PEDIATRICS Vol. 114 No. 4 October 2004, pp. 970-980 (doi:10.1542/10.1542/peds.2003-0668-F)
Plagiocephaly and Brachycephaly in the First Two Years of Life: A Prospective Cohort Study
* Department of Paediatrics, University of Auckland, Auckland, New Zealand
Computer Science Department, Brigham Young University, Provo, Utah
Objectives.Although referrals for nonsynostotic plagiocephaly (NSP) have increased in recent years, the prevalence, natural history, and determinants of the condition have been unclear. The objective of this study was to assess the prevalence and natural history of NSP in normal infants in the first 2 years of life and to identify factors that may contribute to the development of NSP.
Methods.Two hundred infants were recruited at birth. At 6 weeks, 4 months, 8 months, 12 months, and 2 years, the head circumference shape was digitally photographed, and head shape was quantified using custom-written software. At each age, infants were classified as cases when the cephalic index was 
93% and/or the oblique cranial length ratio was 106%. Neck rotation and a range of infant, infant care, socioeconomic, and obstetric factors were assessed.
Results.Ninety-six percent of infants were followed to 12 months, and 90.5% were followed to 2 years. Prevalence of plagiocephaly and/or brachycephaly at 6 weeks and 4, 8, 12, and 24 months was 16.0%, 19.7%, 9.2%, 6.8%, and 3.3% respectively. The mean cephalic index by 2 years was 81.6% (range: 72.0%–102.6%); the mean oblique cranial length ratio was 102.6% (range: 100.1%–109.4%). Significant univariate risk factors of NSP at 6 weeks include limited passive neck rotation at birth, preferential head orientation, supine sleep position, and head position not varied when put to sleep. At 4 months, risk factors were male gender, firstborn, limited passive neck rotation at birth, limited active head rotation at 4 months, supine sleeping at birth and 6 weeks, lower activity level, and trying unsuccessfully to vary the head position when putting the infant down to sleep.
Conclusions.There is a wide range of head shapes in infants, and prevalence of NSP increases to 4 months but diminishes as infants grow older. The majority of cases will have resolved by 2 years of age. Limited head rotation, lower activity levels, and supine sleep position seem to be important determinants.
Key Words: plagiocephaly • brachycephaly • anthropometry • cohort studies • infant care • supine position
Abbreviations: NSP, nonsynostotic plagiocephaly • SIDS, sudden infant death syndrome • OCLR, oblique cranial length ratio • PDQ-II, Revised Denver II Prescreening Questionnaire • PAT, Pictorial Assessment of Temperament • OR, odds ratio • CI, confidence interval
Accepted Mar 16, 2004.
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