Flat head syndrome (positional plagiocephaly and brachycephaly)

What is flat head syndrome?

Flat head syndrome describes an atypical head shape that develops during the first year of a baby’s life, while the skull is soft and growing rapidly. It is also called positional plagiocephaly or brachycephaly, depending on the location of the flatness. Plagiocephaly describes an asymmetric flattening of one side of the head, while brachycephaly describes a central flattening at the back of the head. A combination of these types of flattening is also possible. Flat head syndrome resulting from a positional preference does not affect how a baby's brain develops. It can affect a baby's appearance and cause the head and face to develop unevenly.

In some cases, head flatness can be caused by the plates of the skull joining together too early. This is not flat head syndrome and is a relatively rare condition known as craniosynostosis. Craniosynostosis can affect brain development and requires assessment by a plastic surgeon.

Flat head syndrome

Causes of flat head syndrome

During the first year of life, a baby’s skull is relatively soft and grows rapidly, reaching 85% of its adult size. This makes a baby's head malleable, especially during the first few months of life, and prolonged pressure on one part of the skull can lead to flattening. If your baby spends prolonged periods of time on their back with their head in one position, part of their head may become flat.

Some information about torticollis

A baby with flat head syndrome may also have another condition called torticollis. Torticollis occurs when a muscle of the neck, called the sternocleidomastoid, is shorter (or tighter) on one side of the neck than the other. This causes the head to tilt toward the side of the neck with the tight muscle and the head to be turned away from that side. If your baby has difficulty turning their head, physiotherapy may help stretch the tight muscle and strengthen the weak neck muscles.

Positional plagiocephaly and torticollis are closely associated with one another. After assessing your child's head and neck, the therapist will design a home program for your baby. You may be given exercises and other recommendations.

For more information, see the article about Torticollis.

Treating flat head syndrome

If your baby has a flat spot, start by minimizing the time your baby spends on their back while awake. In addition to tummy time, which has many developmental benefits, baby carriers and exercise centres can be good options to relieve pressure on the back of the head when age appropriate. Try to limit time in bouncers and car seats that make it harder for your baby to turn their head out of their preferred position.

If your baby has an asymmetric flattening, you should talk to your doctor about repositioning your baby while they are awake. This is called counter-positioning. To counter-position your baby, you will want to turn them slightly off their back at about a 45-degree angle away from the flat spot. Use a firm crib roll to prevent your baby from rolling onto their back. This will take the pressure off the flat spot. When your baby is asleep, you can turn their head manually without using a roll. You should continue this new position to keep your baby off the flat spot until their skull becomes rounder and more even. Counter-positioning works best from birth up to five to six months of age. This is because the skull is still soft, and your baby is more likely to remain in one position. Counter-positioning also encourages your baby to look to the less-preferred side.

A corrective helmet may be recommended if there is no change in your baby's head shape with repositioning or if there is a high degree of flattening. A corrective helmet uses gentle holding pressures to reshape the skull over time as it redirects the head’s growth into the areas that are flat. The ideal time to have a child assessed for a corrective helmet is between four and six months of age. For more information, see the article on Treatment with a corrective helmet.

What to do if your baby only looks in only one direction

If your baby prefers to look in one direction, encourage them to look to the less-preferred side until they look equally in both directions. Here are some things you can do:

• Make sure your baby spends time on their tummy during playtime.
• During playtime, use mobiles or brightly coloured toys to encourage your baby to look in the less-preferred direction.
• When you are holding your baby, hold them in a way to encourage them to look in the less-preferred direction.
• If your baby's crib is against the wall, put your baby at opposite ends of the crib each night. Babies prefer to look out into the room.
• If your baby's crib is not against a wall, move a brightly coloured crib-safe toy to encourage them to look in a different direction each night.

Preventing flat head syndrome

To prevent your baby from developing a flattened skull, change their position often. Put your baby on their tummy to play several times a day. Use a firm play surface such as a carpeted floor or an activity mat on the floor.

"Tummy time" will also help your baby:

• develop early control of their head
• strengthen the muscles in their upper body
• learn to roll over
• reach for objects
• learn to crawl

How to make tummy time more enjoyable

Here are some ways to help your baby learn to love playtime on their tummy:

• Lay your baby on your chest. This is a good way to get your baby used to lying on their tummy.
• Put your baby on their tummy after each diaper change. Add a little extra tummy time each day.
• Give your baby support by putting a rolled towel under their chest and propping their arms in front of the towel.
• Place your baby's elbows under their shoulders so they can help support their body with their arms.
• Give your baby lots of interesting things to look at while on their tummy. Put brightly coloured toys or a mirror directly in front of them.

For more information, see the article about Tummy time.

When to call the doctor

If you have followed the suggestions in this guide and you are still concerned about your baby's head and/or neck, speak to your baby's doctor to learn about other help available.