A flat spot on an infant’s head, medically referred to as positional head flattening, is common because a baby’s skull bones are soft and malleable during the first few months of life. The two main types are plagiocephaly, an asymmetric flattening on one side, and brachycephaly, a central flattening across the back of the head. This article focuses on strategies to encourage a more rounded head shape without resorting to a cranial helmet by relieving pressure on the flattened area and encouraging the skull’s natural growth process.
Understanding Positional Head Flattening
Positional head flattening results from external pressure applied to the same area of the soft, rapidly growing infant skull. Its prevalence increased significantly following the successful “Back to Sleep” public health campaign, which instructs parents to place infants on their backs for sleep to reduce the risk of Sudden Infant Death Syndrome (SIDS). While this practice is life-saving, the extended time spent on the back contributes to the flattening. Positional plagiocephaly and brachycephaly are generally considered cosmetic conditions and do not affect brain development or neurological function. The skull is flexible, reaching about 85% of its adult size within the first year, providing a significant window for conservative reshaping.
Active Repositioning Techniques
Tummy Time and Sleep Positioning
The most effective non-helmet strategy involves consistently repositioning the infant to alleviate pressure on the flat area throughout the day. Supervised Tummy Time is the most effective intervention, as it completely removes pressure from the back of the head while strengthening neck and upper body muscles. Parents should aim for at least 30 to 60 minutes of Tummy Time daily, broken up into short, frequent sessions starting from the first few weeks of life. During sleep, always place the baby on their back, but strategically change the crib environment to encourage turning the head away from the flattened side. For example, if the flattening is on the right, place the baby so they must turn their head to the left to look at the doorway or a mobile.
Varying Holding Positions
Parents should utilize “holding therapy” by varying carrying positions to keep pressure off the flat spot. When feeding or carrying, consistently switch the arm used to hold the baby, which encourages them to turn their head in the non-favored direction. Reducing the amount of time an infant spends in stationary devices like car seats, swings, and bouncers is important, as these items place pressure on the back of the skull. Minimizing their use is beneficial when the child is awake and not traveling.
Addressing Underlying Muscle Tightness
A common factor contributing to positional flattening is congenital muscular torticollis, where the sternocleidomastoid neck muscle is tight or shortened. This tightness causes the baby to consistently favor turning their head to one side and tilting it toward the opposite shoulder, resulting in pressure on that preferred side. Addressing this underlying muscle imbalance is often necessary.
Gentle, parent-guided neck exercises help increase the baby’s range of motion and strengthen the weaker opposing muscles. Specific stretches include neck rotation, where the head is gently turned so the chin moves toward the shoulder opposite the tight muscle. The lateral neck tilt involves gently moving the ear toward the shoulder on the side opposite the muscle tightness.
The “football hold,” where the baby is carried face-down over an arm, can also encourage a gentle stretch of the tight neck muscles. Parents should consult a pediatrician or pediatric physical therapist before beginning any stretching routine to ensure the exercises are performed correctly and safely. Early physical therapy intervention for torticollis is most effective, often providing the best results when started before two months of age.
Recognizing When Medical Consultation is Necessary
Repositioning techniques are successful, especially when started early, and are generally most effective before the infant reaches six months of age, when the skull is growing rapidly. Parents should seek a medical consultation if conservative repositioning does not result in noticeable improvement by this age, as the window for non-helmet correction narrows significantly after six months. Medical evaluation is necessary to rule out craniosynostosis, a rare but serious condition where the skull sutures fuse prematurely.
Craniosynostosis is different from positional flattening because it can impede brain growth and often requires surgical intervention. Signs that require immediate medical evaluation include the presence of a hard ridge along a suture line, an abnormally shaped head present at birth that worsens over time, or a disproportionate growth pattern.
A pediatrician can assess the severity of the flattening and provide a referral to a specialist, such as a craniofacial surgeon or pediatric neurosurgeon, for definitive diagnosis and to discuss treatment options, including helmet therapy if necessary.