## 4 Discussion
### Prevention of Positional Plagiocephaly and Risk Factors  
Plagiocephaly is characterized by changes in the shape of the skull, and if not diagnosed and treated early, it can be a lifelong condition [53]. Therefore, identifying risk factors is necessary to adequately inform the parents and guardians of children. Scientific literature has investigated the correlation between positional deformity of the skull, and vitamin D. Vitamin D is essential for bone mineralization; therefore, deficiency during childhood can cause the bones of the head to remain more malleable and deform as a result of pressure [54]. The study by [PERSON] et al. [55] investigates the correlation between positional deformation of the skull in children between the ages of 2 and 4 months and the intake of Vitamin D supplements (10 \(\upmu\)g per day) during pregnancy and the first months of the child's life (Table 3). \begin{table}
\begin{tabular}{p{56.9 pt} p{56.9 pt} p{56.9 pt} p{56.9 pt} p{56.9 pt}} \hline \hline
**Ref** & **Authors (Year)** & **Type of the Study/Days** & **Aim of the Study** & **Materials** & **Results** \\ \hline \multirow{9}{*}{[55]} & & & Analyzing the relationship between intake of vitamin D supplements during the third trimester of pregnancy (mother) and during the newborn period (child) and the emergence of positional skull deformation in infants aged 2 to 4 months. & \multirow{9}{*}{An increased risk of positional deformation of the skull is linked to the pregnant woman’s inadequate vitamin D consumption.} & & \\ \cline{1-1}  & & & & \\ \cline{1-1}  & & & & \\ \cline{1-1}  & & & & \\ \cline{1-1}  & & & & \\ \cline{1-1}  & & & & \\ \cline{1-1}  & & & & \\ \cline{1-1}  & & & & \\ \cline{1-1}  & & & & \\ \cline{1-1}  & & & & \\ \cline{1-1}  & & & & \\ \cline{1-1}  & & & & \\ \cline{1-1}  & & & & \\ \hline \hline \end{tabular}
\end{table} 
Table 3: Risk factors of PP. An increased skull malformation risk has been linked to inadequate vitamin D consumption in early infancy and during the final trimester of pregnancy [55]. Furthermore, the present study [55] found that infant formula consumption after birth was connected to a higher risk of cranial deformity, despite being a source of vitamin D. This seems to be because of the one-sided position during bottle feeding [55]. [PERSON] et al. [56] evaluated the relationship between high folic acid intake and PP. To prevent neural tube defects, a daily dose of 400 ug of folic acid is recommended in the Netherlands from the fourth week before conception until the eighth week of pregnancy [58]. As a result, mothers of children with PP tend to consume too much folic acid each day while pregnant. Further research should be conducted to understand how folic acid might affect bone development (Table 3) [56]. Variables that could lead to positional cranial deformity have been identified in the literature, including multiple-birth pregnancy, premature gestation, prolonged labor, breech presentation and assisted delivery (vacuum/forceps) [59; 60; 37; 61], positional preference, lack of variation in head positioning when sleeping in the first six weeks of life, and position during bottle feeding [60; 61; 62; 63]. [PERSON] et al. [57] investigated the correlation between the positional preference and PP in preterm babies. The study analyzed 192 infants born \(\leq\) 32.0 weeks of gestation. A positional preference was present in 44.8% of newborns in our study who were term-equivalent aged (TEA), compared to the 13-20% found in full-term born infants [64; 52; 61], but only 10.4% had a PP. At six months CA, PP is observed in 13% of the infants (Table 3). A plagioclasely is three times more likely to occur in infants at six months of age with a postural preference for TEA than in those without [57]. The positioning of the equipment on the right side of the incubators may have contributed to establishing a positional preference. Furthermore, the low maturity of the system in preterm babies leads to asymmetrical postures given by different muscle tones [65; 66; 67; 68; 69].