Baby Flat Head and Torticollis: Prevention, Therapy and Helmets

Why flat spots are common

• A baby's skull is soft and grows fast, so steady pressure on one spot can flatten it.
• Flat spots became more common once babies started sleeping on their backs. Back sleeping still saves lives: keep putting your baby on their back for every sleep. A flat spot is a cosmetic issue that usually improves; SIDS is not.
• Positional flattening shows up in the first weeks to months, usually on the back of the head (brachycephaly) or one side of the back (plagiocephaly). With one-sided flattening, the ear and forehead on that side may look pushed forward.
• It doesn't affect brain growth or development.

Preventing and improving it

• Tummy time: awake and watched, starting in the first days with a few minutes several times a day, building to about 15-30 minutes total by around 7 weeks and at least 30 minutes a day after that. See the tummy time guide.
• Alternate head direction in the crib: switch which end the head goes each night, or move the crib so the interesting view is on the side the baby tends not to look toward.
• Change holding and feeding sides: alternate arms for bottle feeds and carrying, and hold the baby upright more often.
• Limit time in car seats, swings, bouncers and other containers: use the car seat for travel, not as a place to nap or hang out. Upright carrying and floor play are better.
• No pillows, wedges or head-shaping positioners in the sleep space. They're a suffocation risk and not recommended.

Torticollis (tight neck muscle)

• One neck muscle is short or tight, often from the baby's position in the womb or birth. It's a common cause of flat spots, because the baby keeps resting on the same side.
• Signs: the head tilts toward one shoulder with the chin turned the other way; the baby always looks one way; trouble turning to one side or feeding from one breast; sometimes a soft lump in the neck muscle in the first weeks.
• Physical therapy works well, especially when started early, ideally before 3 months. The therapist teaches gentle stretches and play positions to do at home. Most babies improve within months.

Helmets

• Considered for moderate to severe flattening that hasn't improved with repositioning and tummy time, usually checked around 4-6 months, when the skull is still growing fast.
• Worn most of the day for a few months and refitted as the head grows. It works best started before about 6-8 months and doesn't work well after 12-18 months.
• Mild flattening usually improves without one as babies sit up and move more.

Craniosynostosis is different

• In this rare condition, one or more of the skull's growth seams (sutures) closes too early. The head shape is unusual from birth or soon after and keeps getting worse, often with a hard ridge along a seam, a narrow or triangular forehead, or a soft spot that closes very early.
• It doesn't improve with repositioning and may need surgery, so it needs a prompt look.

Bring it up at the checkup

• A flat spot that isn't improving after a few weeks of repositioning.
• A head tilt, always looking one way, or favoring one side to feed.
• A hard ridge on the skull, an odd head shape from birth, or a soft spot that seems closed early: ask for an appointment soon, rather than waiting for the next checkup.