Introduction

Did you know that up to 50% of babies are affected by flat head syndrome? This information comes from a study by the American Academy of Family Physicians.

Plagiocephaly occurs when one side of a baby's head becomes flat due to extended pressure on that area. This usually happens within the first few months after birth and is largely influenced by the baby's head position. As more babies are being affected, new treatments have become available.

Studies show that educating parents on proper positioning and care can help prevent it. If plagiocephaly is detected early, especially in cases involving congenital muscular torticollis, physical therapy can help correct it. It's also important to avoid having the baby’s head rest constantly on the flat side and to give them time to lie on their stomach. For severe cases, helmet therapy is often suggested.

Learn more about the causes, risk factors, and how physical therapy can play a role in treating plagiocephaly. Continue reading to ensure you’re well informed about your child’s healthy development.

Causes of plagiocephaly

Plagiocephaly often occurs when a baby consistently sleeps in one position. Research indicates that around 20 to 25% of babies who sleep on their backs develop some form of plagiocephaly. Other factors contributing to plagiocephaly include:²

Position in the womb 

Babies from multiple pregnancies, those in smaller uteruses, or with low levels of amniotic fluid may have a higher risk of plagiocephaly. The birthing process can also temporarily reshape the baby's skull, known as skull moulding, which usually resolves within the first week of life.

Prematurity 

Many premature babies spend prolonged periods in fixed positions in the neonatal intensive care unit (NICU), increasing their risk of plagiocephaly. Some NICUs now use cranial moulding cups to prevent plagiocephaly.

Muscular torticollis 

This condition involves the shortening or tightening of neck muscles on one side, causing the head to tilt in that direction.

Risk factors

Risk factors for developing plagiocephaly include:³

• Assisted delivery with forceps or vacuum extraction
• Being the first-born or male
• Sleeping in the supine position (on the back)
• Limited neck rotation
• Low level of physical activity
• Lack of tummy time (time spent on the belly while awake)
• High association with congenital muscular torticollis, where the baby holds the neck and head in a preferred position for a prolonged period 

Types of plagiocephaly

Positional plagiocephaly, also known as deformational plagiocephaly, is the most frequent form of this condition. Other types include:⁴

• Brachycephaly: This variation results in a flattened appearance at the back of the baby's head, making it appear shorter and wider
• Scaphocephaly: This type leads to a long and narrow shape of the baby's head. It's often seen in premature babies who spend time in the neonatal intensive care unit (NICU)
• Craniosynostosis: Also referred to as congenital plagiocephaly, this is a rare and serious birth defect. It occurs when the fibrous joints between the bones of the baby's skull prematurely close, causing a deformity

Symptoms

Plagiocephaly is characterised by:

• The flattened appearance of the baby's head
• Bump on the back of the head
• Asymmetrical ears or forehead

Although it doesn't hurt or change how a baby acts or does things, these symptoms can cause less hair growth on the flattened area and lead to facial asymmetry.⁴

Diagnosis and assessment

Plagiocephaly is usually diagnosed through physical examinations, with skull radiography used to detect craniosynostosis. Additional tests like ultrasound or MRI may be done for confirmation. Mild to moderate asymmetry is defined by a 9–12 mm difference, while severe asymmetry is >12 mm. The cranial vault asymmetry index determines severity, with an index >3.5 indicating severe asymmetry.¹

Assessing plagiocephaly severity involves using a diagonal calliper to measure differences in head lengths. However, errors may occur due to scalp or hair interference. Imaging helps reduce such errors. 

Treatment of plagiocephaly

According to Stanford Medicine, children with this condition often improve a lot with simple treatments such as:

• Changing how they sleep
• Spending more time on their tummy when they're awake
• Doing exercises to move their neck freely

If repositioning and other treatments don't help, the Plagio team might suggest a special helmet for moderate to severe cases. These helmets are designed to improve your baby's uneven head shape and are typically worn for 2-3 months for the best results. A rehabilitation specialist will assess your baby's head and decide if the helmet is needed.

Note: To prevent plagiocephaly, always put your baby to sleep on their back, which is the safest position. During awake times, encourage "tummy time" and allow your baby to play and move while on their tummy multiple times a day.⁵

Role of physical therapy

Physical therapy for flat head syndrome usually includes exercises that make the neck muscles stronger and help the baby move better.⁶

Stretching exercises help make the neck muscles:⁷ 

• More flexible
• Improve posture
• Stronger
• Help fix the baby's head position

These exercises are often done in a fun way, so both parents and babies enjoy them.

In a study, researchers looked at how physical therapy alone could help improve skull shape in 24 babies with non-synostotic plagiocephaly (caused by an external force). They designed a therapy program involving exercises and manipulations to reduce skull deformity.⁶

After 16 sessions, over four months, they found that all babies showed improvement in skull measurements, especially younger ones and those with more severe cases. This suggests that physical therapy could help treat plagiocephaly.⁶

Other treatment options

Plagiocephaly can be treated in different ways, either with surgery or without surgery. If plagiocephaly happens along with craniosynostosis, surgery is often needed. However, if it's just positional plagiocephaly without craniosynostosis, non-surgical treatments are used.

Non-surgical treatments include: 

• Changing positions
• Physiotherapy
• Massage therapy
• Helmet therapy

These treatments work well, especially when started early because babies' skulls are still flexible.¹

Prognosis

Flathead syndrome gets better over time as babies grow. As they become more active during sleep and start sitting up on their own, the flat spot usually won't get worse. As the skull grows and hair fills in, even severe flattening improves, and the flat spot becomes less noticeable.

Flat head syndrome doesn't harm a baby's brain growth, but it can cause a stiff neck, which might slow down their development. Physical therapy for neck stiffness should include regular checks on the baby's progress and extra exercises to help with any delays.⁸

Parent education

Here are some easy ways to prevent flat head syndrome and encourage your baby's head shape to develop evenly, as a parent:

• Give your baby plenty of "tummy time" when they're awake. This helps them strengthen their neck muscles and prevents pressure on the back of their head
• Always put your baby to sleep on their back to reduce the risk of Sudden Infant Death Syndrome (SIDS). Alternate the direction their head faces in the crib on different days to avoid constant pressure on one side
• If you notice a flat area developing on your baby's head, encourage them to look in different directions by placing interesting things on the opposite side. You can also change the position of their crib or high chair to encourage them to turn their head away from the flat spot
• Limit the amount of time your baby spends in car seats, swings, or bouncy seats, as these can put pressure on the back of their head. Instead, hold them in an infant carrier or let them have tummy time on a soft blanket when they're awake⁹

FAQs

How can physical therapy help with plagiocephaly?

Physical therapy for plagiocephaly focuses on exercises and activities to improve neck muscle strength, range of motion, and head positioning, promoting symmetrical skull growth.

When should physical therapy be considered for plagiocephaly?

Physical therapy is recommended if conservative measures such as repositioning and tummy time do not improve the condition. It is often initiated in infants diagnosed with plagiocephaly and associated conditions like torticollis.

How long does physical therapy for plagiocephaly last?

The duration of physical therapy varies depending on the severity of the condition and the individual's response to treatment. It may involve several sessions over weeks or months.

Can physical therapy prevent the need for helmet therapy or surgery?

In many cases, physical therapy can help improve plagiocephaly and may reduce the need for more invasive interventions like helmet therapy or surgery, especially when initiated early.

How can I find a paediatric physical therapist for my baby's plagiocephaly?

You can consult with your paediatrician or healthcare provider for a referral to a paediatric physical therapist experienced in treating plagiocephaly and related conditions.

Summary

• Plagiocephaly, or flat head syndrome, is a common condition among infants that can often be effectively managed with physical therapy interventions
• Addressing underlying factors such as neck muscle tightness and promoting proper head positioning and movement with physical therapy can promote optimal skull growth and symmetry
• Early identification and intervention are key to maximising treatment outcomes and minimising the need for more invasive measures such as helmet therapy or surgery
• With the guidance of qualified paediatric physical therapists and collaboration with healthcare providers, parents can take proactive steps to address plagiocephaly and support their child's healthy development