Ask an Expert: All About Flat Head Syndrome with Darcy Fass, PT, DPT

Darcy Fass, PT, DPT is a pediatric physical therapist and the founder and owner of Tips and Pediatricks, LLC. She has over 121k followers on her Instagram @tips_and_pediatricks, where she shares PT tips and information.

As parents and caregivers, we all know that babies need plenty of tummy time from birth to build up the head, neck, and trunk strength to be able to sit up, crawl, walk, etc. But, there’s another reason that tummy time plays such an important role in your baby’s development. Your baby’s skull is very soft at birth because the individual pieces of their skull aren’t fully fused until about 18 months of age. This allows them to squeeze through the birth canal, and also allows their brain to grow larger and larger at a fast rate in their first year of life. Since your baby should always be put to sleep on their back, and they do a lot of sleeping in those early months, it’s important that they spend plenty of awake time in different positions to avoid getting flat spots on their head. To learn all about flat head syndrome, we asked Darcy Fass, PT, DPT to share her expertise below.

Q: Is flat head syndrome exactly what it sounds like? Is it just when a baby’s head is flat?

DF: Flat head syndrome does basically mean that the baby’s head is flat, but the area that is flat is what further classifies the head shape. The baby’s skull is soft and will become flat in one spot if too much continuous pressure is on a certain part of the head. The most common type of flat head syndrome is known as plagiocephaly, which means that one side of the back of their head is more flat. Whereas, brachycephaly means that the entire back of their head is flat. There is also scaphocephaly, when the baby has a long and narrow head shape. Lastly, craniosynostosis is a rare birth skull abnormality where the cranial sutures close too early.

Q: Can a baby be born with flat head syndrome or is it something they develop after birth?

DF: Yes! A baby can be born with flat head syndrome due to their position in utero. Some babies are more at risk for flat heads developing in the womb, including multiples births, those developing in a small uterus or with other uterine anomalies, if they are experiencing low amniotic fluid, or if they are of a large fetal size.

Q: Is flat head syndrome common? What causes it?

DF: Flat head syndrome is actually pretty common these days. I feel that we saw a rapid increase in cases after the ‘Back to Sleep’ or ‘Safe to Sleep’ Campaign in the early 1990s. The main recommendation for this campaign was for babies to be placed on their backs to sleep to reduce the risk of SIDS (sudden infant death syndrome.) We know that this is the safest position for sleep, but [after the campaign] people often forgot the importance of supervised tummy time during wake windows that could help prevent flattening of babies’ skulls.

There are a few things that can cause flat head syndrome.
1. Uterine positioning (as mentioned above)
2. Lack of tummy time (too much time spent on the back of their heads)
3. Preference for looking one direction (which could lead to a condition called torticollis)
4. Too much time in containers (bouncers, swings, car seats, etc.)

Q: Are there any health complications that can occur with flat head syndrome? Is it bad for the baby?

DF: There is mixed research out there in terms of potential neurological effects or the effects that misshapen skulls can have on brains. Ultimately, these types of effects would only have potential to happen if it was extremely severe.

Although flattening of the head may not have severe neurological effects, flat head syndrome is NOT just cosmetic, although many believe it to be so. Flat heads can result in facial asymmetries (the back of the head flattening can then move that same side of your forehead forward) with subsequent visual deficits, jaw asymmetries/TMJ discomfort, and a helmet or glasses not fitting on your little one’s head or face properly.

Furthermore, torticollis is a super common diagnosis that will often go hand in hand with flat head syndrome. This is the development of tight neck muscles with a preference for your little one to rotate to one direction and tilt their head to the opposite direction, furthering the flattening of their skull. Torticollis can also lead to asymmetrical movement patterns and motor delays because it alters your little one’s visual attention with their environment and can also lead to more muscular tightness down into their spine/trunk, which can affect all of their extremities as well.

Q: How is flat head syndrome treated?

DF: It is treated slightly differently depending on the age of detection, but the main principles remain the same. If plagiocephaly/flat head syndrome is detected early (before 2 months old), typically, a repositioning program and working with physical therapy to work on muscular tightness can be very effective. It is important that we educate parents on a positioning program so that they understand how to prevent excessive pressure on the flat part of the head and how to modify tummy time positioning to make them more successful at this early age. Furthermore, if it is severe or detected later, helmet therapy may be more effective, in conjunction with the other interventions described above. This would be a supplement to physical therapy and repositioning and generally is not recommended unless the head shape is classified as severe or until the baby is at least approximately 4-6 months old.

Q: If my baby has a flat spot, how long will it take for treatment to correct it?

DF: So, this is completely dependent on the age of detection, how severe the flatness is, and if any other contributing factors or complications are identified. For example, if you identify flatness on your little one’s head in the first month of life and they aren’t significantly restricted in their neck range of motion, you can resolve it pretty quickly with a conservative repositioning program and maybe even the help of a pediatric physical therapist. However, if your little one is not identified until later on or if they have an underlying medical condition, this may take longer to address the subsequent conditions and to correct the flatness, potentially with a helmet.

Q: How do I know if my baby needs a helmet or if the flat spot can be treated with just physical therapy?

DF: Typically, the best thing for you to do would be to follow the recommendations of your pediatrician for referral to the appropriate specialty in your area to make this determination. There are different specialists for this in different regions of the country and of the world. Where I live, babies are referred to one of, or a combination of, the following specialists, such as an orthotist, neurosurgeon, or craniofacial specialist, to name a few. These specialists will be able to do appropriate digital head scanning and measurements to classify your little one’s head shape as mild, moderate, or severe. This will then lead to the most appropriate treatment recommendations to be made. Typically speaking, prior to 4 months, repositioning and physical therapy will be sufficient to start.

Between 4-6 months old, if the plagiocephaly is classified as severe, it may be time to initiate helmet therapy, along with the other conservative methods as well. If they are older than 6 months, most of the time both moderate and severe cases are recommended to initiate helmet therapy, in conjunction with physical therapy and repositioning. Ultimately, it is up to the parent to make the decision whether or not to move forward with the helmet therapy.

Q: After successful treatment, can flat head syndrome reoccur?

DF: If you have underlying muscular tightness, yes it can, to some degree, reoccur. Your little one’s head shape will continue to change up until close to 18 months, so their skull will continue to shape some. The most growth will happen in the first 6 months and then will begin to change less and less as they approach 18 months. However, once your little one is up and moving, flat head syndrome reoccurrence will become less of a concern because they will not be spending as much time on the back of their heads as before when they were in their first months of life. However, if your little one has a medical condition that causes motor delays, where they are dependent on someone else for positioning, this warrants more mindful and continual repositioning on the caregiver’s part.

Q: Is flat head syndrome preventable?

DF: Some cases of flat head syndrome can be prevented, to a degree, when parents understand the causes of it and how to prevent the excess pressure on the back of their heads. The key to prevention is to educate parents on tips for early, supervised tummy time during wake windows and how to be mindful if their little one is developing a preference for looking one way or the other, while providing subsequent strategies for repositioning. On the other hand, sometimes, flat head is not preventable, like in the cases of positioning in the womb, but it has the potential to be quickly treated if identified early and if it is not related to another skull deformity of condition. Bottom line, I don’t ever want a mama to feel that they did something wrong if their baby develops a flat head. Sometimes it is not related to anything that you did or didn’t do. The important thing is that; as soon as you identify it, seek intervention right away. Trust your gut.