“Flat head syndrome” (Plagiocephaly)

Definition: plagiocephaly comes from the Greek word “plagio”, meaning oblique and “cephaly” referring to the skull.

The baby’s skull is made up of bones that have not yet fused, allowing the skull to grow as the brain grows. This also makes it prone to changing shape where pressure is applied overtime.

Positional plagiocephaly occurs as a result of pressure from outside forces on the baby’s skull (such as sleeping on one side). This pressure leads to flattening on one side, which can cause a shift in the placement of other bones in the skull, leading to a change in head or face shape and appearance.

Nelson’s Textbook of Pediatrics, 20th Edition (page 2821)

It is much more common now, as a result of “back to sleep”, where doctors now recommend having babies sleep on their backs as part of safe sleep campaigns.

How common is it?

By 4 months of age, the incidence is 20%, which means that two out of every ten children will have plagiocephaly. Infants under 4 months of age cannot reposition their heads well, and so may sleep or lie down with their heads in the same direction every time. It is most commonly seen at this age, although it can be seen as early as 6 weeks old. It generally starts to get better around 6 months of age because of better head control.

What are some risk factors?

  • Sleeping on their backs with their head in the same direction each time.
  • Congenital torticollis, a condition where the muscle in one side of the neck is shortened and tighter, leading to difficulty in turning the head.

There are some other risk factors, as shown in the table below:

Nelson’s Textbook of Pediatrics, 20th edition (page 2819)

Can you prevent positional plagiocephaly?

Yes, there are things you can do to prevent it, and also to treat it should it occur! I have listed the prevention and treatment options.

  1. Alternate positions: whenever your baby is on his or her back, whether that is during play or sleep, try to get your baby to lie on both sides of their head. There are a few tips to help you achieve this, outlined below. The earlier you start this, the more time your baby will have to get used to it!
    • During sleep:
      • Change the direction they are sleeping in each time they go to sleep. Babies usually look toward a light source or into the room, so if you change the sleep position (i.e., their head at the head of the bed, alternating with their head being on the foot end of the bed), they will likely turn their head naturally.
      • If you are using a mobile, change the placement of the mobile.
    • During play:
      • You can use brightly coloured or toys that make light or noise to get your infant’s attention and get them to turn their head in different directions minimizing the time on one side.
    • Hold your baby in different ways during feeding, playing, or sleeping.
    • Supervised tummy time! 10-15 minutes at least three times a day, or as many times they would like. This would also help with development of gross motor skills like rolling and sitting up.
  2. Physiotherapy: useful for repositioning strategies. Also, if your baby has torticollis, physiotherapy will help release the tightening on the affected side, allowing your baby to move his or her head more freely in all directions.
  3. Helmet therapy: can be used in severe cases. As the skull is growing rapidly in the first few weeks of life, the purpose of the helmet is to help development occur symmetrically. The protects the areas that are flat while the child’s skull grows into the flat spot. Helmet therapy can speed up symmetrical development of the skull compared to repositioning alone. In Canada, according to the Canadian Paediatric Society, the maximum age to consider helmet therapy is 8 months. There is minimal benefit after 10 months of age (Zitelli and Davis’ Atlas of Pediatric Physical Diagnosis, 6th Edition, page 892). However, it can be expensive and needs to be worn essentially all day for many months. It can also cause irritation, discomfort and pressure sores.

Interesting fact: right-sided plagiocephaly is more common, which is thought to be due to mothers being right-handed and baby being in right side down position to nurse causing flattening of that side. (Zitelli and Davis’ Atlas of Pediatric Physical Diagnosis, 6th Edition, page 892).

In a nutshell, positional plagiocephaly is very common, as babies lie on their backs and do not have great head control until 4 months of age. The natural course of positional plagiocephaly is that it improves overtime. Prevention can be through repositioning therapy and physiotherapy. Treatment includes the same, and if the asymmetry in skull shape is severe, helmet therapy can be considered.

I would love to hear your experiences with positional plagiocephaly. Did you have helmet therapy? Did you choose not to? What are your thoughts?

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