Keeping a level head – managing “Flat Head Syndrome” in babies

plagiocephaly positioning infographic

Ask any mother who has faced the eye watering proposition of a vaginal delivery, and they will be thankful that evolution was kind enough to provide our babies with a pliable skull. The deformational nature of an infant’s skull is nature’s way of fitting a relatively big head through a relatively small exit, and to allow a baby’s brain to triple in size over the first few years of life.

“Flat head syndrome”, or positional/deformational plagiocephaly, is an asymmetrical flattening of one side of the skull causing the head to appear misshapen. Plagiocephaly can be caused by the position in utero or by lying in the same position over extended periods of time. More kids are presenting to their GPs with noticeable head asymmetry then ever before, and it is a reflection of the changes in how we care for infants over the last few decades. Take the example below

Danny is 10 weeks old and sleeps 16 hours a day in total. His parents are very careful to follow the SIDS guidelines when they put him to sleep, on his back on a firm mattress with no other toys or pillows in the cot. When Danny is awake, he loves spending time in his bouncer or swing watching his older siblings play and Dad cook in the kitchen. He likes the car, which is an awfully good thing because with one sibling in daycare, one in Kindy, and one in primary school, there is a lot of time spent in the car seat as Mum plays chauffeur to the crew. Like a lot of babies, Danny is not a huge fan of tummy time, and his Mum is slowly working on increasing the time he spends on his tummy – that’s when she can keep the toddler from poking him in the eyes.

Sound familiar? The end result – Danny is spending nearly all day in “containers” (bouncer, car seat, swing) or lying on his back, resulting in near constant pressure on the back of his head. This is a recipe for developing a flattening on the back of the head.

So what can we do about this? Should we worry, or is this something that will go away on its own? Is it just cosmetic, or it it affecting brain development?

Risk Factors for Plagiocephaly

There are a few empirical studies with decent methodology that look at risk factors in the general population[1]. The risk factors identified were

  • Back sleep position

  • Limited neck rotation or preference in head position

  • First born child and male children

  • Lower level of activity and lack of tummy time

Clinically, we also see head preference and plagiocephaly more commonly in children who

  • Were born premature

  • Have severe reflux (GORD)

  • Spend a lot of time in “container” toys and car seats

  • Have been unwell for a large portion of their first months of life

Given that children should be sleeping on their backs according to the Safe Sleeping Guidelines, all children have at least one risk factor for plagiocephaly – and hence it is one of the most common conditions identified by child health nurses and GPs at well baby check ups.

When is it something more serious?

“Why is the baby mainly looking one way, causing flattening on one side of the head?”.

For many kids this is environmental – they may turn towards their parents while in their bassinet, or always suck their right thumb. Once a child starts to favour turning the head to one side and a flattening emerges, it can take a little work to convince them to turn “up hill” and look the other way. Other causes of a head preference that are worth exploring:

Is your baby responding to sound, touch and visual stimulation on both sides? Some children will favour one side due to difficulty hearing, seeing or feeling on one side.

Was your baby born with the flattening from running out of room in utero? This is more common in multiple and breech births. Babies born with a degree of flattening will often continue to turn that way.

Is your child experiencing pain or decreased movement on one side? A cannula in one arm, or a brachial plexus injury during birth, can cause a child to “turn away” from the side that is in pain.

Does your child have full movement available at the neck? A condition called “torticollis” causes restriction in the muscles on one side of the neck and difficulty turning the head to one side. There are also rare conditions that can affect the cervical spine development and cause fusion and decreased movement of the neck.

Does your child have severe reflux symptoms? Babies with reflux often struggle with tummy time, may favour turning to one side to relieve discomfort, and often need to be kept upright after feeds leading to lots of time in swings, bouncers and baby seats.

Was your baby born prematurely? Babies born prematurely have softer skulls that are more prone to moulding, and may be less active when they are first born.

“ Is the asymmetry consistent with external pressure causing changes in skull shape, or is it being caused by something else”

The main differential diagnosis for plagiocephaly is craniosynostosis, or premature fusing of one or more sutures of the head. Craniosynostosis is a more serious condition that requires referral to a specialist for management.

Plagiocephaly will cause the ear and forehead to move forward ON THE SAME SIDE as the flattening at the back of the head (left picture). Everything on one side will be pushed forward by external pressure.

Craniosynostosis causes the skull to stop growing on one side. Instead of the ear and forehead moving forward on the same side, it will move forward on the OPPOSITE SIDE, as the other side of the skull grows faster (right picture).

Plagiocephaly vs Craniosynostosis

When should I see a professional?

Most mild forms of plagiocephaly can be successfully managed with re-positioning strategies and don’t require therapy. It is definitely worth seeing your GP, Paediatrician, Child Health Nurse or a Physiotherapist if you notice the following:

  • Any concerns with your child's hearing, vision or sensation

  • Difficulty getting your baby to turn in the other direction

  • Worsening of head flattening even with attempts at re-positioning

  • Difficulty applying re-positioning strategies due to other issues e.g. in a splint for hip dysplasia, reflux limiting tolerance of most positions

  • Your baby has other medical concerns that are likely to impact development and prolong the time before rolling and sitting e.g. brain injury, prematurity

  • You are worried and would like some professional guidance

What’s the prognosis?

The great news is that mild plagiocephaly is usually fairly self limiting with some attention to re-positioning at home and natural developmental progression. As babies start to roll over, prop well on their tummies and sit independently, they will naturally spend less time on the back of their head. In children with more significant asymmetry or developmental delay, physiotherapy can be a very useful tool to minimise the progression of plagiocephaly while working on independent movement. A small subset of children may need a helmet to manage their plagiocephaly, which is usually commenced between 4-8 months. The current clinical guidelines in Queensland state that there is little evidence to support helmets in healthy and normally developing children.

There have been some recent studies that have alluded to a relationship beween plagiocephaly and developmental and learning challenges later in life. It is important to realise that to date this research does not suggest CAUSATION but rather CORRELATION. In other words, plagiocephaly is unlikely to CAUSE issues with development, but children with developmental concerns are more likely to move less or differently which can often lead to plagiocephaly.

Management of Plagiocephaly

Step 1: Re-positioning Strategies. Print out our handy infographic and stick it on the fridge as a reminder of the main strategies to prevent plagiocephaly.

  • Make sure you continue to follow safe sleeping guidelines – they are there for a reason! That means bub sleeping on their back, and with no positioning aids in the cot.

  • Although babies sleep an awful lot (though some days it certainly doesn’t feel like it), they also spend considerable time awake. Try to spend baby’s awake time off the back of the head.

  • Baby swings, bouncers and capsules are essential parenting tools – but make sure they are not your only tools! There is absolutely nothing wrong with letting bub spend some time in their swing while you get on with your day, but 6 hours a day is likely to start to become problematic. Everything in moderation!

  • Think of all the activities you do in your day and how you can modify them to encourage turning both ways. Do you make sure you swap hands if you bottle feed? Are you picking your baby up by rolling them to their side? Do you pop them with their head at either end of the playmat so they get some variety of visual stimuli?

If you have tried applying these strategies at home and aren’t seeing any progress…

Step 2: See a health professional for further assessment and more specific advice and strategies for your child and family situation. Physiotherapists can be an excellent resource for managing plagiocephaly, and there is a good evidence base to support that physiotherapy alone works in the management of mild to moderate plagiocephaly.

Step 3: Not responding? Might be time for a referral to a specialist.

Complementary Therapies

Therapies like chiropractic and osteopathy are becoming increasing popular as parents try to find holistic alternatives to manage their family’s health. These professions manage plagiocephaly with manipulations of the developing skeletal system in an attempt to correct alignment and restore normal movement. There is little evidence in the literature to support the effectiveness of these therapies in managing plagiocephaly, with the exception of the occasional single patient or small group case study. There is also a paucity of evidence to prove these interventions are safe for all children. This doesn’t mean they don’t work or aren’t safe – but it does make it much more challenging to make an informed decision about the appropriateness for your child. There is however good evidence to support the use of re-positioning and physiotherapy as the initial management strategy for plagiocephaly, and it is the recommended course of action in current clinical practice guidelines. In short – it is up to your judgement as a parent. In this case, and as a parent myself, I choose to DO NO HARM and DO WHAT WORKS – and luckily there are some excellent and proven interventions available to you that can achieve just that!