for infant head shape
‘Plagiocephaly’ is a term for a misshapen head in infants. This occurs in approximately 20 per cent of infants at seven weeks of age. Plagiocephaly occurs because babies’ heads are very soft, and flat spots can happen when they spend long periods of time with their heads resting in the same position. This is usually managed with repositioning and plenty of supervised awake ‘tummy time’. While plagiocephaly does not affect babies’ development, it can alter the appearance of their face and head. It is important to seek the advice of your GP, maternal and child health nurse (M&CHN) or paediatric physiotherapist to rule out any other causes.
What problems occur with infants’ head shape?
Deformational plagiocephaly, also known as ‘positional plagiocephaly’ or ‘flat head syndrome’, is the most common cause of an asymmetrical head shape in infants. It is more common in boys, the first child, twins/triplets and babies born prematurely. It is also more common in children that spend less than five minutes on their tummy each day, and those that prefer to turn their head in one direction while sleeping at six weeks of age or prefer to bottle-feed from the same side every time.
Plagiocephaly is caused by sustained pressure on the soft skull, usually when babies lie on their back with their head turned in one direction. Occasionally, this can be associated with tight neck muscles (called torticollis). Sometimes the flattening is even across the back of the head, which is called ‘brachycephaly’.
Plagiocephaly and brachycephaly do not affect the development of the brain, however, plagiocephaly can alter the appearance of the infant’s face and head. It is estimated that 60–70 per cent of infants with a misshapen head will revert to ‘normal’ by four years of age, with the most dramatic improvements over the first year of life (when the head is growing most rapidly). Children with more severe plagiocephaly/brachycephaly are more likely to retain some asymmetry or flattening in their head shape. It is important to seek your GP, M&CHN or paediatric physiotherapist’s opinion to rule out any other causes, such as an early fusion of part of the skull (craniosynostosis) which occurs very rarely.
Prevention of plagiocephaly is easier than treatment. Babies benefit from plenty of awake, supervised tummy time, which not only takes the pressure off their heads but also helps them strengthen their neck and back muscles. It is important to always sleep babies on their back, no matter how severe their plagiocephaly, in order to reduce the risk of sudden infant death syndrome (SIDS). It is also recommended to alternate the direction that their head is facing for sleeping either nightly or weekly.
Treatment for plagiocephaly is primarily waiting for the head to reshape itself as it grows. This is called ‘conservative management’ and can be helped by plenty of awake, supervised tummy time and alternating the position of your child’s head when lying on their back. If your child also has torticollis, they will be treated with gentle stretching and exercises which are prescribed by a paediatric physiotherapist (see the torticollis page for more details). ‘Helmet therapy’ is only occasionally indicated, and is reserved for severe cases of plagiocephaly in children older than six months that have not improved with conservative management. Recent studies have shown that conservative management and helmet therapy are equally as effective at treating plagiocephaly in children without torticollis.
How can I tell my child is developing a misshapen head?
If your child has plagiocephaly, you may notice a flat spot on the back of your child’s head (usually off to one side) or some facial asymmetry. If you look down to the top of your child’s head, you may notice that one of their ears, or their forehead, may be more forward than the other. These can be signs of positional plagiocephaly (see the torticollis page for information about detecting a torticollis in your child).
It is not uncommon for babies to have slightly ‘lumpy’ heads, or to have some flatness immediately post-birth, due to their position in the uterus. This is normal, however, if the flattening persists after six weeks of age, seek a health professional’s advice (local GP, M&CHN or paediatric physiotherapist).
How do I know if my child’s condition requires physiotherapy or other medical attention?
Plagiocephaly can be diagnosed by your M&CHN, GP or paediatric physiotherapist. Infants with plagiocephaly do not require surgery and rarely require a helmet unless in severe cases. You may find it helpful to seek advice from a paediatric physiotherapist about strategies to improve tolerance of ‘tummy time’ and positioning your baby’s head to their non-preferred side while sleeping. Babies with torticollis will require paediatric physiotherapy input to stretch and strengthen their neck muscles. Children that have other medical conditions, severe torticollis, severe flattening or have not improved with conservative management, may be referred to a deformational plagiocephaly clinic at a children’s hospital.
Should I be worried?
It is not uncommon to worry about your child’s head shape, however, this worry usually diminishes as your child grows and their head shape becomes more normal. This is because plagiocephaly occurs in 20 per cent of infants at six weeks of age, peaks at 20 per cent at four months of age, but drops to just three per cent of children at two years of age. It is important to remember that plagiocephaly will usually improve as the infant grows and that it does not cause any developmental problems. If you have any concerns about your child’s development, please talk with your GP, M&CHN or paediatric physiotherapist.
How can physiotherapy help with infants’ head shape?
Paediatric physiotherapists can assess your child’s head shape to determine the severity of the plagiocephaly, as well as to check for the presence of tight neck muscles (torticollis). If your baby has plagiocephaly with no other medical or developmental problems, it is expected that their head shape will improve over time, although paediatric physiotherapists may be able to suggest strategies to help.
To ensure your child spends time sleeping with their head turned in each direction, put your baby to sleep at alternate ends of the cot (always with their feet at the bottom of the cot) or change the position of the cot in the room—this helps because babies tend to look towards the light, the centre of the room or the door where there is activity. To increase tummy time when your child is awake, aim for three times per day for 10–15 minutes at a time—this also helps your child reach their developmental milestones.
Exercises for your child’s neck, if they also have torticollis, include stretches to lengthen the tight muscle, exercises to strengthen your baby’s neck muscles, and ways to carry your baby to encourage them to look in their non-preferred direction or to stretch their tight muscles. The paediatric physiotherapist can provide suggestions for positions to play with your baby that will help with all of the above and assist their development.
How effective is physiotherapy for infants’ head shape?
It is recommended that children with plagiocephaly are assessed by a paediatric primary health care professional (GP or paediatric physiotherapist) and commence repositioning strategies as soon as possible. The majority of children with plagiocephaly will develop a normal head shape by 2–3 years of age, with only 2–3 per cent of children left with a residual deformity.
There is evidence to suggest that tummy time for 10–15 minutes at least three times per day reduces the development of plagiocephaly, and that children with torticollis as well as plagiocephaly should be treated by a paediatric physiotherapist.
While there are several studies that compare helmet therapy to active repositioning many of them do not compare similar groups, or do not assess the children over a long period of time. This may give a biased or misleading representation of the benefits of helmet therapy. Helmet therapy remains a time consuming and expensive method to treat plagiocephaly and should be reserved only for children with severe deformation who are older than six months old and who have had little or no improvement with other strategies.
What about the SIDS Safe to Sleep campaign?
Since the introduction of the Safe to Sleep (formerly Back to Sleep) campaign, there has been a significant reduction (up to 40 per cent) in the rate of sudden infant death syndrome (SIDS). There has, however, also been a concurrent increase in the incidence of plagiocephaly. We expect that this is related to an increased amount of time that infants are spending on their backs. It is very important to remember that the management of plagiocephaly should never contradict the SIDS guidelines, so all infants should sleep on their backs, without any devices in the bed or under the mattress.
What can I do at home?
Tummy time is safe to start from birth and helps your baby develop strong muscles. It is normal for a baby to be unsettled with tummy time as, initially, it is quite difficult. Babies get better at tummy time with practice, so start with one or two minutes at a time, several times per day—by four months of age, your baby should be able to manage 10–15 minutes at least three times per day.
Ways to make tummy time easier include: putting your baby on their tummy on your chest when you are sitting or reclined, so that they can see your face (a good introduction to tummy time); using a rolled-up towel under their chest and armpits to help support young infants; carrying your baby on their tummy over your arm to get them used to the position; using a rug on the floor, a firm mattress for tummy time or other suitable surface that is not too soft; and getting down on the floor to play with your baby, using your voice, facial expressions and toys. Always supervise your baby’s tummy time.
Put your baby to sleep at alternate ends of the cot (always with their feet at the bottom of the cot) or change the position of the cot in the room. Ensure your baby is put to sleep in a SIDS-safe way. This includes always sleeping on their backs, with their head and face uncovered and feet at the bottom of the cot (either with firmly tucked blankets or a safe sleeping bag).
Try alternating your baby’s position during the day by carrying them in different positions, spending time in their bouncer or supported sitting on your lap.
For more information, go to the SIDS website.
How long until I notice a change in my child?
As your child spends more time on their tummy and becomes more independently mobile, by crawling and walking around, their head shape will also improve. You will notice the biggest change in your child’s head shape in the first 12–24 months when their head is growing most rapidly, however, their head will continue to change shape at a slower rate after this. It is important to remember to always put your baby to sleep on their back and maximise their tummy time during the day when they are supervised. If you think your child might have plagiocephaly, please make sure you see your M&CHN, GP or paediatric physiotherapist for an assessment. For more information on plagiocephaly, go to the Royal Children's Hospital website.