Head Size & Shape

 

Head Size

For all children with suspected abnormal head shape or size:

• Take 3 consecutive measurements of the child’s head circumference at the same appointment.
• Plot the largest of the 3 measurements on a standardised growth chart, corrected for gestational age.

Refer to Paediatric outpatients:

• Any head size < 2^nd centile
• Any head circumference >99.6^th centile

OR

• If there is concerning trajectory (rapid increase/decrease) that differs by 2 or more centile lines from previous measurement (eg. increase from 25^th to 75^th centile, or decrease from 50^th to 9^th centile) and has crossed the 98^th centile.

OR

• has other concerning features such as dysmorphic features/developmental delay.

OR

• If there is ridging of the suture lines and concern about Craniosynostosis (premature closure of the sutures causing an abnormal shaped head) on two separate occasions at least a month apart. 

NB. Contact Paediatric Admissions urgently via the Consultant Advice phoneline if concern regarding symptoms and signs of raised intracranial pressure (not required for well children with isolated macrocephaly).

 

Plagiocephaly and Brachycephaly

Plagiocephaly- asymmetrical flattening of one side of the head.  This can cause the ear, forehead or cheek to be misaligned on one side.

Brachycephaly- flattening across the back of the head.  This can cause the head to widen and the forehead to be prominent.  

• Mild flattening of the head usually corrects itself if you use simple measures to take pressure off the affected area of the skull during awake time eg tummy time, sloping chair, wearing in a sling, changing position of toys to encourage baby to move their head away from the flattened side.  All babies must be laid to sleep on their back with no pillows or props to reduce the risk of sudden infant death syndrome (SIDS). 
• It may take 6-8 weeks of trying these measures before any improvement is noticed.
• Examine sutures in babies with Plagiocephaly as Craniosynostosis can present with flattening of the head on one side.
• The Paediatric Orthopaedic Physiotherapy team accept any referral for plagiocephaly and/or restriction of cervical movement. The earlier the referral the better as this gives the most time for remodelling and increases the compliance of the baby. They do not accept referrals for brachycephaly (flattening of the back of the head).
• There is currently no evidence for Helmet or skull band therapy and NICE do not recommend their use.  Helmets may be associated with pain, pressure sores and may adversely affect the bond between parent and babies.  This treatment is not commissioned. 
• Referrals for helmet therapy will be returned to the clinician.

 

References

1. Plagiocephaly And Brachycephaly Clinical Guideline, RCHT
2. Quality statement 2: Head size and shape in children | Suspected neurological conditions: recognition and referral | Quality standards | NICE
3. Cornwall and Isles of Scilly Commissioning policies and evidence-based interventions.

 

Patient information

• Positional plagiocephaly | Great Ormond Street Hospital
• Helmet therapy

 

Page Review Information

Partial review date             02 May 2025

Next review date               02 May 2026

Author                               Dr Melanie Schick GP,

     Dr S Burns GP

Contributors                      Chris Warren, Paediatric Consultant.
                                          Michelle Jackman, Paediatric Orthopaedic Physiotherapist.