Flat Head Syndrome in Babies: When It’s a Concern, When It’s Not & What You Need to Know
What are flat spots on my baby’s skull? What is flat head syndrome?
Answer: ‘Flat head syndrome’ is a term that describes different types of flattening that can occur on an infant’s head. There are a few different types of flattening that can occur in little ones, including;
Plagiocephaly - refers to flattening more on ONE side of the skull. When it comes to plagiocephaly, torticollis is almost always also present. It’s a bit of a ‘what came first, the chicken or the egg conversation’, but whether plagiocephaly being present caused the torticollis or vice versa, torticollis often has to be part of the intervention process to be sure the child is being seen as a whole and all factors contributing to concerns are addressed. For LOTS more on torticollis, see my full blog HERE.
Brachiocephaly - flattening across the entire back of the head.
*Below is a photo comparing normal, plagiocephalic and brachiocepahlic head shapes for reference.
Scaphocepahly- the head has a longer, narrower shape than typical. *this is commonly seen in premies/former NICU babies.
Craniosynostosis- occurs when the skull bones fuse together faster than normal. *this is much less common and much more serious, many times requiring surgical intervention or more intensive medical management, and must be ruled out when any plagiocephaly or head shape concerns are present. Ruling this out is also the reason a neurologist referral is often the first step in the helmetting process.
Photo credit: www.nhs.uk
Photo credit: https://stanfordhealthcare.org/
What causes flat head syndrome?
The infant skull is very soft and malleable, which is important to to allow passage through the birth canal during delivery. As baby grows, the skull begins to harden and the skull bones begin to fuse together. Due to the skull bones being soft & malleable, flattening can occur in utero OR once baby is born from prolonged pressure on certain spots of the skull. Things like prolonged time spent on their back, lack of tummy time, prolonged hospitalizations or NICU stays, being a multiple or the first born child, or having an assisted delivery with forceps can all increase the risk of development of flattening.
What are signs and symptoms of flat head syndrome?
Signs & symptoms can vary dependent on the type and severity of the flattening present, but can include;
Flattening
A preference towards looking in one direction more often or inability to turn in both directions fluidly (see torticollis discussion below for more!)
A forward shift or bulge of one side of the forehead/eye
A forward shifting of one ear compared to the other (from a bird’s eye view)
A forward shifting of part of the jaw on one side of the
Hair loss on the flattened area
When is my baby developing flatness on their head not a major concern anymore?
Generally speaking, if a child has no current flatness, the concern for the development of flatness really begins to drop around 4-5 months of age. This is because around this time, a child is becoming increasingly mobile - exploring things like rolling from back to side, really lifting their head during tummy time, maybe even sleeping on their side or belly once they can roll there, etc.
Prolonged pressure in certain positions is often a big culprit in the development of flatness on the skull in combination with how malleable the skull is in the first 6-12 months of life. Because of that, when a baby is now shifting the pressure the skull is receiving independently by moving or changing their position, and/or we are doing so for them, less periods of prolonged pressure in one spot typically equal less concern around development of flattening on the skull in general.
My baby has a flat spot on their head, can we skip the helmet?
The short answer:
0-4 months (adjusted age) - likely
4-5 months (adjusted age) - likely if its mild
5-6 months (adjusted age) - it's difficult but can be done if it's mild and parents are compliant with home physical therapy program
After 6 months (adjusted age) - it's probably helmet time and an appointment for consultation should happen as quickly as possible.
The detailed answer:
No matter how old your baby is, if they have a flat spot there is usually an underlying reason as to why they have developed it. Often we can address the underlying cause and if your baby is young enough (less than 4 months) their head shape can be remolded back to normal, but sometimes it's just biomechanically and physiologically impossible to address head shape flatness without a helmet - usually these are the moderate to severe cases (4 months or older).
Physical therapy can be highly effective at improving your baby's head shape between 0-4 months of age (SEE SECTION BELOW FOR TIPS). Effective therapy means that positive improvements in a baby's head shape are noticeable to a parent's eye after 4 weeks of a consistent home therapy program. If you aren't seeing improvements it might be time to change the type of therapy you are using or change practitioners. After 4 months of age, you'll likely need to have digital scans taken by a certified orthotist at 4 week intervals to assess the effectiveness of a physical therapy program. Most certified orthotists will provide scan assessments for free or at a low cost.
If your baby's head shape is showing no signs of improvement with physical therapy and you are concerned about their head shape, it is best to start the helmet conversation sooner rather than later as it takes about a week to have a helmet made and then about a week of slowly increasing your baby's wear time. So a severe case, should be making the decision to move forward with helmet therapy at about 4 months of age.
It is worth mentioning that "just cosmetic" is….an absolute cop out. Head shape can affect the fit of sports or bike helmets in the future, ear/forehead/jaw shift malalignment and it could impact things like feeding/speech/articulation.
Is there anything I can do to help my baby's head from becoming flat, prevent the flattening from getting worse, or help improve it?
YES! In the fourth trimester (aka baby’s first 3-4 months of life), tummy time often gets A LOT of the focus - but did you know there are other positions that are not only beneficial from a motor milestone standpoint, but also from an overall development standpoint, INCLUDING reducing the risk of flat spot formation & even helping reverse flat spots by re-distributing pressure on the skull?!
If that’s news to you - check out my 4 favorite positions for your 0-4 month old that have SO much benefit when it comes to development! Grab a blanket or towel, roll it up, & give them a shot!
Here’s the position breakdown:
SUPPORTED BACK PLAY
Benefits- encourages hands to midline, activation of the front muscles on the body (huge for the skills that start around 3 months), and adding in the activities shown is amazing for brain development, crossing midline, body awareness, and more!
SUPPORTED TUMMY TIME
Benefits: allows baby to get the benefits of tummy time and work their back muscles, while making it slightly easier to avoid frustration.
SIDELYING ON BOTH SIDES
Benefits: encourages hands to midline, activates front muscles, encourages rolling, changes pressure on the skull (which reduces risk of flattening AND can even help improve existing flattening).
To incorporate these positions into wake windows, I focus on ONE position per wake window.
For example: nap, back play, eat, nap, tummy time, eat, nap, sidelying right, eat, nap, sidelying left. It doesn’t matter how long your little one stays in it, remember- quality over quantity!
As they get older/stronger, reduce the height of the towel or blanket roll until they are flat on the floor for all of them. This allows them to work in smaller ranges of motion against gravity, gaining strength & range of motion slowly & without compensations- win win!
The top 3 toys I’ve found help motivate, help baby stay in position & begin to engage & explore are:
The Boppy - GREAT for helping maintain positions outlined above, including helping maintain the alignment we are looking for to help reduce pressure points on the skull!
Baby Einstein Soother - this is also GREAT to strap to their crib and help motivate them to turn their head in the non-preferred direction when there is flattening or torticollis present.
Black & white fold out book - maximizes the vision available in the early months of life (black & white & high contrast) and helps motivation & maintaining their head turned in a non-preferred direction.
For LOTS more of my favorite toys in the first 6 months of life that are not only fun and motivating, but also developmentally beneficial, check out my roundup.
Tips to help you make informed decisions about your baby’s head shape and monitor changes & progress:
Take pictures at 1 month intervals (2,3 &4 months of age): bird's eye view, side profiles, front and back
Ask for a referral to a pediatric physical therapist early on - it can take time to get in to see someone and earlier intervention makes a huge difference on outcomes, length of treatment and even the potential for needing fewer helmets during the course of treatment, depending on severity.
Take note of positions (feeding/sleeping/napping) where your baby's flatness is constantly in contact with a surface (your forearm, your chest) and try to reposition them off of it.
To find cranial helmet locations, check out:
Both Starband and Cranial Technologies are two very large American companies that make helmets for babies who were unable to achieve correction with physical therapy alone. They have expertise in the fit and function of cranial helmets and a basic knowledge of physical therapy interventions to prevent and correct plagiocephaly.
Do I Need A Special Pillow To Prevent My Baby From Having A Flat Head?
"I see tons of ads for pillows to prevent "flat heads". Are they legit?"
Answer: They are not. This is honestly one of those marketing tactics that are so upsetting to me because they can be so manipulative and really prey on a parent’s anxieties. While I can see why at times, someone may want to grab one, it is truly IMMENSELY more beneficial to focus on quality positioning/purposeful play during the day!
Rotating positions from day one, like discussed above will truly help in most cases to prevent the development of flattening on the skull, because it disperses and varies the pressure on the skull!
On top of them not being necessary or helpful in most cases, the FDA actually warns AGAINST the use of special pillows, stating:
“The U.S. Food and Drug Administration (FDA) recommends that parents and caregivers do not use infant head shaping pillows intended to change an infant’s head shape or symmetry or claim to prevent or treat any medical condition. The FDA is not aware of any demonstrated benefit with the use of infant head shaping pillows for any medical purpose. The use of head shaping pillows can create an unsafe sleep environment for infants and may contribute to the risk of suffocation and death. Infant head shaping pillows are not FDA-approved. The safety and effectiveness of these products have not been established for the prevention or treatment of flat head syndrome (also known as positional plagiocephaly), deformational plagiocephaly, or the more serious condition where the developing infant’s skull bones join together too early (known as craniosynostosis).”
For more information on the FDA’s safety statement regarding pillows marketed for use with flattening on the skull, see HERE.
A final note, parent to parent:
All in all, I hope this information arms you with the knowledge you need to feel confident advocating for your little one when it comes to managing flattening on the skull, torticollis, and their overall development. It is NOT your fault, and you are doing a great job - you and your little have totally got this!
Looking for more gross motor support?
For developmental questions, tips and guidance related to milestones about tummy time, rolling & sitting, crawling and walking, check out KC’s developmental Masterclasses linked here.
