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Have you recently noticed a flat spot on the side or back of your infant’s head? If so, you are not alone. This condition is called Flattened Head Syndrome, and it has increased by 60% since babies began sleeping on their backs to decrease the risk of Sudden Infant Death Syndrome or SIDS. Sleeping on the back has been a great thing, because 50% fewer infants have died of SIDS since babies started sleeping in this position, but unfortunately, many parents are hesitant to put their infants on their stomachs even during baby’s waking hours due to a fear of SIDS. This extra time positioned on the back leads to increased pressure on baby’s soft head causing flat spots to form wherever that pressure is applied.
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About Flattened Head Syndrome
In certain cases an infant will have a flat spot that begins in utero. This happens because during the last several weeks of pregnancy, baby may hold his head in the same position, pressing one side against mother’s pelvis causing a flat spot to form. At birth, it will be evident that baby has flattening on one side of the head. Flattened head syndrome also frequently occurs in premature infants because a preemies’ skull is softer than a full-term baby's, and these infants typically must spend prolonged periods of time positioned in their cribs while still in the hospital. However, in many cases, the condition occurs due to an infant spending too much time positioned on the back and not getting enough tummy time during the waking hours.
There are two medical terms for flattened head syndrome. One is Positional Plagiocephaly, which means when viewed from the top, the shape of baby’s head has a parallelogram appearance. This is caused from constant pressure applied to one side of the back of baby’s head. The other term is Positional Brachycephaly and this means that due to pressure across the back of the head, baby’s head has flattened evenly across the back, leaving a short and wide head shape, with the height of the back of the head often being high. Another condition that often co-occurs with Flattened Head Syndrome is acquired Torticollis. This condition results due to baby’s neck muscles shortening on one side because the head is usually turned to that side most of the time. The tight neck muscles cause the baby’s neck to rotate in a twisted position, where the head is positioned to one side and the chin is frequently pointing to the other side. Torticollis actually makes flattened head syndrome worse because baby’s head is usually turned in one direction, causing constant pressure against the same side.
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Flat spots can be prevented by providing plenty of tummy time during the day and by limiting the use of plastic equipment such as car seats, carriers and swings. These products should be used as infrequently as possible because the hard surface of this equipment is unyielding, and when baby’s head lies against these surface for an extended period of time, it places pressure against the soft skull. It is also important to limit the use of bouncers and exersaucers in the first year of life because at this young age infants are gaining neck strength and mobility. Bouncers and exersaucers are very hard on an infant’s flexible neck, especially if muscle weakness or Torticollis is present.
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If you suspect that your infant has a flat spot forming on her head or has tight neck muscles, you should consult with your pediatrician immediately. A home exercise program will frequently be recommended for stretching of the tight neck muscles. I work as a pediatric occupational therapist and for home exercise programs I frequently recommend that parents purchase an exercise ball. Baby can be positioned on the ball in front of a mirror to work on stretching exercises. For these exercises, baby can be held at the waist and the ball tilted to the side to which the neck is usually held flexed. This encourages baby to hold the head in upright position. I often have parents blow bubbles to the opposite side, which encourages baby turn the head and reach with the opposite arm to pop the bubbles. At meal and snack time I recommend that parents always place baby’s bottle and finger foods on the opposite side of the stiff neck muscles. All of these activities provide a nice stretch for baby’s tight neck muscles.
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What the Measurements Mean
With Plagiocephaly measurements, 0 is considered a "perfect head". Plagiocephaly is measured in mm and cases are distinguished as mild, moderate, or severe. According to the American Academy of Orthotists and Prosthetists, mild to moderate cases measure 12 mm or less and moderate to severe measure more than 12 mm. To further distinguish a mild case, additional factors come into play. For example, the asymmetry is limited to one side of the back of the head and the forehead and facial features are not affected. However, with a moderate case, the asymmetry typically involves the back and front sides of the head, with shifting of the ear on the flattened side and protuberance of the forehead on that same side. With a severe case, there is significant asymmetry to the ears, forehead, and facial features and the asymmetry crosses the midline of the head.
Brachycephaly is measured in percentages. The % refers to the Cephalic Index, which is the ratio of the width of the head from one ear to the other ear, relative to the depth of the baby’s head from the front to the back. The average infant Cephalic Index is 78%.
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Flattened head syndrome is a serious condition, but it is important for parents to understand that in the majority of cases it does not lead to developmental problems. However, since it does affect physical appearance, parents should always consider treatment and consult with their pediatrician as soon as they notice a flat spot on their infant’s head. Fortunately, in most situations, positional plagiocephaly or brachycephaly can be resolved through positioning and stretching, but if helmet therapy does turn out to be necessary, the average treatment time is only 4 to 6 months.
- Teichgraeber, J.F., Seymour-Dempsey, K., Baumgartner, J, E, Xia, J, J. MD, Waller, A. L., & Gateno, J. Molding Helmet Therapy in the Treatment of Brachycephaly and Plagiocephaly, Journal of Craniofacial Surgery, 15, 118-123.
- Moss, S. D. (1997). Nonsurgical, nonorthotic treatment of occipital plagiocephaly: what is the natural history of the misshapen neonatal head? Journal of Neurosurgery, 87, 667- 670.
- Zachry, Anne, Ph.D., Personal Experience in Infant and Child Development with a focus on Research in the area of Sudden Infant Death Syndrome and Tummy Time.
- Farkas, L. G. & Munro, I. R. (1987). Anthropometric facial proportions in medicine. Springfield, IL: Charles C. Thomas.