Flat Head Syndrome

An increasing number of parents present at paediatric healthcare centres with concerns about the shape of their child’s head. In my consulting room, I sometimes notice a raised eyebrow from the grandparents when we start discussing “Flat Head Syndrome”. It is not a concept that grandparents would have encountered if their own children were born before 1992. Let’s explain why.

In 1992, the American Academy of Paediatrics (AAP) began a campaign called “Back to Sleep”. The campaign was aimed at reducing the number of Sudden Infant Deaths (SIDS). This campaign urged all parents to place babies on their backs when asleep. Since the start of this campaign, there has been a significant decrease in the number of deaths due to SIDS, but another problem has raised its head. Apologies for the pun but infant plagiocephaly and brachycephaly (DPB) and congenital muscular torticollis (CMT) have been on an upward spiral since the “Back to Sleep” campaign began.

It has been noted that babies spend both sleep and awake times in reclined positions on their backs, be it in a cot, pram, bouncy seat, swing or car seat. Due to our busy lifestyles and a baby’s objection to tummy time, babies spend too much time in one position, which affects the head’s shape. While there are articles claiming that the shape of the head does not affect a baby, more recent studies call on practitioners to be aware that these conditions may be linked to a child’s ability to meet certain neurodevelopmental milestones. Whether the flat head causes neurodevelopmental delays or whether a child with developmental issues is less likely to move its head freely, thereby causing the flat head, is still being debated.

Let’s understand some of the terms used when considering the shape of a child’s head before moving on to the other causes, diagnoses, possible effects and treatment options.

 

What do the terms mean?

The most common term used is Flat Head Syndrome, but in relation to this condition, you may come across other terms such as:

• Plagiocephaly (DP)

  This term refers to a head which is flattened on one side. The face often appears asymmetrical, with one ear being more forward than the other on the head. The eyes are not lined up straight. The face and forehead may bulge a little on the side where the head is flattened.

• Brachycephaly (DPB)

  This term refers to a head that is flattened at the back. It usually causes the head to widen. Imagine a pumpkin lying on the ground. The under-surface of the pumpkin doesn’t become round because of the hard soil. The pumpkin flattens underneath and bulges out on the sides. A baby’s head responds in the same way as the pumpkin if it is allowed to lie on a solid surface for long periods of time. The back of the head flattens, and the forehead may bulge.

• Congenital muscular torticollis (CMT)

  This refers to tight or shortened neck muscles. The muscles on one side of the neck may be tighter than the other leading to a child favouring one side of the head over the other. You know what it is like to wake up with a stiff neck in the morning. We naturally guard the side which is stiff and try to only move to the other side. Babies born with CMT will usually only feed from one breast, avoid turning their heads to look around and favour lying down with their heads facing in one direction. All of these factors will make the baby more likely to face in one direction, which will affect the head’s shape.

What causes Flat Head Syndrome (DP and DBP)?

We have already mentioned two of the possible causes:

• Supine sleeping position

  We have to put babies to sleep on their backs, but studies have shown that 20 to 25% of babies who sleep on their backs develop brachycephaly to some degree or another. This doesn’t mean parents should allow the child to sleep in any other position but should encourage other head positions when the baby is awake.

• Muscular torticollis

  The head tilts in one direction because the muscles of the neck on one side are shortened.

• Prematurity

  These babies have very soft skulls and generally spend time in a neonatal ICU. They spend a long time on their backs, especially if they need to be ventilated. This will cause the back of the head to flatten. Interestingly, during COVID times, the number of premature babies suffering from this condition increased substantially. During this time, visiting was restricted, so it was less likely for the baby to be held by parents and grandparents. When a baby is held in someone’s arms pressure is taken off the back of the head.

• Inadequate space in the womb

  A mother may have a small womb, and this could put pressure on the head before the baby is born. This is also often the case in multiple births. If two or more babies have to grow inside a tummy, there is less space than in the case of a single baby. Where there is too little amniotic fluid in the womb, the head may be squashed against the womb because there isn’t water to cushion the head.

• Inadequate space in the womb

  A mother may have a small womb, and this could put pressure on the head before the baby is born. This is also often the case in multiple births. If two or more babies have to grow inside a tummy, there is less space than in the case of a single baby. Where there is too little amniotic fluid in the womb, the head may be squashed against the womb because there isn’t water to cushion the head.

• Prolonged labour or assisted birth

  A baby in the birth canal for an extended period may experience a lot more pressure on the head, which may lead to flattening in the area of most pressure. In cases where instruments are needed to deliver the baby, the baby’s skull may be affected by the pressure applied to pull the baby out of the mother’s pelvis.

 

How is Flat Head Syndrome diagnosed?

Usually, the first stage in the diagnosis process is the observation of the parents. Often parents will present to their healthcare provider with concerns about the shape of the head around 6 to 8 weeks of life. Those children who do not have a flattened head at birth may develop this condition after a couple of weeks of lying in a particular position for extended periods.

The healthcare provider will examine the baby and look for specific signs. These would include the movement of the head, symmetry of the eyes and ears. In other words, are the eyes in the same position on either side of the nose and are the ears in the same position on either side of the head? At this stage the healthcare provider may opt to refer the baby to a physiotherapist, chiropractor or prosthetist who deals with Cranial Orthotic treatments.

A physiotherapist would assess the baby’s muscle strength and range. The physiotherapist works on the baby to improve neck movement and would provide caregivers with exercises to do at home, encouraging better head movement and motor development. Certain paediatric chiropractors have techniques to assist with the shape of the head. The prosthetist is usually the professional who advises on the use of a helmet to correct the flat head. The assessment usually involves scientific measurements and tests, looking for adequate space inside the skull for normal brain growth and development.

 

What are the effects of Flat Head Syndrome on a baby?

In mild cases of this condition, the research seems to indicate no long-term effect on children either from a medical or neurodevelopmental point of view.

In moderate to severe cases, parents and practitioners are advised not to treat this condition merely as a cosmetic problem; in other words, doctors should not just assume that the flat head only affects the way the child looks. Doctors are advised to be aware that this condition may be associated with developmental delays, reduced gross and fine motor skills, hearing and sight problems, communication problems and a lowered ability to solve problems.

When a parent brings a child to the doctor because their baby’s head looks odd, parents are not generally worried about how their baby looks in photos but are more concerned that the strange shape is affecting their baby in some way. Recent studies confirm that parents are right to be concerned about the shape of their child’s head as it may well affect the baby’s future development.

It is still unclear whether Flat Head Syndrome causes these developmental delays or if a child with developmental delays is more likely to develop Flat Head syndrome. Let’s leave this question for the academics to answer. As parents, you need to know that there is a possibility of developmental problems when a child has an odd-shaped head, so seeking advice and a treatment plan is critical.

 

How or why does a flattened head cause problems?

This is not an easy concept to explain but let me try to use an analogy which you will hopefully relate to. Imagine you are driving along the highway at 120km an hour. Suddenly you encounter one of those yellow barriers blocking your lane. You are forced to hit breaks and wait and see when you are clear to change lanes and get going again.

A study performed in 2020 suggests that this is what occurs in the brain. Messages are rushing along the white material of the brain, carrying instructions for various parts of the body. They suddenly hit an obstruction in the form of a flattened skull, and the instruction is either interrupted or slowed down. The result of this interruption is delays in neurodevelopment, sight, speech and so on.

Since this is a new science, much more work is required to understand Flat Head Syndrome. Having said this, the current studies use modern MRI techniques and have methods which make the study of white matter easier. These studies suggest that a child with a flattened head requires intervention.

If you would like to look at the study, there is an abstract that you can read. The link is https://pubmed.ncbi.nlm.nih.gov/32884966/

 

What can be done to prevent Flat Head Syndrome?

If your child is born with a flattened area of the head, there is obviously nothing you can do to prevent it, but some of these prevention techniques may help to improve the condition:

• Tummy time. I cannot stress this enough. There is so much evidence showing why a baby needs to experience tummy time from day one. Flattened head syndrome is another reason to institute tummy time. While the baby is still tiny, you can institute tummy time by the way that you hold your baby. This would include your baby:
  • Lying with its face on your chest
  • Lying over your lap
  • Leopard in the tree position where baby lies over your arm
  • On the floor, tummy down with a towel or blanket rolled under the chest.
• Change the way baby spends his or her day. Carry your baby in a sling, put baby into a sloping chair or have the pram back slightly elevated if you are taking baby for a walk. This way baby won’t always be lying on the back of his or her head.
• Change the position of mobiles and toys in the baby’s cot. Babies do like watching mobiles and brightly coloured toys, so shifting their position in the cot will encourage your baby to turn their head.
• Alternate the side of your body where you carry or feed your baby. Most parents carry or feed their baby, favouring their dominant side, but this will also mean that baby is always in the same position.
• If you notice that your baby holds his or her head in a particular position and doesn’t easily move the head from side to side, consult a paediatric physiotherapist for help.
• If your baby appears to have or is developing a flattened head, then I suggest you roll up a little receiving blanket and put it under the head, shoulder, waist and hip of the affected side. This will lift that side of the body and take pressure off the side of the head affected when in the car seat. We had a friend with a very premature baby. They used to change the position of the blanket each time the little one went in the car chair. This was to avoid the head developing flat spots. They used to call it her “panel beating”.
• If your baby is learning to sit, then an upright chair with good back support is wonderful to get the pressure off the back of the head. This can be used from about 3 to 4 months of age and the length of time slowly increased.
• A child must be transported in a car seat, but I would propose getting the baby out of the car seat when you get to your destination. Leaving baby in the chair will increase the amount of time that pressure is kept on the head.

 

What if these conservative measures don’t work?

If the flattening of the baby’s head has not improved by about four months of age, then I would suggest that the child needs further intervention. At this stage, a helmet or headband may be indicated.

The purpose of the helmet or headband is to apply pressure to the bulging part of the head. The treatment is usually started around the age of 5 or 6 months when the skull is still soft. The child needs to wear the helmet for about 23 hours a day at the beginning of treatment and for less time as the condition improves.

There are certainly challenges with regard to the helmet, and these include:

• The length of time that the child needs to wear it
• Some medical aids do not pay for the helmet, and the treatment is expensive. At present, you are probably looking at around R40 000.
• It can be uncomfortable.
• Some children develop skin rashes, cradle cap and eczema.
• The baby needs to be checked regularly to monitor the growth and make adjustments where necessary.

Conclusion

Flat Head Syndrome is a relatively new concept. Certainly, around the world, centres that treat babies are experiencing ever-increasing numbers of children with this condition. Views around the treatment of Flattened Head Syndrome vary, and parents may find that they get conflicting views.

In my practice, I encourage parents to institute tummy time techniques from day one. If babies struggle to move their heads, I strongly believe in physiotherapists being consulted for torticollis. I had a child come into my practice for the first time at age four. The child’s head was at such a strange angle that he walked completely skew. With an off-centre head, a child is likely to suffer from Flat Head Syndrome but is also at a high risk of jaw, hip dysplasia and postural issues. This particular child was too old for helmet treatment but did go to physiotherapy to help correct the posture.

With regard to helmet therapy for Flat Head Syndrome, the Congress of Neurological Surgeons (CNS) updated their guidelines to state that repositioning, tummy time, physiotherapy and chiropractics are important but concluded that:

“more significant and faster improvement of cranial shape in infants with positional plagiocephaly treated with a helmet in comparison with conservative therapy, especially if the deformity is severe, provided that helmet therapy is applied during the appropriate period of infancy.”

Given all the new data, I would encourage parents and caregivers to institute all conservative methods to avoid or treat Flattened Head Syndrome from day one. Hopefully, these conservative measures will improve the child’s condition and avoid the knock-on effects of untreated Flattened Head Syndrome.

If your baby still has a flat head by three to four months, you should seek medical assistance. In my discussions with Yovanka Torrente, a medical prosthetist and orthoptist, she stated, “I have noted time and time again that my Brachycephaly patients are my late starters.” meaning that these children achieve their milestones later than children without Flat Head Syndrome.

Image source: https://www.healthline.com/health/parenting/flat-head-baby