Plagiocephaly: Adorable Babies with Flat Heads!
If you are around babies with any regular frequency, the chances are high that you have seen a baby wearing a helmet. It is probable that the child looked ridiculously adorable, and perhaps their helmet was even decorated to showcase their (or their parents’!) favorite things.
You may have wondered what sort of condition or problem that child has.
It is very likely that the child has Plagiocephaly, which is simply the medical term for flattening of the head. Sometimes this flattening is straight across the back of Baby’s head (brachycephaly), and sometimes it is more on one side (left or right) than the other (deformational plagiocephaly).
What causes this flat spot, and why are we seeing more babies in helmets these days?
The cause of the flat spot is often positional in nature. Whether in-utero or after Baby is born, Baby was positioned very often in a way where that flat spot was down along the surface. The more time the head remains in the flat spot, the more flat it becomes. Think of the baby’s head as a pumpkin growing in a field: the spot on the ground remains flat while the rest of the head grows out in a round fashion around it. Other causes of plagiocephaly include: small maternal pelvis, large fetus, multiple fetuses, prolonged labor, use of forceps/suction at delivery, time spent in the NICU, and torticollis, or asymmetrical tightness and weakness of the neck muscles.
A big reason we are seeing a higher prevalence of babies in helmets is the ‘Back to Sleep Campaign.’ The Back to Sleep Campaign began in the 1990s as a way to reduce the incidence of SIDS, or Sudden Infant Death Syndrome. Parents in the US (and some other countries) are now instructed to lay their baby to sleep on their back at all times and to only allow the baby to sleep on their belly or side once they roll themselves into that position independently. Not all countries promote this teaching. While the Back to Sleep Campaign has (very importantly!) helped to reduce the incidence of SIDS, it has also brought about more cases of plagiocephaly, torticollis (tightness at neck muscles), dislike of Tummy Time, and delayed gross motor development.
Another reason for the higher numbers of babies with plagiocephaly is increased access to various types of infant ‘equipment’ and general misconception that all of these ‘containers’ are necessary/important for baby. Strategic marketing from these equipment companies does not help—especially as it is aimed at new parents who are desperate for a calm/content/sleeping baby!
You may wonder to yourself, ‘How will that baby do over time?’
In the medical world, we call this the baby’s prognosis. The great news is that prognosis of plagiocephaly is good; it is almost always just a cosmetic concern and does not result in any problem with the baby’s brain or development. In severe cases, an atypical head shape due to plagiocephaly could lead to future difficulties with the child wearing eyeglasses or a bike/baseball helmet.
If you see a significant asymmetry with your baby’s head shape, it is important to talk with your primary care doctor or physical therapist about it. In some presentations, it is important to rule out a more severe condition called craniosynostosis: the premature closing of sutures between skull bones. There can be 1 or more sutures that prematurely close. It is sometimes associated with a genetic syndrome but can often be seen alone. Depending on the type of craniosynostosis, treatment may involve surgery. Signs and severity depend on how many sutures are involved and at what age the premature closing happened. Locally, many children who have or may have this condition are referred to the Craniofacial Clinic at Children’s.
The million dollar question is this: How can we prevent and treat plagiocephaly?
Well, here are some ideas, from the least involved intervention to the most involved, in how you can help your baby:
Positioning strategies while baby is awake and asleep
Position baby so that their flattened side is AWAY from the activity in the room (ie encouraging head turn in the direction opposite of their preferred way)
When bottle feeding baby, sometimes hold baby in your left arm and sometimes in your right arm.
When you lay baby down in their crib/bassinet to sleep, switch head of bed frequently—and/or position baby so that they must look AWAY from flattened side to see toward parents/door.
Limited use of baby equipment
Floor time is best when awake/active/playing! If you are worried about older kids or a pet, consider temporarily bringing a Pack N Play into your living space. When baby is awake and supervised, experiment with sometimes having them on their back, belly, or side.
Try to decrease time spent in a baby swing/bouncy seat/car seat (except when in the car, of course). Of course you will need to use these items occasionally. Try to limit to 15 minutes or so, just a few times per day.
Once your baby is old/heavy enough to use a baby wrap/carrier, that is a great option for where to put baby at times throughout the day.
Once baby has good head control and is likely 4-6 months old, use of the Boppy, Bumbo seat, Fisher Price ‘Sit-Me-Up,’ ‘Upseat’ floor seat, or similar is fine. Most babies still only tolerate 15-20 minutes or so at a time, but these options are better for helping head shape than swings or reclined bouncy seats.
FYI—when baby is older, try to also limit the amount of time they spend in a stand-up bouncer (doorway jumper, Exersaucer, etc). I still say to shoot for a max of 15 minutes at a time, just a few times per day. I encourage parents to wait until baby is rolling, sitting, and starting to move forward in Tummy Time/quadruped before trying these bouncers. Frequent/prolonged use can result in toe-walking as the child gets older.
Frequent Tummy Time—from day 1
Tummy Time can occur in a variety of ways: on the floor, over a towel roll, over a Boppy, in parent’s arms, across parent’s lap, on parent’s chest, on a therapy ball…
Aim for your baby completing 60-90 minutes of Tummy Time (while awake and supervised) per day by the time they are 4 months old.
Try to incorporate at least one session of Tummy Time for each hour your child is awake during the day.
It is normal for baby to only tolerate 2-3 minutes at a time to start—and then you’ll work your way up from there!
Stretching (especially if child also has tight neck muscles or ‘torticollis’)
Strengthening exercises (especially if child also has tight neck muscles or ‘torticollis’)
Evaluation and Treatment by Physical therapy, Occupational Therapy, and/or Chiropractor
‘Tortle’ hat or other positioning pillows/devices
Please read directions and/or consult with your pediatrician about recommended use.
‘Cranial Orthosis’—otherwise known as a helmet.
Considered for a child over 4-5 months of age. Worn 23 hours per day. Typically worn for 2 – 3 months.
At your medical provider’s office, the severity of your baby’s plagiocephaly may be measured. We look for numbers such as the Cranial Vault Asymmetry Index (CVAI) and the Cephalic Index (CI) and can then use those numbers to determine if your child would benefit from a helmet.
As you may have inferred from above, though, the vast majority of children who have plagiocephaly can do very well without a helmet. More conservative measures, such as positioning and stretching, are often highly effective treatment strategies, particularly in a very young baby.
If you have a young baby and have any concerns about the shape of their head, please ask your pediatrician about it, and when in doubt, consult with a pediatric physical therapist or occupational therapist who treats this condition frequently.
And most of all, remember that you are an amazing parent, and if you do end up needing a helmet for Baby, you will all do just beautifully!
All my best,
Lizzie
