What you need to know about flat head syndrome—including how to treat it

Lots of babies have asymmetrical or pointy heads—and it’s totally normal. Newborns are born with fairly thin, flexible bony plates instead of hard skulls, which makes them all the easier to squueeeze through the birth canal. But a softer skull means your baby may end up with a flat spot on their head in the first few months of life, simply from the pressure of lying on a mattress, or in a car seat or baby swing.

That’s what Cloey Bradcliff* discovered at her son Henry’s* two-month checkup. “The paediatrician noticed Henry had a tendency to lean his head to the left, which can be a symptom of tight neck muscles from always keeping his head turned to the right when he was on his back. He also had a small flat spot on the right side of his head,” says the Toronto mom. She was surprised. “I had no idea that this was a thing.”

Plagiocephaly, or flat head syndrome as it’s commonly known, is when a baby’s head has a flat spot or is misshapen. The number of babies with the condition has soared in the past 15 years or so, because babies are put to sleep on their backs, which is the safest and only recommended sleeping position. A 2013 study in Calgary found that almost of half of babies between the ages of seven and 12 weeks had a flat spot. Flat head syndrome is not dangerous and doesn’t affect brain development, and as long as they're doing tummy time, most little ones grow out of it on their own by around six months, when they’re rolling over and starting to sit up.

But if they don’t grow out of it, they end up with a permanently misshapen head, so some simple early intervention is the route that many families take. “I tell parents that this is super-common and it’s very fixable, especially if we catch it early,” says Jennifer Halfin, a paediatric physiotherapist in Toronto.

Here’s what you need to know about flat head syndrome.

What are the signs of flat head syndrome?

Either your doctor will notice your baby’s flat head at one of your regular well child visits or you might recognize some of the common symptoms. Halfin sees babies as young as five weeks old for an assessment, although she usually first sees them around the two- to four-month mark.

There are three types of flat head syndrome. The most common is positional plagiocephaly, which means there is a flat spot on the left or right side of the head because the baby keeps their head turned to that side. One ear may be further forward than the other; one eye may appear smaller than the other; and one cheek may be fuller than the other.

Brachycephaly means there is a flat spot at the back of the baby’s head. The head may be wider or taller than usual, and the tips of the ears may stick out.

Finally, positional scaphocephaly is a flattening of both sides of the head. This is quite common in babies who are in the NICU and spend time lying on their side. It can also be caused by the early fusion of the plates of the skull.

What causes flat head syndrome?

A few different situations can lead to flat head syndrome. In addition to being caused by the repeated pressure from a mattress or car seat on one side of the head, it can also develop during pregnancy if the baby is positioned in a way that puts pressure on their head (for example, if they’re pressed up against the pubic bone), or if you have multiples. It’s also common in preemies who spend a lot of time in the NICU lying on their back or side.

Some babies, like Henry, have tight neck muscles on one side, which is called torticollis, and that can contribute to a flat spot. Torticollis can develop during pregnancy or delivery, or the muscles may tighten simply because your stubborn kiddo prefers to keep their head to the left or right.

There are a few rare conditions that can cause an asymmetrical skull as well, such as scaphocephaly or craniosynostosis, where the skull’s bony plates start to harden and fuse together earlier than they ought to, so schedule a doctor’s appointment to assess the situation.

Treatments for flat head syndrome

If your baby has a flat spot, your doctor will refer you to a physiotherapist, or you can schedule an assessment with a physio yourself. Your doctor may also refer you to a neurosurgery clinic or craniofacial centre.

It typically takes about two to four months to get a rounded, more symmetrical head shape through physiotherapy. Your physiotherapist will not only give you some activities to do with your baby, but also suggest some simple lifestyle changes to treat the flat spot.

“It’s really important to figure out the underlying cause of plagiocephaly or brachycephaly and then use that information for treatment,” Halfin says.

A physiotherapist will do head measurements to see your baby’s current head shape and check your baby’s active and passive neck range of motion (for example, their ability to turn their head side-to-side on their own, and with gentle guidance).

Halfin’s biggest tip for parents is to take pictures once a week to check your baby’s progress. “Take a bird’s-eye view of your baby’s head, with your baby lying flat. Then use an app to make a little photo collage so you can notice changes from one week to the next, because it can be tough to see a difference when you see your baby all the time.”

To help Henry’s tight neck muscles, his physiotherapist showed his mom how to gently and safely stretch Henry's neck while he was lying on his back, which Bradcliff did daily at home. While she was a bit nervous at first—a baby’s head is terrifyingly wobbly—Henry is fortunately a mellow kid who didn’t fuss during the stretches.

One common treatment for flat head syndrome is lots of tummy time to get the pressure off the skull, which use muscles in different ways and develops baby’s neck strength so they can turn their head on their own. (Yes, babies often have a white-hot hate for tummy time, but it really is crucial!)

Halfin also goes over a baby’s home environment with parents. “Sometimes you don’t even realize that everything in your baby’s life is on, say, the left side of their world—if you walk into their room, they have to turn their head to left; if they’re in a car seat, you’re sitting on their left; they’re in a baby chair and you’re on their left. They develop a preference for one direction,” she says.

If that’s the case, it’s time to switch everything to the other side to get baby’s range of motion back—this can be as simple as moving the mobile to the other side of the crib. She may work with parents and babies to achieve motor-skill milestones—like rolling over—a tiny bit earlier, again to encourage movement and muscle development.

While these low-intervention approaches are usually enough to correct a mild flat spot, sometimes a doctor or physio will recommend an appointment with an orthotist to see if a custom-made cranial moulding helmet is required to help shape the skull. This generally happens around the four- to six-month mark if your baby’s plagiocephaly has gotten more severe, or if corrective progress isn’t happening as quickly as it could be. The helmet gently corrects the shape of the baby’s skull, giving space for the flat spot to grow properly as the brain grows, says Mike Hall, a certified orthotist at the prosthetics and orthotics department of the Ron Joyce Children’s Health Centre, which is part of McMaster Children's Hospital in Hamilton, Ont.

Hall says the best time to begin helmet treatment is when your baby has good head and neck control, which is usually around the four-month mark.

How to get a cranial helmet

An orthotist uses a handheld scanner to take digital measurements and create a 3-D model of the head, or sometimes creates a plaster or foam model of the head, from which a foam liner and a laminated or plastic shell is fabricated (which can feature cool patterns or colours). There are also companies that use a 3-D printer and more of a rigid headband style than a full helmet. 

Your baby will have to wear the helmet for 23 hours a day, for usually six months or more. One of the first questions parents ask is: “Will my baby hate wearing the helmet?” Hall's answer: “The kids are fine—I usually have more trouble with the parents!”

Every few weeks, an orthotist takes measurements to make sure growth is on track and the helmet isn’t irritating the skin. Your baby will likely continue physio if torticollis is present while they’re wearing the helmet.

Be aware that the helmets aren't cheap—around $2,000 to $3,000—and they generally aren’t covered by provincial health plans. Your private insurance company may pick up part or all of the cost though.

Can I prevent flat head syndrome?

Like many kid conditions, awareness is key. “The feedback I get from a lot of parents is: ‘I wish someone had told me about this right when my baby was born,’” says Halfin.

To help prevent flat head syndrome, gently turn your baby’s head from one side to the other every hour or so when they’re in the stroller or car seat, and change their position in the crib or bassinet (if baby’s head is at the top of the crib one day, switch to the foot of the crib the following day). Do 10 to 15 minutes of supervised tummy time three times a day. Halfin also encourages baby-wearing with a wrap or carrier to get the pressure off your baby’s head.

You can also ask your doctor or physiotherapist about special anti-flat head gear to be used during playtime, like a breathable pillow to help support the head, or a hat with a foam bar that stops baby from putting their head to one side all the time.

Henry’s now six and a half months old, and it only took about 10 weeks to get to the point where his head shape and neck movements were completely normal, his mom says.

“The combination of physio, stretches, regular tummy time and baby-wearing worked,” she says. “I’m glad they caught it early so we were able to take action.”

*Names have been changed

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