Plagiocephaly (flat head syndrome)
What is plagiocephaly?
Positional plagiocephaly occurs when a baby's head develops a flat spot or becomes asymmetrical due to some kind of external pressure. Many babies are born with an abnormally shaped head as a result of the pressure exerted on them during birth, but most babies' heads will correct themselves within about six weeks.
If your baby's head remains asymmetrical beyond age 6 weeks, or if you start to notice a flat area after 6 weeks of age, you'll want to see your baby's doctor for referral to a specialist. (Babies with severe plagiocephaly may also have prominent foreheads, misaligned ears, and uneven facial features.)
Positional plagiocephaly is similar to and often mistaken for craniosynostosis, a more serious congenital condition in which one or more joints between the bones of the skull close up too early and the baby's head becomes deformed.
What causes plagiocephaly?
Another increasingly common reason that some babies develop a flat spot is that they spend so much time on their back. Starting in the early '90s, parents were told to put their babies to sleep on their back to reduce the risk of SIDS. While this advice may have saved thousands of babies' lives, experts have also noted a fivefold increase in the incidence of misshapen heads since then, says Michael Edwards, a pediatric neurosurgeon in Sacramento, California.
Babies are born with a soft, pliable skull, and when they sleep on their back every night, their head can develop a flat spot where it presses against the mattress. This happens most often in infants who are born with a common form of torticollis, a condition in which a tight or shortened muscle on one side of the neck causes the head to tilt to one side. Premature babies are particularly at risk. (See below for tips on repositioning your baby to avoid both SIDS and plagiocephaly.)
A baby may also develop an abnormally shaped head if development in the womb is constricted somehow. This can happen when there's more than one fetus, if the mother's uterus or pelvis is especially small, or if there's too much or too little amniotic fluid. It can also happen to a breech baby whose head gets wedged under the mother's ribs.
What should I do if my baby's head seems to be developing a flat spot?
In many cases, even a serious-looking flat area will round out on its own as a baby starts crawling and sitting up (especially if you follow our repositioning tips below). But to be safe, it's a good idea to insist on a referral to a pediatric neurosurgeon or craniofacial specialist as soon as you notice the flattening.
A specialist should be able to tell whether your baby's situation is severe enough to warrant treatment and what your options are. Get the referral and make an appointment right away because you may still have to wait weeks or even months to see a specialist for a diagnosis, and the earlier you catch a severe case, the easier it will be to correct.
What's involved in getting a diagnosis?
In most cases, the specialist will need only an X-ray to distinguish plagiocephaly from craniosynostosis (which requires a different treatment). But some doctors may also recommend a special kind of CT scan.
In certain cases, a very experienced specialist may be able to tell just by looking at your baby's head what's causing the deformity. He will want to know whether your baby was born with the flat area or whether it developed several weeks after birth. If you can't remember when you first noticed the flattening, go back and carefully examine any pictures you have of your newborn.
If the doctor determines that your baby has plagiocephaly, he'll most likely recommend repositional therapy first — that is, ways you can reposition your child to avoid putting pressure on the flattened areas. This kind of therapy is most likely to be successful if you try it before your baby reaches 6 months of age. After that it's much harder to control the position your baby sleeps in.
If repositional therapy doesn't correct the problem, your doctor may recommend cranial orthotic therapy, a band (or sometimes a helmet) custom molded to fit your child's skull. (Reconstructive surgery is no longer recommended except in the most severe cases or in the case of craniosynostosis.)
If your baby has torticollis, he'll have to have physical therapy as well to treat this condition.
What does repositional therapy involve?
If your baby's case isn't severe, your practitioner will probably tell you to try several things at home to help your baby's head round out. First, try to make sure your child spends plenty of time on his tummy (while supervised and awake) during the day to strengthen his neck muscles.
You may start out trying this for only a minute or two at a time. Stronger neck muscles will allow him to move his head around more during sleep, so that it doesn't always rest in the same position.
Your baby's doctor may also recommend alternating your baby's sleeping position from back to side. You can keep him from rolling onto the side where the flattening is by placing a rolled-up towel or blanket behind his head or by placing crib toys on the opposite side of the flat area to entice him to look in that direction.
You might also try putting him down to sleep in his crib with his head pointing in the opposite-from-usual direction. He'll want to look out into the room and will probably flip his head over to do so, giving the flat side of his head a break from the mattress.
Also be sure to alternate his position from one side to the other when bottle- or breastfeeding.
Finally, try to be aware of how much time your baby spends in a car seat, stroller, infant carrier, bouncy seat, or infant swing in which he may be leaning back and putting pressure on his flat spot. Make sure you take him out of these devices for a good part of each day and hold him and give him plenty of tummy time instead.
What does cranial orthotic therapy involve?
If your baby's plagiocephaly is severe, he'll probably have to wear a special custom-fitted headband (called a cranial orthotic) for 23 or 24 hours a day to correct the shape of his skull. This treatment generally lasts from two to six months, depending on how early you start and how severe the problem is.
This therapy is most successful when started before the age of 6 months. Some experts think the headgear offers little help after 10 months, but others say it can be used as late as 18 months.
Your doctor can tell you where you can get a band made. You'll probably want to research the comparative success rates of several devices before you choose one. Once you do, they'll need to take a casting (or a scan) of your child's head to custom-fit the device.
While casting isn't fun for a baby, it's painless and takes only a few minutes. As frightening as the headgear may sound and look, it's lightweight and most babies are not bothered by it or quickly get used to it.
Treatment can cost up to $3,000. Some insurance companies will cover it under their orthotic benefits, but others consider it cosmetic or investigational and won't pay for it. However, many parents have successfully appealed their insurance company's rejection and received payment in the end.
The success rates for this kind of therapy are high when it's started early. If you're starting treatment late, you should know that your baby's skull may not become perfectly symmetrical again, but you can take heart that when your child's hair grows in fully, it will most likely hide any remaining flatness.
Where can I get more information?
Two websites that offer information about this condition, lists of specialists, and access to support groups are Plagiocephaly Information Web and CAPPS (Craniosynostosis and Positional Plagiocephaly Support).
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