It is known that posterior positional plagiocephaly (PPP) can be prevented, but it is also known that some individual or environmental factors, prenatal, neonatal, and postnatal, may give way to its onset [7–10].

The identification of these risk factors can be helpful in the diagnostic process and support the care management (Table 5.2).

With reference to Table 5.2 information about the prenatal, neonatal, and postnatal period, let make us presume the positional nature of the disorder.

Observational data and medical history will be sufficient to enable us to orient ourselves in the differential diagnosis between postural plagiocephaly and synostotic plagiocephaly.

If we are oriented towards the diagnosis of positional plagiocephaly and we have checked the absence of postural head anomalies of clinical relevance (head tilted to the contralateral side of rotation, deficit of contralateral rotation), we will not need to conduct further diagnostic exams, and we can explain to the parents the developmental dimension of the clinical features addressing the case to a pediatric physiotherapeutic treatment.

PPP has a prognosis of spontaneous improvement, but in the most “serious” cases, a residual deformity can still be observed at the end of preschool age [11]. The possibility that PPP may represent a clinical problem not only concerning “aesthetics” has been studied by evaluating the quality of case studies of neurobehavioral development in children.

It has been reported that children with PPP get different achievements in neurobehavioral development at 18 months and at 36 months (according to the Bayley Scales of Infant and Toddlers Development – III Edition): the cognitive and the linguistic areas seem to be those which mostly show recognizable immaturity [12, 13].

It has been reported that PPP can alter the development of the visual field [14] and determine disorders of the auditory processing [15].

It has been observed that, when beginning primary school, 39.7 % of children diagnosed as having PPP at 6 months of age required special care and educational needs in comparison to only 7.7 % in the control group [16].

The observational diagnosis of synostotic plagiocephaly requires confirmation by neuroimaging studies. The three-dimensional computerized tomography (3D CT) of the head will be the investigation of choice to confirm the clinical hypothesis of synostosis (Fig. 5.2).

The 3D CT study will help us to verify the presence of other cranial suture synostosis (differential diagnosis between single synostosis and multiple synostoses).

Magnetic resonance imaging (MRI) of the brain is not universally recommended for routine examinations in isolated craniosynostosis as it usually does not add any information that may affect treatment decisions [17]. MRI of the brain may, however be useful, even in isolated forms, to assess the presence of brain malformations (i.e., agenesis of the corpus callosum, Chiari malformation type 1, or conditions of intracranial hypertension) [18].

Neuroimaging has otherwise a specific indication when neurobehavioral delays, dysmorphisms, or malformations of other organs and systems are detected during the clinical observation of the child. In this diagnostic context, a consultation by a geneticist pediatrician becomes very useful.

The diagnosis of a specific syndrome may provide prognostic factors of great importance in order to define a correct therapeutic approach to the cranial shape disorder. Some genetic syndromes that include the presence of cranial synostosis are listed below (Table 5.3).