Prevention and Correction of Flathead Syndrome

In 1992, to reduce the incidence of sudden infant death syndrome, the American Academy of Pediatrics recommended that all infants sleep on their backs to reduce the risk of suffocation. Positional plagiocephaly, or the positional flattening of the back of an infant’s head, has increased in frequency since the introduction of the “Back to Sleep” initiative. In assessing the risks and benefits of placing an infant on his or her back to sleep, the reversible consequence of a flattened head far outweighs the irreversible consequence of SIDS.

Infant skulls are very malleable as the bones of the skull have not yet fused together. This is necessary to allow for passage through the birth canal and to accommodate the rapid brain growth that occurs in utero and during the first year of life. The pliable skull bones can conform to the flat mattresses or infant swings that they might be in contact with for long periods of time. Lack of time in an upright position and inadequate tummy time, along with increased time in a swing, can lead to flattening of the head.

Often torticollis coexists with positional plagiocephaly. Torticollis is a persistent same-sided position of the neck leading to decreased range of motion of the neck. If an infant has difficulty moving his head, he is likely to be in the same position each time he is put down, which increases the chances of flattening of the back of the head.

Craniosynostosis syndromes, other forms of abnormal head growth, are caused by early closure of the bones of the skull leading to various head shapes that often require surgical correction. This is very different from benign positional plagiocephaly, which rarely requires surgical correction and can usually be managed with repositioning techniques or helmets.

Prevention
Prevention of plagiocephaly lies in education and early detection. Your child’s pediatrician or health care provider should be assessing your child’s head shape at each well-child check. If you notice that your infant’s head is beginning to take on a flattened appearance, bring this up with your pediatrician.

The easiest, most cost-effective prevention strategy is position changes. Early on, you can institute tummy time to strengthen your infant’s neck and shoulder muscles. This can be done as often as the infant will tolerate it. Tummy time gives the posterior of the infant’s head relief from constant contact with a flat surface. Limiting the time an infant lies in a swing or bouncy seat also can be helpful.

Changing the infant’s orientation to various environmental focus points while in the crib also has been successful in preventing and treating plagiocephaly. For example, each time you place the infant down to sleep, place his or her head at a different end of the crib. This allows for the right and left sides of the head to have alternate contact with the crib mattress, which fosters a more round, symmetric head shape. If an infant also has torticollis, there are additional stretching exercises that can be done throughout the day to assist with neck rotation and flexibility.

Correction
Once plagiocephaly is recognized by your health care provider, usually by 4-6 months of age, you can increase the amount of positional changes you make and add additional exercises. Typically, a change back to a more rounded head shape can be seen within two to three months once positional changes are instituted. If the infant initially presents with a severe positional skull deformity or if the infant fails positional changes, then a skull-molding helmet may be considered.

Your pediatrician can determine if your child will need further evaluation for a skull-molding helmet. With consistent helmet use, the best results occur between 4 and 12 months of age. Skull molding helmets can be very expensive, but have excellence success rates.

Dr. Nicole McCoy is a resident pediatrician at Carolinas Medical Center, and Dr. Erin Stubbs is a board-certified pediatrician at CMC Myers Park Pediatrics.