When third baby was sooooo incredibly easy, I definitely took advantage of the fact that she was just fine in her car seat carrier… just fine in her swing… just fine in her bouncy chair. By her two month appointment, her pediatrician pointed out she was getting a flat spot. Having never had this issue with our other children, the hubby and I felt terrible… and never set third baby down again. And that is only a slight exaggeration. She was either carried by my husband or me or in a Bjorn or placed on her tummy while supervised, but we avoided the many products that make it so easy to put your baby on their back at all costs. And as difficult as it has been, I have done my best to do the same for my twins. Although my arms are getting a great work out, I was still curious – is the flattening of babies’ heads hereditary or is my suspicion correct that it’s because of all of today’s products that make it convenient to lay them on their backs? Breezy Mama turned to Aaron Smith, Certified and Licensed Orthotist specializing in cranial remolding treatment, to get these answers, how to avoid the flattening of your child’s head, what to do if there’s already a susceptible spot and more.
What is your advice to avoid having a baby’s head become flat?
During an infant’s first few months of life, parents are encouraged to change the baby’s position often. Since a baby sleeps on his/her back at night [to prevent SIDS], we encourage lots of handling, holding, and tummy time that changes the baby’s position during the day. For instance, imagine an infant on their back at night. Then they wake up and mom is holding them as they lie in her arms (on the back), then they spend some time in their swing or bouncy seat (on the back), then they are moved to the floor where they can look up at toys hanging overhead (on the back), then they are moved to the car seat for a trip to the grocery store where their car seat is moved from the car to the grocery cart while they are still in it (on the back). During all of these daily activities, the baby is still on his/her back. An infant’s head is very moldable, meaning it is soft and the sutures between the skull plates are open. When an infant is in one position for a prolonged period of time, like the example above, that is when the skull has the greatest likelihood of flattening. It is similar to a water balloon that you place on a desk. The water balloon is going to spread out towards the sides, and flatten where it is touching the desk. The same type of things happens with the baby’s head. When an infant spends a lot of time in one position where part of the head is always in contact with a firmer surface, the skull can not grow in that area, and instead grows in the opposite direction, creating flatness on the skull. To avoid this, encourage the baby to turn their head from side to side when lying on the back – this allows the contact to be on different sides of the head. The parent may place the baby on one end of the crib one night, and the other end of the crib the next night, altering the position the baby has to turn to look into the room or at the parent. Also, have the baby spend time when awake and supervised on their tummy, either across mom’s lap, on her chest, or propped up on a Boppy pillow on the floor looking at toys. Once old enough encourage supported sitting. When going shopping or out of the house, have mom or dad carry the baby in a front carrier instead of their car seat. Since babies have to sleep on their back at night, encourage lots of different activities and holding techniques during the day that takes the baby off their back and changes the contact that their head is making with their surroundings. All of these activities are often refer to as “repositioning.”
When a flat spot started to develop on my daughter’s head, I was also told to sit her down in opposite directions each time I changed her diaper and to switch her positions when breast feeding her. Do you have other suggestions to stop the flattening of the head once there is a concern?
Once a flattening is noticed, the main goal is to keep the baby off that flattened area. For example, if the flat spot is on the back right side of the head, then encourage the baby to stay more on the left side or look to the left more often. When playing on their back on the floor, prop the baby over to the left side and put all the toys on the baby’s left to encourage looking to the left. When holding the baby, hold them on the mom’s left side so the baby has to turn to the left to look at everyone. If the baby’s head shape is flat completely across the back of the head, tummy time is the most important tool. Again, this keeps the baby off the flat spot. Tummy Time Tools is a parent handout that we created at Children’s Healthcare of Atlanta – it has a lot of photos and gives great examples of ways to encourage tummy time and incorporate it into your daily life. It is accessible through the Children’s Healthcare of Atlanta website (click here)and has been translated into multiple languages.
Does nature play a part in the development of a flat spot? For example, can it be hereditary that a child might be more likely to be susceptible?
There is no evidence that flattening of the head is hereditary. However, we do often see children from the same family with this condition. Some possibilities could be that the mom’s pelvis is smaller than usual and the baby has less space to move around while in utero and they are born with flattening of the head. Another option could be that children in one family have softer skulls than other children and this places them at more of a risk for flattening. In some cases however, when parents are educated on repositioning and tummy time, they are often able to avoid future children from developing flattening.
At what point is a baby prescribed to wear a helmet?
Typically, when the flattening does not appear to be improving with repositioning and tummy time, a helmet may be prescribed. A helmet works the best to encourage corrected head growth during the ages of 4-12 months, due to rapid growth of the skull during this time. As an infant gets older (9-12 months of age), the growth of the skull begins to slow and the window of opportunity for correcting the skull shape with a helmet begins narrowing. During the ages of 12- 18 months, the skull growth is typically very slow and outcomes are uncertain. After 18 months of age, treatment with a helmet is not recommended due to the hardening of the skull and closing of the sutures. So, early intervention is always best. Typically, if the head flattening is noticed when the baby is only a few months old, repositioning and tummy time are strongly encouraged in an effort to correct the baby’s head growth without the need for a helmet. Once the baby is 5-7 months old, if the head shape does not appear to be correcting, or the parents continue to have concerns about the shape, we recommend an evaluation by an orthotist or cranial remolding specialist who has experience in this area to determine whether the child would benefit from helmet treatment. Not every child with some flattening will be referred for a helmet. Everyone has a little bit of asymmetry to the head shape and that is normal. What we look for is how significant or severe the flattening of the head is and what other features are involved. Often, babies who have flattening on the back of one side of the head will also have some flattening on the forehead section, and they may have ear misalignment or differences in their cheek or eye size. So, whether a child needs a helmet depends on the following: the degree of the asymmetry or flattening, the age of the child, the effectiveness of repositioning, torticollis or other medical involvement, and the parent’s concerns.
How long generally must a helmet be worn?
Most infants wear a helmet for about 3-4 months. The length of treatment depends on how quickly the infant’s head grows and corrects.
Do children wear their helmets 24 hours a day?
No, babies wear the helmet for 23 hours a day. They have it off an hour each day so the parent can clean the helmet, bath the baby, and check the baby’s skin for any issues.
I have a friend whose son did not need the helmet but she had to take him to physical therapy regularly. What sorts of things can a mom suspect if her pediatrician advises her to take her child to PT?
Babies with a flattening of the head are diagnosed with plagiocephaly. Some babies who have plagiocephaly also have a condition called torticollis. Torticollis is when the neck muscles on one side are tighter than on the other side. Babies with torticollis often will tilt their head in one direction, or have a strong preference to always turn their head in one direction, or a combination of the two. When a baby is diagnosed with torticollis, the pediatrician will refer them for physical therapy. A physical therapist will work with the baby on assessing the amount of tightness and developing a plan to improve the neck movement or strength. They will also educate the parents on stretching techniques and activities for the parents to work on at home that will improve the baby’s neck range of motion and posture. Sometimes, the flattening of the head is a result of the tightness on the neck muscles. Imagine if one side of the neck is tight; it makes it difficult for the baby to turn their head equally in both directions. Therefore, they spend a lot of time in one position and this could lead to plagiocephaly. Thus, by working with the physical therapist to improve the neck movement, the baby will be able to move the head in more variety of positions, possibly allowing for some improvement in the head shape as well.
Why are some kids prescribed PT while others need the helmet?
See the note above and, also, physical therapy alone does not correct the head shape. However, a trained physical therapist will be able to provide education on repositioning and tummy time in an effort to change the baby’s position to allow for better symmetrical head growth. Physical therapy also addresses the tightness in the neck that may be limiting the effectiveness of repositioning. If a family is active in repositioning at home and/or physical therapy and have not seen an improvement in the baby’s head shape, a helmet may be prescribed. Babies who do not have tightness in the neck muscle will not be prescribed physical therapy, but may be referred for a helmet based on the head shape. If a baby has both plagiocephaly and torticollis, it is important that both are treated. With torticollis, the tight neck muscle actually can pull on the head shape and encourage growth in the wrong direction, making the head look flatter. If a baby wears a helmet for the plagiocephaly but the family is not addressing the torticollis with therapy, the helmet will not be as effective.
Any other advice to help parents who are concerned their child may be developing a flat spot and/or how parents can avoid it all together?
If a parent has a concern about their child’s head or neck, they should speak to their pediatrician about a referral to a cranial remolding specialist or physical therapy, depending on the concern. There are options and education that can be provided regarding repositioning, tummy time, and physical therapy for the neck if needed. Not every child needs a helmet, but it is important for parents to understand that it is a treatment option that works successfully in most cases when appropriate.
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Aaron is a Certified and Licensed Orthotist specializing in cranial remolding treatment. She has a B.S.E. in BioMedical Engineering from Mercer University and a Certificate in Orthotics from Northwestern University. She has been at Children’s Healthcare of Atlanta for 13 years and provides direct patient care to children with a variety of conditions. The Cranial Remolding Program at Children’s is one of the largest in the nation and a leader in education, intervention, research, and treatment of skull abnormalities. As program leader, Aaron provides inservices and speaks nationally to pediatricians, physical therapists, orthotists, and community groups to further educate them on plagiocephaly and treatment options. At home, Aaron enjoys spending time with her husband and two active little girls.