Flat Head Infants - Plagiocephaly -

This page answers these questions on flat head infants which is known as plagiocephaly, positional plagiocephaly and deformational plagiocephaly:

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What is Plagiocephaly?

Flat head infants (or flat spot on head in babies) is also referred to as plagiocephaly which describes an asymmetric head shape. The term plagiocephaly comes from Greek - oblique head. The condition is also called positional plagiocephaly.

flat head infantPlagiocephaly
plagiocephaly above viewView from above

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Why does Plagiocephaly occur?

Plagiocephaly can occur before birth - in this case this is due to the way the baby's head was positioned and molded in the uterus (womb). It will get worse after birth if your baby continues to lie on the flat spot on his head, because the skull bones are still relatively soft and malleable. Flat head infants are not uncommon because of this.

Sometimes plagiocephaly occurs after birth and flat head infants tend to lie on their heads causing a flat spot on the head. Infants can get this because there is a tightness in the neck muscle, called torticollis, or just because they are spending a lot of time lying on their backs and all the interesting things to look at are on one side of the room. Nobody likes looking at a blank wall.

I have seen a baby who spent a lot of time in a baby hammock - this caused a very obvious flat spot on the head because the hammock molds around the baby's head and there is no space for the head to remold if it is flat.

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My baby has a normal symmetric head shape. How can I keep it that way?

Prevention is always best and you can prevent flat head infants. Preserve your baby's symmetric head shape by:

  • When you put your baby to sleep on his back, alternate the side his head lies on. Some mothers put a picture on the side of the crib (cot) and change this from side to side at each sleep time (to remind them which side to put the baby's head to sleep and to give the baby something to look at).
  • When your baby is awake and you can watch him, give him supervised "tummy time". Put him on his tummy for at least 5 - 10 minutes per day - he needs to be awake and you need to be watching him.
  • Do not let your baby spend too long on his back if he is not sleeping.
  • Do not let your baby spend too long in car seats if he is not traveling.
  • Do not leave your baby in a baby hammock for prolonged periods
  • When your baby is on his back, make sure you alternate where all the interesting things to look at are. You might want to turn the crib (cot) around at each sleep or alternate the end you put your baby's head to make sure your baby doesn't get in the habit of always looking one way.

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What will happen to my baby's head shape if he already has a flat spot on his head?

The body will naturally remold the skull of flat head infants into a symmetric shape if it can. The flat spot on his head needs space, not pressure, to remold. To help the body do its job, it is important that the baby does not lie on the flat spot on his head, which is still relatively soft and malleable.

You can do the following to help flat head infants:

  • Place your baby to sleep with the rounded part of the head on the mattress - you might need to reposition your baby's head if he rolls onto the flat spot while sleeping. In the past, placing a wedge under the flat spot had been advocated but as a wedge may pose a suffocation risk, repositioning alone is recommended.
  • Make sure that the interesting things to look at are on the side away from the flat spot on head.
  • Give your baby at least 5 - 10 minutes of supervised "tummy time" every day. Your baby must be awake and you must be supervising this, though. Never let your baby fall asleep on his front.
  • Do not let your baby spend too long on his back if he is not sleeping.
  • Do not let your baby spend too long in car seats if he is not traveling.
  • Do not leave your baby in a baby hammock for prolonged periods
  • Continue to put your baby to sleep on his back - this is the safest way for babies to sleep.

It may take 2-3 months to see an improvement in head shape. Flat head infants usually remold the skull so that the flat spot looks less obvious as they get older.

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What is "tummy time" and why is it important?

"Tummy time" refers to time your baby spends lying on his tummy - ie. the prone position. It is important for babies to have "tummy time" to develop good tone in their trunk muscles. It also gives them time when there is no pressure on their heads and flat head infants can remold their head shape. It is important that "tummy time" is supervised and that babies don't fall asleep on their tummy. Give your baby at least 5-10 minutes of "tummy time" per day.

It is important for babies to be put to sleep on their backs - this is the safest sleeping position and helps prevent sudden infant death syndrome (or crib death or cot death).

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My baby doesn't like being on his tummy - what shall I do?

Babies just need to get used to being on their tummies. Start early by putting your baby on his tummy on your chest so he can see your face. When you put him on the floor for the first time, get down on the floor with him so he doesn't get scared. Persevere and he will get used to it - it is important for his development for him to have tummy time.

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Are there other treatment options for flat head infants?

In some countries, not New Zealand or England, babies with plagiocephaly can be offered helmets to help the flat spot on the head remold. Helmets must be worn for 23 out of 24 hours daily and babies may need treatment for up to 6 months. In mild to moderate cases where there is a flat spot on the head, there is no benefit of helmets in re-molding the head shape compared to the simple re-positioning techniques outlined above for flat head in infants.

Occasionally, surgery is required. This is usually when there is abnormal fusion of the skull bones causing the flat head infants- this is called craniosynostosis. From above, the head will look like a rhomboid with craniosynostosis and like a parallelogram with positional plagiocephaly. So with fused skull bones, one side of the head will look shorter than the opposite side.

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Is plagiocephaly caused by babies sleeping on their backs?

There has been a rise in the incidence of plagiocephaly since the campaign to put babies to sleep on their backs, but the cause of plagiocephaly is not sleeping on the back. However, it is aggravated by spending extended periods lying on the flat spot on the head when not asleep. If you ensure your baby doesn't always lie on the flat spot on his head, then there shouldn't be a problem.

Putting your baby to sleep on his back is absolutely the safest position for him.

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What is torticollis?

Torticollis refers to a tight muscle in the neck (the sternomastoid muscle) which means the baby can't fully turn the head. There are several causes of a tight muscle in the neck (it can be the cause or the result of flat head infants), but the important thing is to give gentle stretching exercises to the muscle to prevent it shortening and tightening further.

If there is torticollis, the American Academy of Pediatrics advises the following exercises at each diaper (nappy) change:

  • Holding one hand on your baby's chest, gently turn the head to one side and hold for a count of 10 (turn the head so the chin goes towards the shoulder). Repeat on the other side. Now do that 2 more times on each side (so 3 times in all)
  • Holding one hand on your baby's chest, gently lean the head to one side and hold for a count of 10 (lean the ear towards the shoulder). Repeat on the other side. Now do that 2 more times on each side (so 3 times in all)

Remember, these stretches are gentle - never force your baby's head.Sometimes, you will need to see a physiotherapist.

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When should I see my doctor?

See your doctor for flat head in infants if:

  • your baby's head shape is getting more asymmetric despite your interventions
  • your baby has a very tight neck muscle - your baby may need to see a physiotherapist
  • when you look from above, your baby's head looks more like a rhomboid shape (the opposing sides are not the same length- your baby may have fused skull bones. Positional plagiocephaly looks more like a parallelogram from above (so the opposing sides are similar lengths) as in the photo at the top of the page
  • your baby's head is very flat
  • your baby's head is very narrow and long
  • your baby's head is very asymmetrical
  • you are concerned about your baby's development

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References:

  • American Academy of Pediatrics. Clinical Report. Prevention and Management of Positional Skull Deformities in Infants. Pediatrics 2003; 112:199-202
  • Community Paediatric Review. Royal Children's Hospital, Melbourne. Deformational Plagiocephaly. www.rch.org.au/ccch/pub
  • Ministry of Health, New Zealand. Protecting your baby's head shape. February 2004. Code 1227. Ministry of Health, New Zealand
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Last reviewed on 11 November 2011

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Dr Maud MD

Dr Maud MD (MBChB, FRACP, FRCPCH), a specialist pediatrician, provides health information and medical advice for parents of babies and toddlers. Read more about Dr Maud.


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