. You should alternate sides similarly when bottle-feeding.

Tummy time: Giving your baby “tummy time” from early on helps prevent posterior cranial deformation. Beginning with the first days of life, your baby should spend a few minutes every day in the prone position while under supervision. You can gradually increase your baby’s tummy time to 15–30 min or more when he or she starts supporting his or her head.

Carriers, bouncers, and car seats: Because newborns have little control over their head position, you should minimize the time spent in bouncers and car seats. Prolonged periods in carriers (backpacks and carrying cloths) may hinder their motor development. Whenever your baby is in a bouncer, car seat, or carrier, be sure to alternate the head position regularly.

Play, socializing, and interaction: Your baby should have a room to move about freely. Toys and other interesting objects should be spread out on the floor evenly. Hanging toys should be avoided, as they may promote passiveness and cause the baby to extend or twist his or her neck too much. Parents should attract their baby’s attention from both sides equally. If the lighting or other surroundings cause the baby to turn his or her head in that direction, the baby’s position should be alternated accordingly.

If your baby constantly keeps his or her head turned to one side, or if your baby starts showing signs of occipital flattening on one side, try favoring the opposite side when putting your baby to sleep. The opposite side should be favored similarly when your baby is awake by placing him or her so that interesting objects and stimuli come predominantly from that side. You can also try feeding your baby predominantly from the less preferred side; this encourages your baby to turn his or her head to and strengthen his or her cervical muscles on the less preferred side. If your baby shows signs of a muscular imbalance of the neck, such as the inability to turn or laterally flex his or her head in one direction, you should do neck-stretching exercises. Depending on the type of restriction, you should laterally flex and/or rotate the head towards the restricted side by applying gentle but firm pressure to the head for 10 s at a time approximately five times daily.

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Aarnivala, H., Vuollo, V., Harila, V. et al. Preventing deformational plagiocephaly through parent guidance: a randomized, controlled trial. Eur J Pediatr 174, 1197–1208 (2015).

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  • Plagiocephaly
  • Nonsynostotic plagiocephaly
  • Cranial deformations
  • Torticollis
  • Prevention
  • Motor development