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What is Flat Head Syndrome? Ask The Baby Expert ~ Question #36

February 5, 2017
"Ask The Baby Expert #36: What is flat head syndrome?

Ask the Baby Expert: Question #36

What is Flat Head Syndrome ?”

Does your baby’s head seem to be taking on a funny shape? Have you noticed your baby’s head flattening on the back? Does your baby seem to always look to one side? Have you seen all the flat-headed babies out there these days? Did you know that up to 50% of babies have at least mild flattening by four months of age? Do you worry about your baby developing flat head syndrome?


The most common diagnosis for babies that are referred to our clinic is flat head syndrome (plagiocephaly), with or without torticollis.


The questions I hear the most from worried mommas about flat head syndrome will be answered in this post:

1. What is Flat Head Syndrome?

2. Why do babies get flat heads?

3. Will my baby have to wear a helmet?

4. What Happens if It Doesn’t Go Away?

5. When should I talk to my doctor about it?

6. How can I prevent it?

(Skip over to “5 Easy Things You Can Do To Prevent Flat Head Syndrome” for this answer.)

7. How do we fix it?


 Are you taking notes? Write down your questions as we go along. Sit back, relax and enjoy the ride!

1. What is Flat Head Syndrome?

Plagiocephaly described by a pediatric physical therapists at

“Flat head syndrome” is the common term for a deformity of the shape of a baby’s head called Plagiocephaly.  It is the flattening of an infant’s skull in the back, but more to one side.

Plagiocephaly means “oblique head” in Greek. (play-gee-oh-sef-a-lee).  I will use these terms interchangeably in my writing.  (If the back of the baby’s head is flattened right in the middle, it’s called brachycephaly.)

Flat head syndrome has become very common since the “Back-to-Sleep” Campaign in the early ’90s. Putting our babies to sleep on their backs has reduced the total death rate from Sudden Infant Death Syndrome by 50%!! So THOUSANDS  of kids and young adults are alive today because they slept on their backs instead of their tummies. But this has caused a huge rise in the prevalence of flat head syndrome. The most recent, reliable study reports up to 50% of babies have at least “mild” plagiocephaly at four months of age. Read the study here. 

For more information about SIDS, read “10 Things You Need To Know About SIDS”


2. Why do Babies get Flat Heads?

Flat Head Syndrome

A baby’s skull is a group of soft bones that will later be fused at the “sutures.”  (Thank goodness for this miracle because it’s hard enough to push that melon out as it is!)  😉  So if a baby spends prolonged periods of time with his head supported on a flat surface, the skull bones flatten to accommodate the surface.

This is called positional plagiocephaly.  Today, this is the most common type of flat head syndrome.  It is worsened and prolonged if a baby also spends too much time in swings, car seats, and bouncers. All of these “baby containers” have a flat surface, so the skull will flatten wherever the head rests the most. Babies who only look one direction or hold their heads tilted to one side most of the time are likely to develop moderate to severe plagiocephaly if it’s not caught and treated early (before 4 months of age.)

Read more about positional plagiocephaly here.

Prior to the ’90s when most babies slept on their tummies, it was more common to have congenital plagiocephaly, which was a cause of the baby’s position in momma’s belly. It was even more common for twins since the living environment was so cramped!

Congenital plagiocephaly was often accompanied by congenital torticollis. Torticollis is the tightening/shortening of neck muscles on one side of the head.  (Post on torticollis coming soon.)

Positional plagiocephaly affects only the baby’s skull and sometimes face bones. If the flat head is severe enough, the skull bones will shift forward causing the ear to be “sheared” forward, and the forehead, cheekbone and eye socket will be more pronounced on the same side.  If the flat spot is on the right side, there will also be a shift toward the left, and you may see a “bulging” of the skull bones. The more severe and prolonged the flat spot, the more asymmetrical the head and face will look, and the harder it will be for the bones to even out years later.


3. Will my baby have to wear a helmet?

This depends on several factors including severity of the deformity and the age of the baby. It’s best to start helmet therapy between 4 and 6 months–when the bones are still soft and growing quickly– to get the best results.

Unfortunately, in Idaho where I practice, Medicaid stopped paying for helmets a couple of years ago. Funding for helmets by private insurance companies has always been slim to none, as the common belief is that helmet therapy is only cosmetic and there are no medical benefits.

Therapists and orthotists (helmet makers) will tell you from experience how medically beneficial helmets are in a lot of cases, especially for babies with severe plagiocephaly, torticollis, or babies with other developmental issues like hypotonia (floppy muscles) and visual deficits.

Unfortunately, we don’t have enough good research to prove this. Flat head syndrome was not very common before the ’90s, and it takes upwards of 10-15 years for physical therapists to create and publish quality research.

In my practice, parents usually ask about helmets on visit #1, and we continue to have a dialog about it throughout the course of treatment.  Several other factors come into play, too, like how often baby spends time on his back in daycare or in a car seat as the youngest of several children and a soccer mom. 


4. What Happens if It Doesn’t Go Away?

Typically, positional plagiocephaly is not related to any problems with the brain or the baby’s overall health.

If your baby is otherwise healthy and does not have torticollis, and flat head syndrome is caught and treated early, the shape of her head is suspected to resolve naturally as she gets older. When your baby starts to roll onto her tummy at night–and starts crawling and walking–there will be less time on the flat spot which will allow the bones to grow and even out more.

If the deformity of the skull is severe or prolonged (left untreated past 6-9 months of age), it may never fully resolve. Sometimes it’s less noticeable if your child eventually grows a lot of hair to cover it up, but if there is ear shearing that doesn’t resolve, your baby could have problems with ear infections and difficulty fitting glasses and helmets in the future. If the flat head syndrome causes jaw shearing, the gum line and teeth don’t line up directly which can cause nursing difficulties, chewing problems, and jaw pain.

What I see often in the clinic are mild to moderate developmental issues secondary to flat head syndrome, particularly with the babies that only look one way or have reflux in addition to flat head syndrome.  If you baby only looks to the right, for example, she is only learning and interacting with the right side of her world.  This makes finding midline and crossing midline difficult, which are fundamental concepts for healthy, symmetrical motor and visual development.


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Sometimes positional plagiocephaly develops secondary to infant reflux (GERD, gastroesophageal reflux disease, aka “baby heartburn”).  About 75% of babies with flat head syndrome will have the flat spot on the right. We think this is because the stomach sits more to the left side of the abdomen, and a baby suffering with pain from reflux will arch their backs and pull their heads back and to the right, to get the throat as far away from the stomach and the stomach acid as possible.

If your baby gets really fussy, especially during feeds, after feeds, and when laying flat on the floor, and insists on arching back and throwing her head back to the right, please tell your doctor as soon as possible. Untreated reflux can lead to developmental delays and significant feeding issues in the future.  And who wouldn’t want their baby to have less pain and better sleep??!  

If you have more questions about reflux and infant fussiness, just ask me, The Baby Expert!  The post hasn’t been written just yet but is coming soon!

The only other time plagiocephaly is a major concern is when it’s a result of craniosynostosis. Kray-nee-o-sin-os-TOE-sis causes significant deformity of a baby’s skull because one or more of the cranial sutures (stitch-looking lines between the skull bones) fuse too early.  (The brain isn’t fully formed until age 4).

This is a very rare disease that almost always requires plastic surgery to separate the fused bones so the brain and skull can continue to grow normally. These babies will always require a helmet.

Remember, it’s very rare and your physical therapist or pediatrician will refer you to a specialist if craniosynostosis is suspected. I’ve only had two patients with this diagnosis in my 10+ years of practice.


5. When should I talk to my doctor about it?

Talk to your doctor as soon as you notice 1) the flat spot; 2)that your baby only looks in one direction, or 3) only holds his head tilted to one side. And call your doctor as soon as possible if you are also seeing signs of reflux– like pain, arching back and to the right and excessive fussiness especially around feeding time.

If you haven’t noticed any signs or symptoms, ask your doctor if she suspects flat head syndrome or torticollis at your 2-month appointment. If they say they are not concerned, ask again at your 4-month appointment.  Sometimes it can be subtle at 2 months and many docs will overlook it or tell you it will go away on its own.

This isn’t true as much anymore. When babies slept on their tummies back in the olden days ;-), muscle tightness and flat heads would resolve quickly because they stretched out their necks very early on when lifting their heads in tummy time, and they were rarely placed on their backs or carried in car seats or positioned in latest and coolest, hard plastic containers.

(The post about “Why baby containers are bad” is coming soon. If you can’t wait, just ask in the comments and I’ll give you a sneak peek!)


Did You Know?: Projectile vomiting is not the only symptom of reflux. Sometimes the only symptom is unexplained fussiness. Click To Tweet


6. How can I prevent it?

Well, this post is quite long already. (As usual. Boy do I like to talk!) So just head on over to this other great post,  “5 easy things you can do to prevent flat head syndrome!”  It’s way shorter! 🙂



7. How do we fix it?

Wait a sec, let me put on my cape….

Doot, doo da doooo! The PEDIATRIC PHYSICAL THERAPIST is here to save the day!!!!! (Ahhhhhh and the crowd goes wild!)

Oh and I should mention that a lot of pediatric occupational therapists can treat babies with flat head syndrome, also. But I recommend asking if they’ve had any additional training in plagiocephaly and torticollis since they graduated from OT school. (Not every pediatric therapist goes on to get advanced training in this area.)

I have had three levels of training (grad school, infant specialization courses, and advanced courses) specifically in treating plagiocephaly and torticollis because I love babies!!!! 

Your doctor may give you some tips on stretching and positioning your baby, but you really should insist on a referral to a pediatric physical therapist as soon as possible.  

Read: The top 5 reasons why you must see a pediatric physical therapist for flat head syndrome if you’re not yet convinced. 😉


Ask the Baby Expert! Free 30min consult with Wendy Rohin, pediatric PT at

OK, Mommas and Dadas, it’s YOUR turn to talk!

I hope you learned a lot from this post. If you have any questions at all, JUST ASK!

Please let me know what you think in the comments below and share with your friends!


Ask The Baby Expert #36: What is Flat Head Syndrome

Ask The Baby Expert #36: What is Flat Head Syndrome

5 Easy Things You Can Do To Prevent Flat Head Syndrome at

5 Easy Things You Can Do To Prevent Flat Head Syndrome at

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