Infant head shape (plagiocephaly)

--What is plagiocephaly?

Plagiocephaly is a term used to describe the shape of a baby’s head when it is not rounded but has a flat area at the back or side. (This is not the same as the commonly seen misshapen head from the birth process that usually settles in the first weeks). Plagiocephaly is suspected after 7-8 weeks when a flat spot has been noticed or has persisted. Suddenly noticing a flat spot at the back of the head is quite common and has been observed in up to 40% of infants aged 7-12 weeks. It is more common in boys, first-born children, twins/triplets and babies born prematurely. It is also more common in children that have larger heads in proportion to length, because it is harder for them to move it themselves. Sometimes the flattening is quite even across the back of the head, which is called ‘brachycephaly’.

Plagiocephaly occurs because at first, babies’ heads are heavy, and the skull bones are flexible to allow rapid growth of the brain. It is known babies often will turn their heads one way, or rest in the same position. This position can be in the cot, pram, carry seats, or baby bouncers. If baby gets into a favoured position, it can be difficult for them to change it themselves, and sometimes the flat area will further develop (or become more noticeable) because they are not yet strong enough to move or control the head by themselves against gravity.

Occasionally, plagiocephaly can be associated with tight neck muscles (called torticollis) and for this it is important to seek professional advice from your paediatric physiotherapist, Maternal Child Health Nurse (MCH) and/or General Practitioner (GP).

--Does plagiocephaly cause problems?

Most commonly, plagiocephaly and brachycephaly do not appear to affect the development of the brain. Often it is the appearance and the effect on the shape of baby’s face that causes most concern. “Remodelling” of the child’s head shape will continue at a slower rate until the final head shape is reached at around the age of 5 or 6 years old.

Children with more severe plagiocephaly/brachycephaly are more likely to retain some asymmetry or flattening in their head shape. In severe cases a baby could be referred for a remodelling helmet. It is estimated that 60–70 per cent of infants with a misshapen head will revert to ‘normal’ by four years of age, with the most dramatic improvements over the first year of life when the head is growing most rapidly.

While there is a likelihood that most cases of plagiocephaly will resolve, is also important to remember that the brain needs movement experience to grow. It is ideal for babies to be able to move their heads and bodies symmetrically in all directions and by 4-6 months be strong to hold the head themselves including turning each way, holding the head when pulled forward to sitting, and holding it up when on the tummy. Plagiocephaly has been shown to be a link to slower movement development and this may be due to lack of early movement experience.

--How can I tell my child has, or is developing, plagiocephaly?

If your child has plagiocephaly, you may notice a flat spot on the back of your child’s head (usually off to one side) or some facial asymmetry. If you look down at your baby’s head from above, you may notice that one of their ears, or their forehead, may be more forward than the other. These can be signs of plagiocephaly.

--How do I know if my child needs physiotherapy or other medical attention?

Paediatric physiotherapists can assess your child’s head shape to determine the severity of the plagiocephaly, as well as to check for the presence of tight neck muscles (torticollis). A paediatric physiotherapist can monitor your baby’s head growth, advise you on positions and ideas, and tailor an exercise program to help your baby learn to move their head themselves.

They will also assess your child for other concerns such as an early fusion of part of the skull (craniosynostosis) which occurs very rarely. Your MCH nurse and/or GP also monitor for these and might refer you to physiotherapy or a medical specialist.

--What can I do at home?

Ask your MCH nurse for the brochure from the Australian Physiotherapy Association “How to protect the head shape of your baby by encouraging head control” this introduces the concept of “face time” as well as “tummy time”.

"Face time"

Interacting with your baby face to face from birth when they are awake is very rewarding. You will notice that your baby will try to turn their head to your voice and if you are supporting the head and have eye contact, they will try to follow you turning their head side to side. Move slowly and wait for baby to try to move themselves. This interaction is an important early movement experience for babies called “face time” and can be done at nappy change time, in your arms or on a mat on the floor.

"Tummy time"

Tummy time is safe to start from birth, and at first this might be lying on your chest. The more you are lying flat, the more difficult it will be for baby to lift their heads against gravity, so start when you are sitting relatively upright. It can be quite difficult at first, so keep it short, and provide lots of support with your hands. Babies get better at tummy time with practice, and your physiotherapist can advise on different positions to try. Always supervise your baby’s tummy time.

"Safe sleeping"

Remember that is important that baby follows “Safe Sleeping”. It is important to always sleep babies on their back, no matter how severe their plagiocephaly to reduce the risk of sudden unexpected infant death syndrome (SUIDS). It is also recommended to alternate the direction that their head is facing for sleeping. See your Maternal Child Health nurse for further advice on sleep position. For further information see the Safe Sleeping (formerly Back to Sleep) information.

--How long until I notice a change in my child?

As your child gets stronger head control and spends more time looking around and, on their tummy, they will become more independently mobile, by crawling and walking around, so their head shape will also improve. You will notice the biggest change in your child’s head shape in the first 2-12 months when their head is growing most rapidly.

However, their head will continue to change shape at a slower rate after this. It is important to remember to always put your baby to sleep on their back but maximise their supervised awake face to face play (face time) and tummy time for short times during the day. If you think your child might have plagiocephaly, please make sure you see your MCH nurse, GP, or paediatric physiotherapist for an assessment.

--Links for more information

Australian Physiotherapy Association

1. Brochure: How to protect the head shape of your baby by encouraging head control”
2. Choose.physio: Torticollis 

The Royal Children’s Hospital Melbourne

1. Prevention “Baby’s head shape”
2. Information on Plagiocephaly