Studies estimate that somewhere between 20% and 40% of all babies develop some form of head flattening. A baby’s head will flatten when two factors are present – back sleeping on a firm, flat surface, and reduced movement (meaning the same part of the head rests continually on that flat surface). Reduced movement is caused by one of three things; prematurity, developmental delay, or torticollis. Of these, torticollis is the most common, although the exact incidence is unknown.
What is torticollis?
Torticollis is a contraction of the sternocleidomastoid (scm) muscle on one side of the neck, as a result of restricted in utero positioning. Risk factors include multiples (ie twins or triplets), first births, male babies, larger babies, breech positioning and other factors, few of which can be influenced. Using the contracted muscle is painful for the baby and as a result it is more comfortable for the baby to look in a particular direction. The baby’s head is turned away from the damaged muscle, and the top of the head tilted over towards the damaged muscle. This means that left-sided torticollis presents as a baby who turns his or her head to the right, and tilts it left.
This “head-turning preference" is often dismissed as a baby’s desire to face into the room, but is in fact due to discomfort rotating the neck the other way. Torticollis ranges in severity from minor (and rapidly self-correcting) to complete fibrosis.
Mild cases of torticollis will self-resolve, but a baby with a strong and persistent head-turning preference (i.e. torticollis) should receive physiotherapy in order to gently stretch out the contracted muscle and enable the baby to turn to both sides equally in an unrestricted manner. A baby with more pronounced torticollis will require physiotherapy in order to gently stretch out the muscle and achieve equal head rotation. In a small percentage of cases, surgery is required to transect the muscle and relieve the contraction.
A baby with torticollis will persistently turn in one direction and when placed on a firm, flat surface on which to sleep, is likely to develop deformational asymmetry – a “flat head”.
Why is my baby’s head flat?
A baby’s head grows very quickly during the first 4 months of life in order to accommodate a fast-growing brain. Small babies spend a lot of time sleeping – as much as 12 hours during the course of the night (perhaps punctuated by feeds) and several hours during the day. When a baby lies continually on the same side of the head, growth is discouraged at that spot and redirected to the side on which the baby does not lie, creating an asymmetry. This is termed Plagiocephaly. In a baby who does not move their head to either side, and instead sleeps only with their head in a central positioning, looking straight up, flattening will develop at the back of the head – this is called brachycephaly. Brachycephaly may present as overgrowth on both sides (creating a wide head with a flattened back) or overgrowth at the top of the head (termed turricephaly) which appears overly tall.
Head flattening is not caused by a lack of tummy time, use of “baby containers” (including car seats, bouncers etc) or neglect. Increasing tummy time does nothing to counteract the forces which occur at night. Simply “holding the baby more”, or “picking up the baby” – comments which also imply a lack of love and appropriate care – demonstrate a profound lack of understanding regarding the mechanisms by which head flattening occurs. Similarly, babies do not develop flat heads due to their heads being “soft”. This persistent myth may sound compelling and even somewhat logical, but it is absolutely incorrect for several reasons. First, study of babies with plagiocephaly or brachycephaly identifies no evidence that their bones are somehow “weaker”, or “softer”. Second, if all babies had “soft” heads, almost all babies should flatten, whereas the majority (at least 60%) do not. Third, observation of any baby laid on a firm flat surface will not identify immediate deformation, and when the baby is picked up, no corresponding change in shape occurs. Flattening will not spontaneously resolve following temporary removal of pressure. Plagiocephaly develops over time, as the head grows to conform to the surface is it most commonly in contact with (the flat mattress)
Most parents report initially seeing the flattening around 6-8 weeks, as it takes that long for it to develop. Flattening continues to progress until an average of 4 months old, at which point three factors significantly reduce the likelihood of further flattening – the baby is stronger and more mobile; torticollis has likely been resolved (with or without the assistance of formal physiotherapy) and cranial growth (driven by brain expansion) is no longer as rapid as it was in the first 4 months of life.
There are only two options to offset this developing problem. The first – repositioning – is unpredictable and largely ineffective. It is impractical to expect exhausted parents to wake up every hour to alter their baby's head position. This is the reason parents turn to solutions which alter the surface on which the baby rests. There are many pillows sold for this purpose, but they are largely ineffective because they are soft and not shaped like a baby’s head. In addition they violate safe sleep recommendations against soft, loose items in the cot, and create neck flexion, restricting the baby’s airway. The Perfect Noggin is different; effective and safe. Its patented, adjustable, soft foam liners are anatomically shaped to fit your baby’s head shape, and the platform design maintains the safest and most ergonomic head-neck-torso alignment.
What are the consequences of flat head syndrome?
Head flattening is purely cosmetic. No scientifically robust studies exist which link head flattening to an increased incidence of ear infections or dental malocclusion, or to delayed motor or cognitive development. There is no truth to the claim that children will be unable to wear glasses, swimming goggles or protective headwear later in life, or that they are certain to suffer bullying. Babies are more frequently viewed from above and in combination with little to no hair coverage, plagiocephaly can be obvious. In contrast, only a hairdresser may regularly see young people and adults from this angle.
On the other hand, what is also not true is the claim often made by health professionals that the head flattening will “resolve itself”, or that the flat spot will “pop out” once the baby can sit or roll. In some cases there may be a small amount of natural improvement, but some degree of flattening will almost certainly persist for life – with no medical repercussions for the child. Brachycephaly is very common in adults and easy to see in men with short hair, but goes completely unremarked upon in society, with most casual observers being completely unaware of the many famous actors, athletes, politicians and media personalities who have brachycephaly. Studies assessing CT scans of young adults to rule out cranial injury following car accidents concluded that at least 12% of adults have unresolved plagiocephaly. The issue therefore is more immediate and is purely related to you – the parent – and how you feel about the aesthetic of your baby’s head. For many parents, the visual appearance is distressing and they simply do not want to wait until the child is grown and the asymmetry is no longer noticeable. These parents may choose to helmet their child, as the right helmet (fitted and monitored by a competent orthotist) can produce a great result, especially if started early. However, the cost is often prohibitive and we believe a far better path is to avoid, halt or reverse any flattening which could occur within the first 5 months of life, and potentially avoid the need for a helmet entirely. This is the purpose of The Perfect Noggin.
There is no association between tongue or lip tie, and torticollis or head flattening. Tongue tie is a developmental anomaly arising from failure of programmed cell death; torticollis is a neck muscle imbalance that arises from constraint in utero. These two processes have no relationship.
Once your baby can roll, and begins to sleep on their stomach (approx. 6 months of age) only a properly fitted helmet will improve head shape.
