'My baby's head has a flat spot'
4/29/2024 by Aaron Downs, M.D.
You're at home playing with your beautiful new baby. They're starting to smile. You've been doing tummy time, and today there hasn't been a single diaper blowout. All is right in the world. But then, as you stare at the top of their head, you notice that one side looks a little different than the other. Should you be worried? Is it nothing? What do you do?
Abnormal head shape, or plagiocephaly, is extremely common in newborns and infants. The vast majority of kids with abnormal head shapes will grow and develop a normally shaped head, though a small group may need further interventions. Most head shape differences are related to the positioning of the head against surfaces. Regardless, if you have any questions or concerns, you should talk to your child's clinician about your baby's head shape.
What causes a baby's head shape to change?
A baby's skull has soft, bony plates that haven't yet fused. The bony plates can move a bit, which helps the baby's head to pass through the birth canal. The plates also allow room for the brain to grow. These bones typically fuse when babies are about 1 year old.
Many things can cause a positional skull deformity:
- Preferred head position. Some babies like sitting or sleeping with their heads turned a certain way.
- Not enough tummy time. Tummy time is for babies who are awake and being watched. It helps babies master milestones like head lifting, turning over, sitting up and crawling.
- Torticollis. An estimated 85% of babies with torticollis, a condition where the neck muscles are tight or imbalanced, have a positional skull deformity. Infants who have torticollis also will need physical therapy.
- Twin or triplet. Cramped or unusual positions in the womb can lead to changes in head shape.
- Birth complications. The baby's position when moving through the birth canal can affect the head shape. Some other things that affect a baby's head shape at birth are using forceps, vacuum extraction or even a difficult labor.
- Abnormal fusion of skull plates. Occasionally plates of the skull can fuse early or abnormally, leading to differences in head shape. This effect is known as craniosynostosis.
But what if your baby has a positional skull deformity?
Thankfully, positional skull deformities DO NOT affect brain growth or intellectual development. It is typically a purely cosmetic issue. The majority do not require surgery.
What is the treatment?
The best treatment is to prevent a positional skull deformity. When it is found early, simple changes to your baby's position will help. For example:
- Avoid too much time in a car seat, bouncy seat, baby swing or other carrier.
- Increase tummy time. It is important to put babies on their backs to sleep. But babies need supervised time on their tummy to play during the day. Start with short spurts of time, at least 5 to 10 minutes, 3 to 4 times a day. Gradually work up to an hour per day in several short sessions.
- Switch or alternate arms when holding and feeding your baby.
Even with all these interventions, it's still possible that your baby can develop positional plagiocephaly. Your doctor can recommend further treatments such as physical therapy, evaluation by a head shape specialist, or you may be referred to a facility that does formal head shape measurements and helmeting.
Early intervention and therapy for positional skull deformity
- Physical therapy. The therapist will check your baby for delayed motor skills caused by poor head and neck control. They will also check for torticollis. You will learn stretching and positioning exercises to do with your baby. Depending on the severity, your baby may need weekly therapy.
- Helmet therapy. If your baby has moderate or severe head flattening that does not respond to treatment by 5 or 6 months of age, they may benefit from helmet therapy. Molding helmets work by re-shaping the baby's head. They are typically worn 23 hours a day for 3-6 months.
- Surgery should only be considered when all other options have been exhausted. In addition, surgery should only be considered after consulting with a neurosurgeon or pediatric plastic surgeon who specializes in these types of cases.
In short, differences in head shape are common. Even without treatment, mild to moderate differences in head shape typically resolve by 2 years of age, even without helmeting. However, if there are significant differences, it's worth talking to your primary care clinician. There are many interventions to help normalize your baby's head shape, from at-home exercises to helmeting.
Here are additional references to help you navigate head shape evaluation and management:
- When a Baby's Head is Misshapen: Positional Skull Deformities.
- New guidelines review evidence on PT, helmets for positional plagiocephaly.
- Guidelines for the Management of Patients with Positional Plagiocephaly.
Aaron Downs, M.D., is a resident in his second year at Mayo Clinic in Rochester, Minn. He loves spending time with his cat and dog, long walks on the beach and chocolate chip cookies. He is interested in Pediatric Epilepsy and Functional Neurologic Disorders.