Positional plagiocephaly and brachycephaly, known as “flat head syndrome,” involve the development of a flattened area on an infant’s skull. This condition is primarily a cosmetic concern that does not affect brain development or intellect. Positional skull flattening is highly preventable through simple, non-medical changes to your baby’s daily routine. This guide focuses on the mechanical reasons this flattening occurs and the specific strategies you can employ to relieve pressure and encourage a rounded head shape.
The Mechanics of Positional Skull Flattening
An infant’s skull is composed of several malleable plates separated by fibrous joints called sutures. This flexibility allows the head to pass through the birth canal and accommodates the rapid brain growth that occurs in the first year of life. Because the skull bones are soft, prolonged pressure on a single area can cause that spot to flatten over time.
The “Back to Sleep” public health campaign recommends placing infants on their backs to sleep to reduce the risk of Sudden Infant Death Syndrome (SIDS). An unintended consequence of this practice is the increased incidence of positional skull flattening, as infants spend more time resting the back of their head against a flat surface. This vulnerability is highest in the first few months, and the period before six months is the most important for prevention. If a flat spot develops, gravity causes the baby’s head to settle into that area, which can worsen the flattening.
Daily Strategies for Pressure Relief and Repositioning
The most effective way to prevent a flat spot is to relieve pressure on the back of the head throughout the day. This starts with supervised “Tummy Time.” Tummy Time should be introduced immediately, starting with short sessions of three to five minutes several times a day while the baby is awake. As your baby gets older, work toward accumulating 30 to 60 minutes of Tummy Time daily by the time they are three to four months old.
During sleep, always place your infant on their back. You can alter the direction their head faces within the crib or bassinet to encourage repositioning. If your baby prefers to look toward a window or sound source, change the crib’s orientation so they turn their head to the opposite side on alternate nights. This passive repositioning helps distribute pressure across different areas of the head while maintaining safe sleep practices.
Minimize the amount of time your baby spends in restrictive equipment that applies constant pressure to the back of the head. This includes car seats, swings, bouncers, and inclined sleepers when the baby is not actively being transported. Maximize awake holding time by carrying your baby upright against your shoulder or using a soft-structured baby carrier. These positions remove pressure from the skull and support neck muscle development.
When feeding or rocking your baby, switch the side you hold them on. This encourages them to turn their head equally in both directions. This practice helps strengthen the neck muscles symmetrically, preventing a preference for turning the head only to one side.
When to Consult a Pediatrician and Treatment Options
Most mild cases of positional flattening improve naturally with repositioning efforts and increased mobility, but some situations require a professional evaluation. Consult your pediatrician if you notice severe asymmetry, such as one ear appearing significantly further forward than the other, or if the forehead or cheek on one side seems to bulge. These signs may indicate the flattening is more pronounced or related to a secondary condition.
Congenital muscular torticollis is a tightness in the neck muscles that restricts the baby’s ability to turn their head equally in both directions. If your baby consistently holds their head tilted to one side or struggles to turn their head away from the flat spot, a medical assessment is necessary. Torticollis is often treated with a referral to a physical therapist who provides stretching and strengthening exercises.
For moderate to severe cases that do not improve with repositioning therapy by four to six months old, your doctor may recommend a consultation with a specialist. The specialist may prescribe a cranial orthosis, commonly known as helmet therapy. These custom-fitted helmets gently redirect the rapid growth of the baby’s skull into the flattened areas. Helmet therapy is a prescribed medical intervention and is most effective when started between four and eight months of age, while the skull is still rapidly growing.