Ask An Expert: Preventing Flat Head Syndrome and Torticollis with Dr. Lindsey Sandys, OTD, OTR/L

Dr. Lindsey Sandys, mom and owner of Koa Pediatric Therapy, lends us her expertise as an occupational therapist and a doctor of occupational therapy.

Tummy time, tummy time, tummy time. It’s short, catchy, alliterative, and every new parent’s life seems to revolve around it. Tummy time refers to the time that a newborn spends on their tummy, on the floor, while awake and supervised. It’s incredibly important for your baby’s development because it strengthens the muscles in their neck, shoulders, and trunk, and it’s the precursor to gross motor milestones, like rolling, sitting, crawling, and walking. 

Because babies aren’t born with the strength to hold up their head on their own, they need to work up to it by spending time on their belly. Many newborns find tummy time challenging at first, and it’s common for them to cry from discomfort. However, if you notice that your little one is struggling to turn their head to one side, they may be suffering from infant torticollis. Untreated, torticollis can lead to developmental asymmetries, as well as flat head syndrome.

What is torticollis? 

Torticollis is a fairly common condition in babies that happens when their neck muscles become tight, causing the baby’s head to tilt to one side and rotate in the opposite direction. This twisted movement can make it harder for the baby to turn their head fully to one side, limiting their range of motion and creating imbalances, which often leads to inefficient movement patterns.

This is most commonly seen in infants and can be caused by factors like limited space in the womb, a tricky delivery, or positioning during pregnancy (like being breech).  The good news is that it’s treatable with therapy and it doesn’t often lead to any long-term repercussions. 

What are the symptoms of torticollis? 

The symptoms of torticollis are often visible in a baby’s posture and movements. Parents may notice that their baby has a preference for looking in one direction or that the baby’s head tilts to one side, often with one ear closer to the shoulder than the other. They may also notice their baby consistently sleeps or sits with their head tilted to one side (mostly seen in their car seat) or struggles to rotate their head during feeding, tummy time or play.

Parents who are worried that their child may have torticollis should try to gently position their baby’s head facing opposite from their preferred side. If the baby struggles or is fussy, it may be an indicator that the baby should get looked at for torticollis.

What is flat head syndrome?

 “Flat head syndrome"  or positional plagiocephaly is when a baby develops a flat spot on one side or the back of their head due to prolonged pressure in one position. It typically occurs when the baby spends a lot of time lying on their back or preferred side, either during sleep or while awake, which can cause the skull to flatten in the areas that are in constant contact with the surface. 

This condition is most common in infants under 6 months old because the skull at this age is still very soft and malleable.Positional plagiocephaly can result in an uneven or asymmetrical head shape. The condition can be influenced by other factors like prematurity, limited movement in the womb, or muscular issues, such as torticollis. 

Even though “flat head syndrome” is the most widely known, there are other terms used to characterize certain types of abnormal head shape such as brachycephaly, which is when the skull is short and wide, and scaphocephaly, which is when the skull is longer than it is wide. 

How are torticollis and plagiocephaly diagnosed? 

Torticollis is typically diagnosed by a pediatrician during a routine checkup, usually around the 1-month or 2-month visit. A trained doctor or therapist can detect the condition by observing the baby's head posture and range of motion. Torticollis can sometimes be identified before birth, based on the baby’s positioning in the womb. While doctors are usually first to identify this issue, parents should ask their pediatrician to examine their baby further if they notice any of the typical signs, such as a head tilt or neck stiffness.

Plagiocephaly can be seen at home by looking at the height of their baby’s ears. In plagiocephaly, you may notice that one ear is closer to the face or positioned slightly forward compared to the other. Parents should speak with their child’s pediatrician if they notice this difference.

Are torticollis and flat head syndrome related? 

Yes, torticollis and flat head syndrome (plagiocephaly) are closely related. Babies with torticollis may have a preference for turning their head to one side, which can cause them to sleep or rest in a position that places pressure on the back of their skull. This constant pressure can lead to flat spots developing on the head, particularly at the back or sides. As torticollis affects neck mobility, babies with this condition are more likely to develop plagiocephaly.

Can these conditions go away on their own or do they always need treatment?

 Both infant torticollis and plagiocephaly often require intervention to resolve fully. In some cases, mild torticollis can resolve with oppositional changes. However, in most cases, therapy and exercises to stretch and strengthen the neck muscles are essential to resolve torticollis.

Similarly, plagiocephaly won’t automatically correct itself without changes in positioning, exercises, and potentially a helmet for more severe cases. Early intervention with professional therapy is essential for the best outcomes, and it could save the need for a helmet.

If left untreated, what are the consequences?

If torticollis and plagiocephaly aren’t addressed, they can lead to long-term challenges, such as a persistent head tilt, facial asymmetry, and limited neck mobility. Over time, the baby might also experience motor coordination issues, since imbalances in the head and neck can impact muscle development and movement skills.

For plagiocephaly, leaving it untreated can result in noticeable skull deformities that affect facial symmetry, eye alignment, and jaw positioning. In the long run, this can also lead to difficulties with feeding, sensory-motor skills, or even vision. Fortunately, early intervention can help prevent these complications and support your baby’s development!

Are torticollis and plagiocephaly preventable? 

While it’s not always possible to prevent torticollis or plagiocephaly (which means caregivers should give themselves some grace if either condition develops in their child), there are steps caregivers can take to reduce the risk. 

1. Tummy Time: Begin tummy time as soon as your baby is home from the hospital. To avoid irritating the umbilical cord, tummy time can be done on a caregiver’s chest for the first few days. Start with a gradual incline for tummy time and short, supervised sessions several times a day, then gradually increase the time as your baby grows stronger.
2. Invest in a safe play space: Having a safe space for your baby to move around on the floor is a secret key for development. When babies can naturally move around and explore how their body moves, the less likely they are to have the same amount of pressure on the back of the skull. A Toki mat provides a soft, comfortable place for them to practice tummy time, and the play mat grows with them as they hit milestone after milestone.
3. Avoid time on back: While it’s essential for babies to sleep on their back (to reduce the risk of SIDS), you should try to use alternate positions while the baby is awake. For example, you can encourage them to lie on their side while supervised, or explore baby wearing. Baby containers, like car seats, bouncers, and swings, should be used only for short periods of time to avoid putting constant pressure on the back of the head. Prioritize tummy time on a soft mat in their safe play space.
4. Encourage head and neck movement: Caregivers should look for opportunities to encourage their baby to turn their head and look in different directions. For example, place toys or other interesting objects just out of reach at different angles relative to your baby’s head.

By incorporating these tips into your baby's daily routine, you can help reduce the likelihood of developing positional plagiocephaly and support your baby’s head and neck development. However, if you’re concerned that you see flat spots developing, please don’t hesitate to reach out to your pediatrician to ask for further examination.

How does helmet therapy work?

Helmet therapy is a treatment used for plagiocephaly to help reshape a baby’s skull. It works by applying gentle pressure to the skull, encouraging the head to grow into a more symmetrical shape. The helmet is custom-made to fit the baby’s head and worn for most of the day, per the provider’s recommendation. However, traditional occupation therapy or physical therapy treatment should be the first line of defense for a flat head or torticollis. If therapists are brought into the treatment plan early enough, they may be able to offer exercises that will allow for your baby to avoid a helmet or reduce the length of time a helmet is needed.

Both torticollis and “flat head syndrome" are common conditions in infants, but they are treatable with early intervention. If you notice any signs of head tilt or flat spots on your baby’s head, don’t hesitate to consult your pediatrician. With appropriate treatment, such as occupational or physical therapy, adjustments to positioning, and sometimes a helmet, most babies can resolve the flat spot and alleviate a tilt. Early attention to these issues can prevent long-term complications, helping your baby grow with a healthy, symmetrical head and neck.

Dr. Lindsey Sandys OTD, OTR/L
Occupational Therapist
Owner of Koa Pediatric Therapy