Plagiocephaly (flat head syndrome)

What is plagiocephaly?

Plagiocephaly is a condition that causes a baby's head to have a flat spot (flat head syndrome) or be misshapen.

The most common form is positional plagiocephaly. It occurs when a baby's head develops a flat spot due to pressure on that area. Babies are vulnerable because their skull is soft and pliable when they're born.

Positional plagiocephaly typically develops after birth when babies spend time in a position that puts pressure on one part of the skull. Because babies spend so much time lying on their back, for example, they may develop a flat spot where their head presses against the mattress.

Starting in the early 1990s, parents were told to put their babies to sleep on their back to reduce the risk of SIDS. While this advice has saved thousands of babies' lives, experts have noticed a fivefold increase in misshapen heads since then. (See below for tips on repositioning your baby to avoid both SIDS and plagiocephaly.)

More rarely, babies develop positional plagiocephaly when movement in the uterus is constricted for some reason – because their mother is carrying more than one baby, for example. It can also happen to breech babies who get wedged under their mother's ribs.

Another type of plagiocephaly is craniosynostosis, a birth defect in which the joints between the bones of the skull close early. Babies born with craniosynostosis need surgery to allow their brain to grow properly.

Signs of positional plagiocephaly

Many vaginally delivered babies are born with an oddly shaped head caused by the pressure of passing through the birth canal. This usually corrects itself within about six weeks. But if your baby's head hasn't rounded out by age 6 weeks – or if you first notice that your baby has a flat spot on her skull after 6 weeks of age – it's probably a case of positional plagiocephaly.

Plagiocephaly shows up most often in babies who are reported to be "good sleepers," babies with unusually large heads, and babies who are born prematurely and have weak muscle tone.

Babies with torticollis can also develop a flat spot on their skull because they often sleep with their head turned to one side. Torticollis occurs when a tight or shortened muscle on one side of the neck causes the chin to tilt to the other side. Premature babies are especially prone to torticollis.

When to be concerned about a flat spot on your baby’s head

Everyone's skull is a bit asymmetrical. And in many cases, a flat spot on a baby's head will round out on its own around 6 months of age, as she starts crawling and sitting up. Nevertheless, if you notice flattening of your baby's head at any time, don't wait – talk with her doctor about it right away.

A baby's skull becomes less soft and pliable as she grows. So if you do need to take steps to correct the condition, the younger your baby is, the easier it will be. Your baby's doctor may refer you to a specialist, such as a pediatric plastic surgeon or neurosurgeon for diagnosis and treatment.

Tip: If you notice a flat spot your baby's head early on, you might want to take photographs of the top of the head from above every month or so. Then you can see whether the flat spot is improving over time. These images may also be helpful for your baby's doctors.

Treatments for positional plagiocephaly

If a doctor determines that your baby has positional plagiocephaly, his recommendations will depend on your baby's age and the severity of the condition.

If your baby is young enough and the condition is mild, he'll probably recommend repositional therapy, a combination of simple measures designed to help your baby's head round out. In severe cases, cranial orthotic therapy (using a helmet to change the shape of the head) may be required. Keep reading to find out more about these therapies.

Repositional therapy

Repositional therapy involves regularly changing your baby's position to avoid putting pressure on the flattened area of the head. (Babies tend to settle into the same comfortable position in their crib and infant seats.)

Here are ideas for changing your baby's position during daily activities and strengthening neck muscles:

• Bedtime and naps: Alternate the direction your baby's head is facing when you put her to sleep. To encourage this, lay her down with her head at a different end of the crib for naps and each night. If her crib is against a wall, she should naturally turn her head to look out into the room. (Or you could hang a mobile outside the crib to attract her attention.) Vary the direction she has to turn to look and she'll change the side of her head that's pressed against the mattress.
  Caution: Don't use rolled up towels or positioners in the crib to get your baby to keep her head to one side. These increase the risk of SIDS and suffocation.
• Feeding time: Alternate sides whenever you feed your baby a bottle. (You'll do this automatically when you breastfeed.) Adjusting your baby's position during feeding helps avoid pressure on the flat spot.
• Sitting time: Avoid leaving your baby for extended periods of time in a car seat, infant seat, baby swing, baby carrier, or other place where her head is likely to rest on the same spot.
• Tummy time: During waking hours, supervised tummy time is essential for the development of motor skills. Tummy time also helps prevent plagiocephaly by strengthening babies' neck muscles. Stronger neck muscles enable babies to move their head around while sleeping so it doesn't always rest in the same position.
  To make sure your baby enjoys being on her tummy, take the opportunity to put her on her tummy when she's not asleep starting in the first few days of life. Babies who aren't used to being on their tummy from day one may have to be coaxed into it, starting with a minute or two at a time.
• Physical therapy: The doctor may also recommend daily physical therapy exercises to help increase the range of motion in your baby's neck. These must be done gently but consistently.

If these measures aren't successful, the next step is to consider cranial orthotic therapy.

Cranial orthotic therapy with a baby helmet or headband

Babies with severe plagiocephaly usually wear either a custom-fitted helmet or a headband (called a cranial orthotic) for about 23 hours a day to correct the shape of their head. This treatment generally lasts two to six months, depending on how early you start and how severe the problem is.

Helmet therapy is always coordinated with physical therapy to achieve the best results. It's most successful when started around 6 months of age. Some experts think the headgear offers little help after 12 months of age because the skull resists reshaping as the bone thickens.

If your baby needs cranial orthotic therapy, your doctor can recommend a helmet or band and tell you where you can have it made. You'll need to have a 3-D photographic image taken of your child's head so the device can be custom-fitted.

Wearing headgear all the time may sound awful, but the helmets and bands are lightweight, and most babies quickly get used to wearing one.

This kind of treatment can cost up to $4,000. Some insurance companies will cover it in their orthotic benefits, but others consider it cosmetic or experimental and won't pay. However, many parents have successfully appealed their insurance company's rejection and received payment in the end.

The success rates for this kind of therapy are high when it's started early (around 6 months). If you're starting late, your baby's skull may not become perfectly symmetrical. Keep in mind that some asymmetry is normal. And as your child's hair grows, it will likely hide some of the remaining flattening.