Written by Amy Leung: M Phty (Paed), Grad Cert Phty (Paed), PD Phty.

Since 1992, paediatric professionals have been promoting the ‘Back to Sleep’ campaign to reduce the risk of Sudden Infant Death Syndrome (SIDS). Research has shown that over the years, this campaign has resulted in a significant reduction in SIDS cases, which is awesome. However, this change of sleeping position has, unfortunately, increased the number of babies presenting with heads that ‘look out of shape’ due to a flat spot developing on the back or the side. Plagiocephaly is the term given for a flat spot on one side of the back of the head, while brachycephaly occurs in the middle portion of the back of the head. Sometimes plagiocephaly and brachycephaly can co-exist. To distinguish from other causes of a flattened head shape, positional plagiocephaly (PP) and positional brachycephaly (PB) are discussed in this article.

Newborn babies commonly show a preference for keeping their heads in certain positions. Since they spend most of the time asleep on their backs, their heads are exposed to prolonged pressure on the part that is in contact with the supporting surface. Persistent external forces pressing on the soft and malleable skull bones can flatten the skull. The flat spot is easily noticeable when viewed from the top of the baby’s head. Usually, it is obvious when the baby is about six to eight weeks of age. For PP, it is common to have uneven facial features and ear position. For PB, the facial features are symmetrical. Some babies are born with a flat spot on the head due to their position in the womb. These babies are more likely to stay lying on the flat spot and the flattening will become more pronounced.

Natural correction is believed to occur when the baby develops better head control and mobility at around three months of age. However, full correction may not be obtained, and the asymmetry may persist into late childhood, especially in severe cases. Studies have shown that fewer severe cases are reported if early physiotherapy intervention is given. Treatment of PP and PB includes re-positioning in young babies. Helmet-therapy can be considered for those with moderate to severe cases for babies older than four months. Correctional surgery is not recommended. The general concern of these flattened head shapes is mainly cosmetic, however recent research 1 suggests that tight neck muscles and PP and PB impact motor development.

Have a listen to paediatrician Dr Meredith, talking about PP and PB in GymbaROO’s free online video series here: Active Babies Smart Kids: Video 1 Tummy Time

There are several important positioning strategies that can be adopted to prevent flat spots from developing in young babies.

Play Time: It is important to vary the baby’s play positions.  This can avoid prolonged pressure on one spot of the head and also creates opportunities for babies to strengthen their muscles and balance. Babies love to play and interact with you, providing great opportunities to have the baby in different positions.

Supervised tummy time play: Tummy play position is crucial for a baby’s development. The best time to do this is before a feed, after a nap or a bath or when the baby is ready to play. Tummy time can be started from birth. Commonly, newborns are able to have short but frequent tummy play time. Babies at around two months of age should be able to manage 10 – 15 minutes, at least 3 –4 times a day. For more information on tummy time and lots of activities to do from birth, click here: GymbaROO’s free tummy time video.

When putting babies on their tummies, it is important to bring the arms slightly forward and prop them on their elbows.  This makes it easier for a baby to raise their head. So too will placing the baby on an inclined surface. The inclined surface can be your chest, a wedge, a triangular pillow, a rolled-up towel or a gym ball. This elevated tummy play position is more comfortable for babies with reflux.

If the baby cries or becomes distressed while they are on their tummy:

• Try for shorter periods of time but more often
• Get down there with your baby and interact with them; sing, talk or use toys
• Do not leave an upset baby in any position

Laying on the side: Besides the tummy position, place babies on their side to play.  Alternating the sides prevents prolonged pressure on the head, and the baby will experience different spatial orientations, which is terrific for development!

Alternating toy position while playing: It is important to change the position of toys that the baby likes to look at or play with. This will encourage the baby to turn their head to either side.

Sleep time: Babies spend many hours sleeping in the early months. The head position during sleep is a determining factor for developing PP or PB. Points to note are as follows:

• Continue to put baby to sleep on the back as per SIDS recommendation
• Putting a baby to sleep on the side is nota strategy to prevent PP or PB
• Alternate the baby’s position to both ends of the cot, as the baby tends to turn the head to stimulations such as; light source, door, parent bed, etc.
• Alternate the side of the baby’s head when you put the baby down to sleep. You may like to use the slogan ‘Right morning, Left afternoon’ as a reminder

Day to day care

Position of the baby in relation to stimulation: If you are using baby positioning equipment, be aware of the baby’s position in relation to the light source, TV, doorway and family activities. A baby will tend to turn their head to these stimulations. Remember to change the position of the baby’s equipment regularly so the baby is encouraged to turn their head to both sides.

Carrying position: Most of us have a dominant hand; therefore, we will carry and nurse the baby with our preferred hand or arm. The baby may develop a preference when they turn their head to one side. Alternating the arm or hand when carrying or nursing your baby will prevent the development of head orientation preference.

Feeding: Breastfed babies are already alternating their head position during feeding, however for bottle-fed babies, the carer should alternate the arm for every feed.

Despite implementing the above strategies, if you notice that your baby still has a strong preference to turn the head to one side or has a flat spot on the head, seek advice from your paediatrician, family doctor, child health nurse or paediatric physiotherapist.

References:

Bialocerkowski AE, Vladusic SL and Howell SM (2005). Conservative interventions for positional plagiocephaly: a systematic review. Devel Med & Child Neuro, 47: 563-570.
Park H-S, Kang M-Y, Choi C-W, Koo J-W, Jeong Y-G. The relationship between postural torticollis abnormalities and plagiocephaly on the early motor development milestones of lying and rolling activities in infants: A retrospective study. Developmental Neurorehabilitation. 2024;27(5-6):179-85.
van Vlimmeren LA, van der Graaf Y, Boere-Boomekamp MM, L’Hoir MP, Helders PJ and Engelbert RH (2008). Effect of pediatric physical therapy in children with positional preference.  Arch Pediatr Adolesc Med, 162: 712-718.

Amy is a paediatric physiotherapist and holds a Masters Degree in Paediatric Physiotherapy Studies. She has more than twenty years of experience in the field and has particular interest in orthopaedic and developmental paediatrics.