New parents are somewhat prepared for the challenges they face with baby, at least when it comes to sleep issues and breast-feeding. Everyone talks about those. 

But Elizabeth Muller of Berkeley wishes someone had told her to look out for positional plagiocephaly, or flat head syndrome, a condition characterized by an asymmetrical distortion of the skull.

By the time Muller's daughter, Layla, was three months old, there was a flat spot on the right side of the back of her head. And, when she looked at Layla's face, she noticed that her ears were not aligned.
"We were told it would go away on its own," Muller says. "But it didn't."

Whether in a crib or car seat, infants spend the majority of their time on their backs. And, since 1992, when the American Academy of Pediatrics advised parents to stop putting their babies on their bellies in order to prevent Sudden Infant Death Syndrome, plagiocephaly has increased fourfold. While the condition is cosmetic and can be corrected or improved with a helmet or physical therapy, treatment can be long and carry a hefty price tag. But, with awareness and positional changes, experts say plagiocephaly is preventable.

Positional plagiocephaly develops during the first eight to 12 weeks of life and progresses until the baby can roll over and spend more time off his back, says Mark Dias, a Pennsylvania pediatric neurosurgeon and plagiocephaly spokesman for the American Academy of Pediatrics.

"There's no convincing medical evidence that plagiocephaly does anything rather than make a child's head look odd," Dias says. "Some people have talked about an increased risk of ear infections, eye problems, scoliosis, and hip dysplasia associated with it, but that hasn't been proven."

Boys are particularly vulnerable. They account for two-thirds of all cases because they have increased fluid around the outside of the brain that makes their heads more susceptible to being molded, Dias says. With that in mind, the best weapon against plagiocephaly is awareness.

"Parents should always be looking at their baby's head," he says. "Give them supervised tummy time when they're awake. Carry them upright. And alternate which side they turn their heads while sleeping." Dias says positional changes can improve head flatness by 50 percent.

They're certainly working for Jennifer Telford's 7-month-old son, Trent. He began sucking his right thumb at age 10 weeks. According to his mom, that's when he developed a preference for and flatness on his right side.

In addition to plagiocephaly, their pediatrician diagnosed Trent with torticollis, a condition where the neck muscle is short or tight on one side and makes it difficult for baby to turn the other way. It is present in 15 percent of plagiocephaly cases.

Physical therapy

Trent is a good candidate for physical therapy. In mild to moderate cases, pediatricians recommend (and insurance companies often cover) regular visits to a physical therapist who works with the child on stretching and strengthening exercises to build the weaker neck muscles, Dias says.

In addition to increased tummy time, Telford has learned from the physical therapist to turn Trent's neck to the left and hold it for 10 seconds as well as to gently pull and stretch out that side. It is a ritual they do several times a day.

"This gives us peace of mind, so we know we're doing everything so he develops correctly," says Telford, of Pleasant Hill. "It's reassuring to go to the therapist, although I think it would have gotten better on its own. Once he started spending more time on his tummy, it got a lot better."

It's difficult to say when a flat head will round out. Dias says improvement is based on the degree of deformity and how the child's head grows and develops. But with positional changes and physical therapy, you should generally notice a difference by nine months of age, when the child is rolling over and spending less time on his back.

Help from helmet

When positional changes are not enough or the deformity is moderate to severe, experts recommend helmet therapy. Using three-dimensional digital scans, providers create a customized mold of the baby's head and design a lightweight helmet out of foam, says Trish Collins, a certified orthotist with Centers for Independent Rehabilitative Services in Oakland. 

Helmets can cost up to $4,000 and are covered by insurance companies, based on the degree of deformity, Collins says. They round out the head by applying gentle pressure where the skull needs to grow and gaps where it doesn't, explains Bryant Toth, co-director of the Craniofacial Center at Children's Hospital & Research Center in Oakland. Most babies are required to wear their helmet 23 hours a day for about six months. The earlier they are treated, the faster the response will be.

"I like to see them by four months of age," says Toth, who sees about 80 babies a month with positional plagiocephaly. "What is nice about the helmet is it takes the guilt and pressure off the family to get up in the middle of the night and change the baby's position."

Dias is less fond of helmet therapy. He recommends helmets about 20 percent of the time because long term studies show that infants who have been treated with helmets are no better off than those who did nothing, he says. In other words, no matter what they do, their heads always will be a little flat.

It took a week for little Christopher Henry to adapt to his helmet. According to his mother, Holly, of San Jose, Christopher wore it for four months. She found it made nursing difficult, she says.

"It seemed uncomfortable for sleep, too, but he got used to it, and it worked," Holly says.

Obvious improvement

Not completely. Christopher, now 19 months old, has been out of his helmet for almost a year. Holly says her son's ears and eyes are symmetrical, but his head is still a bit flat. "I can tell when I look down at the top of his head," she says.

Both of Mabel Kimball's children had plagiocephaly. Kimball, of San Jose, didn't pursue treatment for her daughter, now 4, because she figured her long ponytail always would cover the flatness and resulting bump on her head.

But, in case her son, Ian, ever went bald or wanted to shave his head, she didn't want him to feel self-conscious, she says. Ian is 9 months old and has been wearing a helmet decorated with bright cars and trucks for two months.

Her baby is perfectly happy in it. If anything, Kimball says the helmet is hard on her.

"I can't quite get close enough to kiss him," she says. "I'll aim for his cheek and then he turns his head and whacks me in the face with his helmet."

Preventing plagiocephaly

  • Look at your baby's head often. Point out any bumps or areas of flatness to your pediatrician.

  • Give your baby tummy time early and often. But make sure you are always in the room.

  • Carry him whenever possible. Keep him upright.

  • Vary the baby's sleeping position. Alternate which side you turn his head to each night when you put him to bed. Do the same at naptime.

  • Unless he's riding in a vehicle, limit the amount of time your baby spends in a car seat. The same goes for swings, carriers or bouncy seats, where the back or side of your baby's head rests against them.

  • Hang toys in the direction you want your baby's head to turn. Or, roll up a small towel, tape it shut and place it under baby, from shoulder to bottom, to help lift him off the side he favors.