What is plagiocephaly?

Plagiocephaly is the medical term for flat head.  With plagiocephaly, the flattening is in the back of the baby’s skull, and on one side, the right or the left.  The diagram below shows a right sided plagiocephaly, as the right back portion of the head is flattened, and the opposite side of the forehead (the left) is flattened as well.  In severe cases, the ears can be very misaligned, as well as the eyes and jaw can also become asymmetrical. 

There are other types of flat head, such as brachycephaly (flat across the entire back of the head), and scaphocephaly (a long, narrow head shape).  See the images below for a comparison of these:

For the purpose of this blog post, we are going to focus on plagiocephaly, but if your baby’s head is starting to take on any of these shapes, speak to your pediatrician or health care provider as soon as possible!

Why is flat head syndrome so common?

In 1992 the American Academy of Pediatrics (AAP) published a report recommending that healthy infants be placed to sleep on their backs.  This led to the Back to Sleep campaign in 1994, now known as the Safe to Sleep campaign.  This was funded by the National Institute of Child Health and Human Development (now the Eunice Kennedy Shriver National Institute of Child Health and Human Development), and other programs.  The Safe to Sleep campaign brings awareness, educates and offers many resources on safe sleep environments. Since the Back to Sleep campaign, the incidence of sudden infant death syndrome (SID) has decreased by more than 40%, which was the main goal of the campaign.  On the other hand, the referrals for plagiocephaly have increased by 600%.

So while we know that sleeping on their backs is the best and safest place for babies to be, too much awake time on their backs as well can lead to flat head syndrome.  Changing up the position that your baby is in when they are awake will help prevent flattening of their heads.  In infants developing typically, greater time spent in the prone position (on their stomachs) while awake is positively correlated with higher scores on developmental standardized tests, and fewer delays in achieving milestones such as rolling, unsupported sitting, and in areas of fine motor control.  So get those babies in tummy time as much as you can!

What causes plagiocephaly?

Persistent use of supportive equipment, or “containers”, in lieu of time spent playing on babies’ bellies or on their sides, may result in the deformation of the developing skull due to gravitational forces.  Always being in the same position on their backs leads to the deformities of their soft and pliable heads.  Increased time spent in containers and supportive devices (baby seats, swings, etc.) also increases the risk of torticollis and other asymmetrical developmental movement patterns.  

So – supervised and unrestricted floor play is best for your baby, at any age!  Allowing unrestricted movements directly on the floor, or on a small mat or blanket, is the most beneficial place for your baby to learn and grow.  You may have to build up your baby’s tolerance to floor time, tummy time, and even just being out of your arms.  With encouragement, a safe environment, and a lot of repetition, you can help your baby build up tolerance to floor time.  The amount of containers, seats, swings, jumpers, and walkers that are marketed to parents is astronomical!  A lot of these products do not have your baby’s best interest in mind, and are not made to foster your child’s development.  It can certainly be overwhelming when browsing through your local department store or even online, to feel like you are getting everything your baby “needs.”  Well, as a pediatric physical therapist and a board-certified pediatric clinical specialist, I can tell you that less is definitely more when it comes to baby products!  Since your baby is spending so much time on their backs at nighttime and during naps,  when they are awake, try to position them off their backs as much as possible. A tummy time mat, or blanket, is the best place for your baby to be.  Start small, with only minutes at a time on the floor, and as your baby’s tolerance improves, increase the time they are in these different positions.  Getting down on the floor with your baby if you are able, using toys, mirrors, siblings, and even pets can help improve your baby’s tolerance and make floor time a fun and enjoyable experience for you both!

What is torticollis and how is it related to plagiocephaly?

Torticollis is a common pediatric musculoskeletal condition, described as a postural deformity of the neck evident at birth or shortly thereafter.  It is typically characterized by a head tilt to one side and rotation of the neck to the opposite side.  This is due to the tightening, or shortening, of a muscle in the neck called the sternocleidomastoid muscle. The incidence of torticollis ranges from 3.9% to 16% of newborns and may occur slightly more frequently in males than females.

In the picture below, you can see that this baby’s head is tilted towards their right shoulder, and their head is rotated to the left.

Torticollis is diagnosed by a health care provider when the baby shows a preference for this posture, and has difficulty maintaining their head in midline.  This muscle becomes tight so it is difficult for the baby to turn their head to the other direction and tilt towards the other shoulder.

Torticollis may be accompanied by flattening of the head (plagiocephaly), hip dysplasia, brachial plexus injury, or other conditions that affect the bones of the legs.  You can see how if a baby was also in the position above, they would start to develop a flat spot on the back of their head from always being in this position, and not having the strength or range of motion of their necks to move their head out of this position.  If a baby has this preference to be in this posture, then placing them in containers such as swings, bouncy seats, infant seats, or walkers/jumpers, will most likely exacerbate this condition. 

How is torticollis treated?

Torticollis is typically treated with conservative treatment (physical therapy, exercises, stretches and positioning), and if these treatments are started early, most cases resolve by the time babies reach their first birthday.  Pediatric physical and occupational therapists have specialized training in treating all aspects of torticollis, and any baby with torticollis or a flat head should be referred to a specialist for treatment as soon as possible.  There are many different options depending on the state you live in.  Every state has an Early Intervention program, and this website allows you to search for a program near you in your state.  Early Intervention is a federal and state funded program that offers home-based intervention with licensed healthcare professionals for children 0-3 years old.  If you prefer taking your baby to an outpatient physical therapy center, reach out to your local children’s hospital for their recommendations. 

When should I talk to my baby’s pediatrician?

Most often, parents will either notice that their baby is only looking to one side, or they will notice a flat spot on their heads.  Sometimes, the pediatricians are the ones who will notice it first at a baby’s well check.  I often have parents look at pictures they have taken of their babies and see if they notice that their baby is always looking or turning to one side, no matter where they are.  You might notice your baby has difficulty breastfeeding on one side, or only is able to bottle feed when held in a certain position.  You might also notice that when your baby is sleeping, their head is always facing the same direction.  Severe torticollis can be diagnosed at birth, or only days after your baby is born.  The earlier the detection and referral to a pediatric therapist, the better the outcomes.  Don’t wait for your baby’s next check-up, if you notice any of these signs, the best thing to do is talk to your pediatrician right away!  

My experience with helmets:

In cases of severe plagiocephaly, babies will sometimes require a helmet to correct their head shape.  Timing is everything when it comes to plagiocephaly and avoiding helmets.  The good news is that if repositioning and interventions are started when a baby is less than four months old, the odds of correcting their head shapes without a helmet are great!  Even if your baby is older and does require a helmet, that is OK too, and those outcomes are also very good!  The helmets are custom to your baby, and are fabricated by licensed professionals called orthotists.  They scan a baby’s head and then create a helmet that the baby wears for 23 hours/day.  Typically babies are in helmets for anywhere from 3-6 months depending on the age they start treatment and the severity of their head shape.  Most babies get used to them very quickly, and the design of them have come a long way, even in the last few years, to allow for better airflow.  One of my clinical affiliations was in Houston, TX at Texas Children’s Hospital, during the Summertime.  We had a lot of babies on our caseload at the time with helmets, and even though their heads would be sweaty and hot with the helmets, they still tolerated them pretty well! 

I can’t tell you how many different and creative designs I have seen on baby’s helmets.  I have seen them used as part of a Halloween costume, such as Amelia Earhart, a Star Wars themed helmet, helmets designed with a sports team in mind as a baseball or football helmet, and many more!  Plagiocephaly sounds like a scary diagnosis, but really it is just a flattening of the head from being in the same position repeatedly.  Even if you are sure that your child has plagiocephaly and you feel confident in repositioning them and giving them a lot of tummy time and floor play, always make sure a licensed healthcare professional is the one to make the diagnosis and refer you to specialists for help! Torticollis and plagiocephaly are so common, there are some Physical Therapists that ONLY treat these diagnoses!  You know your baby best, and you are their biggest advocate – so be sure to always speak up to your pediatrician if you have any concerns with any aspect of their development.  Also be sure to check out Rahoo Baby on their social media platforms for tips on how to play with your baby and for more education by pediatric therapists! 

This blog was written by Pediatric PT Karen Veilleux from www.inchstonespt.org

Additional resources:

Kaplan, Sandra L. PT, DPT, PhD; Coulter, Colleen PT, DPT, PhD, PCS; Sargent, Barbara PT, PhD, PCS Physical Therapy Management of Congenital Muscular Torticollis: A 2018 Evidence-Based Clinical Practice Guideline From the APTA Academy of Pediatric Physical Therapy, Pediatric Physical Therapy: October 2018 - Volume 30 - Issue 4 - p 240-290

Safe to Sleep website:  https://safetosleep.nichd.nih.gov/activities/campaign

Baby Begin (pediatric therapists who specialize in torticollis and plagiocephaly):  https://babybegin.com/ 

Early Intervention Contact Information by State:  https://www.cdc.gov/ncbddd/actearly/parents/state-text.html