Craniofacial New Consult

PATIENT IDENTIFICATION:
We had the pleasure of meeting Emily and her caregiver at Regional Pediatrics Clinic on December 7, 2025. This was her first visit to our clinic. Emily is a 6.5-month-old female who was born preterm at 36 weeks and 4 days gestation with a history of intrauterine growth restriction and oligohydramnios. She was referred for evaluation of cranial asymmetry (plagiocephaly). Her caregiver is 24 years old and attentive to Emily’s care.

CURRENT CONCERNS:
The primary concern is cranial asymmetry, specifically plagiocephaly. The caregiver reports that the flattening has improved as Emily has become more mobile, now rolling over independently and spending more time in the prone position. There were previous concerns about weight gain between four and six months, possibly related to breastfeeding supply, but Emily’s current weight is approximately 15 pounds. The caregiver also inquired about Emily’s developmental progress, feeding, and sleep.

PREGNANCY & BIRTH HISTORY:
Emily was born at 36 weeks and 4 days gestation via induction due to intrauterine growth restriction and oligohydramnios. Her birth weight was five pounds. There were no other significant complications during pregnancy or delivery.

NICU Course Issues:
No NICU admission was required.

OTHER MEDICAL HISTORY/ISSUES SINCE NICU DISCHARGE:
There have been no hospitalizations, surgeries, or significant medical events since discharge.

REVIEW OF SYMPTOMS:
Emily is breastfed approximately five times per day and receives solid foods three times daily. There are no reported feeding difficulties, gastrointestinal concerns, abnormal stool patterns, behavioral issues, or mental health concerns. Sleep is described as very good, with Emily sleeping approximately twelve hours per night. She passed her newborn hearing screen; no subsequent hearing evaluations are recalled. No vision concerns were reported.

DEVELOPMENTAL REVIEW:
- Gross Motor: Emily is able to roll from back to stomach consistently and has rolled from stomach to back on a few occasions, though she struggles with this. She can sit with support for brief periods and is beginning to push up when prone.
- Fine Motor & Adaptive: She reaches for and grasps objects, brings hands to mouth, bangs objects, and transfers objects between hands.
- Communication: Emily vocalizes frequently and babbles, but does not yet use specific words such as "mama" or "dada." She responds to her name inconsistently, which the caregiver attributes to the use of multiple nicknames. She demonstrates appropriate social engagement and eye contact.

SERVICES & SUPPORTS:
No formal developmental programs or physiotherapy services are currently in place. The caregiver has been encouraged to continue providing opportunities for prone play and to monitor Emily’s developmental progress.

SOCIAL & FAMILY HISTORY:
Emily is the first child of her 24-year-old caregiver. There is no reported family history of developmental or genetic conditions. The caregiver is attentive and engaged in Emily’s care.

MEDICATIONS:
None.

ALLERGIES:
None known.

IMMUNIZATIONS:
Not specified.

Prior Investigations & Assessments:
Emily passed her newborn hearing screen. No imaging or other investigations have been performed to date.

PHYSICAL EXAMINATION:
Emily is an alert, interactive, and well-appearing infant in no acute distress. Weight is approximately 15 pounds (as of two weeks ago). Head circumference is 43 cm. Growth parameters are within normal percentiles for age. She is normocephalic with no dysmorphic features. Anterior fontanelle is open, soft, and flat; posterior fontanelle is closed. No scalp lesions or torticollis. Eyes, ears, nose, mouth, and throat are normal. Neck is supple with full range of motion. Chest and lungs are clear. Heart exam is normal. Abdomen is soft and non-tender. Genitourinary exam is normal. Musculoskeletal exam reveals normal tone and spontaneous movement of all extremities, with no asymmetry or deformities. Neurologically, she demonstrates normal tone and strength, symmetric reflexes, and age-appropriate developmental skills.

IMPRESSION:
Emily is a 6.5-month-old female with a history of prematurity and intrauterine growth restriction, presenting for evaluation of plagiocephaly. Her cranial asymmetry has improved with increased mobility and prone positioning. She is meeting most developmental milestones, with some mild delays in gross motor skills (struggles to roll from stomach to back, not yet sitting independently), which are not unexpected given her prematurity. No evidence of torticollis or other neuromuscular concerns was found on examination. Growth parameters are appropriate for age.

RECOMMENDATIONS:
Continue to encourage prone play and supervised tummy time to promote further improvement in cranial shape and gross motor development. Monitor Emily’s developmental progress, particularly gross motor milestones such as independent sitting and rolling in both directions. No need for helmet therapy at this time. Follow up with primary care provider for routine health supervision and immunizations. If concerns about developmental progress or cranial asymmetry persist, consider referral to physiotherapy or further specialist evaluation.

Thank you for the opportunity to be involved in Emily’s care. Please do not hesitate to contact me with any questions or concerns.

Priya Patel, MD  
Pediatrics  
Regional Pediatrics Clinic