Pediatric Neurosurgery

Positional Plagiocephaly (Flat Head Syndrome)

Comprehensive Head Shape Clinic for Babies at UH Rainbow Babies & Children’s

What is positional plagiocephaly? Also known as flat head syndrome, positional plagiocephaly is a condition in which an area of an infant's head develops an abnormally flattened shape. The condition usually occurs when an infant always sleeps with its head turned to the same side during the first few months of life.

University Hospitals Rainbow Babies & Children's Hospital offers a multidisciplinary Head Shape Clinic that specializes in the evaluation, diagnosis and treatment of children with head shape abnormalities, including positional plagiocephaly and craniosynostosis.

Your child’s health is important. Make an appointment today.

Schedule an appointment today with the pediatric experts at UH Rainbow. Call 216-844-5741, press option 3.

What Causes Flat Head Syndrome?

A baby’s sleep position is the most common cause of a flattening of the head. Because the safest sleep position for infants is on their backs, and because infants often lie on their backs for a large portion of the day, their heads can flatten in one area. This happens not only during sleep but also when sitting in carriers, infant car seats, strollers, bouncy seats and swings. When a flattening occurs at the back of the head, the condition is referred to as brachycephaly.

Because their skulls are softer than those of full-term babies, premature babies are more likely to develop positional plagiocephaly than full-term newborns. Preemies may spend more time on their backs without being moved or picked up as a result of their medical needs and their time spent in a neonatal intensive care unit (NICU).

Positional plagiocephaly can begin before birth if the presence of a twin or the mother’s own pelvis creates abnormal pressure on the baby’s skull. It’s not uncommon for children from multiple births to be born with flat spots on their heads.

Another cause of flat head syndrome is a neck condition called torticollis. Also known as wryneck or twisted neck, torticollis is a twisting of the neck that causes the head to rotate and tilt at an odd angle. Because babies with this condition have difficulty turning their heads, they tend to keep their heads in the same position when lying down. As such, torticollis sometimes leads to a flattening of the skull. Once a flat spot develops, the torticollis itself can worsen.

What Are the Symptoms & Signs of Flat Head Syndrome?

Parents can usually identify positional plagiocephaly themselves. The main symptoms are:

The back of the baby’s head is flatter on one side.
On the flatter part of the head, the infant typically has less hair.
The ear on the flattened side of the head may appear pushed forward when you look down at the baby’s head.

In severe cases, the child’s forehead may bulge on the side of the flattening and may appear uneven. If torticollis is the cause of the positional plagiocephaly, the face, neck and jaw might be uneven, too.

How Is Positional Plagiocephaly Diagnosed?

Doctors can generally diagnose positional plagiocephaly by a simple examination. The doctor may also check for torticollis by observing how a baby moves its head and neck. Further medical testing is usually not necessary. In certain cases, we may use the STARScanner laser data acquisition system – special technology that is safe, takes less than 2 seconds and captures detailed head shape measurements, particularly if craniosynostosis or a similar condition is a suspected cause of the skull flatness. Craniosynostosis is a condition in which the flexible, fibrous joints (called sutures) that separate the plates of the baby’s skull close too early, causing problems with normal skull and brain growth. A STARScanner scan provides definitive information on the volumes, symmetry ratios, circumference and linear measurements of the head. If craniosynostosis is the cause of a baby’s positional plagiocephaly, our team may be able to facilitate a same-day appointment with one of the members of our craniofacial team, including a pediatric craniofacial surgeon and/or pediatric neurosurgeon.

Other imaging technologies we may use in the diagnosis and assessment of positional plagiocephaly include ultrasound, x-ray and CT scan imaging.

How Is Positional Plagiocephaly Treated?

UH Rainbow’s multidisciplinary Head Shape Clinic is located at the Zagara Pediatric Specialty Clinic at our main campus in Cleveland, Ohio. The clinic includes a team of clinicians from Pediatric Neurosurgery, Pediatric Plastic Surgery, Pediatric Physical Therapy, a representative from Hanger Clinic (our helmet vendor), and access to the STARScanner for a complete evaluation in one visit for patient/family convenience.

Correction of positional plagiocephaly at the clinic focuses on assessment, repositioning, physical therapy and helmet therapy.

Treatment of positional plagiocephaly at the clinic focuses on a comprehensive evaluation from the following experts and services:

Assessment

Pediatric neurosurgery and plastic surgery team members conduct an initial assessment of the baby’s head.

Scanning

In certain cases, we will scan the baby’s head using the STARscanner laser data acquisition system. This advanced, completely safe scanning technology provides instant, precise 3-D data that can be viewed in multiple planes to assess cranial deformities. The STARscanner is particularly useful in determining the projected growth pattern of the skull, providing definitive information on the volumes, symmetry ratios, circumference and linear measurements of the head. In using this imaging technology to monitor a baby’s progress beginning in early infancy, the physician can develop the most effective course of treatment.

Regardless of whether your child receives manual therapy or helmet therapy to correct his or her flat spot, the STARscanner can be utilized throughout the course of treatment to monitor progress and determine if any modifications in treatment are needed. The scanner has a feature that allows the doctor to compare follow-up scans with the initial baseline report in order to view your infant’s progression or improvement.

Repositioning

As part of the clinic, parents are instructed in the importance of repositioning in correcting positional plagiocephaly.

In keeping with American Academy of Pediatrics guidelines, parents and other caregivers should always place infants on their backs when they go to sleep to help prevent sudden infant death syndrome (SIDS) despite the possibility of the development of flat head syndrome. When possible, avoid using car seats, bouncy chairs, swings, and other devices for a baby’s sleep time, as sleeping in such devices can restrict movement of a baby’s head.

If positional plagiocephaly develops due to a sleeping or lying position, the following practices can make the flat spot go away:

Practice tummy timez. Make sure your baby has plenty of supervised time to lie on the stomach while awake during the day. Tummy time:
- assists in normal shaping of the back the head
- strengthens babies’ neck muscles and helps them learn to push up on their arms, thereby developing the muscles needed for sitting up and crawling
- encourages a baby’s learning and discovery of the world
Hold your infant more often. Limit the time your baby spends lying on the back or with the head resting against a flat surface (such as in strollers, car seats, swings, bouncy seats, etc.) Picking up and holding your infant often will take pressure off the head. If your little one falls asleep in a car seat, take the baby out of the seat as soon as you get home rather than leaving the infant sleeping in the seat.
Change the head position while your baby sleeps. Change the position of your baby’s head (from left to right, right to left) when your baby is sleeping on the back. Even if your baby moves around during the night, place your child with the rounded side of the head touching the mattress and the flattened side facing up. Don’t use wedge pillows or other devices to keep your baby in one position.
Switch your infant’s positions in the crib. Be conscious of how you lay your baby down in the crib. Most right-handed caregivers carry babies cradled in their left arms and lay them down with their heads turned to the left. When lying in this position, the baby must turn to the right to look out into the room. Placing your baby in the crib in this manner encourages active turning of the head to the side that’s not flattened.

Physical Therapy

Most babies with positional plagiocephaly also have torticollis to a varying degree. As such, physical therapy and a home exercise program usually are part of treatment plant for positional plagiocephaly accompanied by torticollis.

As part of our Head Shape Clinic, a representative from UH Rainbow Pediatric Physical Therapy is present to refer you to physical therapy services and also begin neck stretching exercises. The goal of these exercises is to stretch the baby's neck so that the neck muscles become longer and the neck straightens itself out.

Helmet Therapy

In some cases, we will prescribe a special helmet to correct positional plagiocephaly. The helmet is engineered to fit loosely where the head is flat and tightly where it is round. When enveloped by the helmet, the infant's head will only grow where it’s flatter.

At the Head Shape Clinic, we use the most recent clinical guidelines to determine when to recommend helmet therapy if your baby’s flat spot is severe and/or if positioning does not help fix the flat spot over time. If indications are that helmet therapy will be beneficial, a representative from the helmet company is on site to meet with the family during the visit – shaving off three weeks of the process for treatment to begin.

Positional Plagiocephaly Improves With Time & Natural Growth

As they grow older, babies start to change position themselves while sleeping so that their heads aren’t always in the same position. Once a baby can sit on their own, their flat spot usually will not worsen. Over months and years as the skull grows, the flattening will improve, even in severe cases. In addition, the flat spot often becomes less noticeable as hair grows in over the child’s first few years of life.

Positional Plagiocephaly does not affect the growth of child's brain. However, neck stiffness can slow early development. Physical therapy for torticollis will usually include evaluation of the infant's progress and additional exercises to address any delays.

Hours

The Head Shape Clinic is open on the first, third and fifth (when applicable) Thursdays of every month, 9 a.m. – noon.

Referrals

To refer a patient to the Head Shape Clinic, contact Brianna Moss at Brianna.Moss@UHhospitals.org or 216-844-5741, option #3.

The UH Rainbow Head Shape Clinic is staffed by pediatric nurse practitioners Catherine Harrigan and Charles Novince from Pediatric Neurosurgery and Plastic Surgery. If they are concerned that a baby may have a diagnosis beyond positional plagiocephaly, they will arrange for further physician evaluation.