Physical Therapist's Guide to
Head-Shape Flatness in Infants: Plagiocephaly, Brachycephaly, and Scaphocephaly
Plagiocephaly, brachycephaly, and scaphocephaly are skull deformations caused by an infant lying in 1 position for too long. These conditions are also known as “flat head syndrome.” Newborn baby skulls are soft, as the bone has not hardened yet. When a baby’s head rests against a surface in the same position for too long, the infant’s soft skull may flatten. Skull deformations like plagiocephaly, brachycephaly, and scaphocephaly may affect up to 45% of newborn babies. The skull flattening can occur in the womb due to the baby being stuck in 1 position or having limited space when there are multiple fetuses, such as twins or triplets. When seen at birth, the condition is called “congenital”; when it occurs after birth, it is called “acquired.” More severe head-shape deformities are linked to problems in baby development, such as movement, vision, hearing, and behavior problems that may last a lifetime.
A physical therapist can help reduce the flattening of a baby’s skull and restore a more normal, rounded skull shape, which may help reduce the risk of developmental delays and other disabilities later in life.
Head-Shape Flatness in Infants: Plagiocephaly, Brachycephaly, and Scaphocephaly
Plagiocephaly, brachycephaly, and scaphocephaly are different types of skull flattening that occur when pressure is put on one part of a baby’s skull for too long.
Plagiocephaly is flattening of the side of the back of the skull caused by a baby lying for too long on its back with the head turned slightly to the side. Before birth, plagiocephaly can occur in the womb if the mother’s amniotic sac does not contain enough fluid, or if there are multiple fetuses, such as twins. It also is often associated with premature birth, as premature babies often lack strength in their necks to move the head into different positions when they are lying down. When the head is left in 1 position too long, the soft skull deforms and becomes flatter where it is in contact with the mattress or whatever surface the baby is lying on.
Plagiocephaly is more common in male babies than female babies, and more commonly occurs on the right side of the back of the skull. Babies who have torticollis, a painful muscle tightness in the neck that forces the head to stay rotated to 1 side, may be particularly susceptible to developing plagiocephaly.
Brachycephaly is flattening of the back of the skull, caused by the baby lying on its back for too long. Before birth, brachycephaly can occur in the womb if the mother’s amniotic sac does not contain enough fluid, or if there are multiple fetuses, such as twins. After birth, it can occur if the infant lies on its back or is placed in a container, such as a car seat, for too many hours per day. Brachycephaly is the second most common skull deformation, after plagiocephaly.
Scaphocephaly is flattening of the side of the skull, causing an elongated skull. This is caused by the baby lying on its side for too long. This commonly happens in the neonatal intensive care unit (NICU), as premature babies are positioned on their side for ease of treatment. Scaphocephaly can also happen prior to birth; for example, if the fetus’s head is pressed against the mother’s rib cage.
If untreated, more severe cases of flattening of the skull have been associated with:
- Problems with speech and language development
- Delayed intellectual and motor (movement) development
- Balance problems
- Social interaction problems
- Neuropsychiatric problems, such as attention deficit disorder (ADD) and attention deficit and hyperactivity disorder (ADHD)
- Appearance problems
- Facial or skull asymmetries (the sides of the face or the shape of the skull appear uneven)
- Uneven ears
- Uneven eyes
The good news is that a baby’s skull remains soft for a few months, so if the flattening is noticed and treated early, it can re-form to a more normal, rounded shape. Reshaping of the head will also help prevent the disabilities early and later in life that plagiocephaly, brachycephaly, and scaphocephaly can cause.
Rising Incidence in Recent Years
In 1992, the American Academy of Pediatrics (AAP) introduced guidelines to help new parents prevent sudden infant death syndrome (SIDS). Sudden infant death syndrome was thought to be caused by infants sleeping on their stomachs, with soft materials around them that could block their breathing and cause the infant to suffocate. The phrase “back to sleep” was coined to help parents remember to clear the crib of soft blankets, pillows, and stuffed toys, and place the baby on its back to sleep, all of which was intended to keep the baby’s airway (nose and mouth) free of obstacles.
Although SIDS has decreased by 50% since the guidelines were introduced, reports of skull deformities including plagiocephaly and brachycephaly have risen dramatically. This is likely due to infants being placed in the same position (on their backs) every night, so the same part of the skull is in contact with the bed surface. The prolonged contact of the same part of the skull with the bed surface leads to flattening of the skull.
Container Baby Syndrome
The rising incidence of plagiocephaly and brachycephaly is also due to another new syndrome, container baby syndrome. It can occur when newborns are kept in “containers” such as car seats, strollers, and bouncy seats for too many hours in a day. If their heads are in contact with a surface for too long, even when sitting, the soft skull can deform and become flattened.
How Does it Feel?
There is no evidence that plagiocephaly, brachycephaly, or scaphocephaly cause pain. However, hearing and vision development can be delayed in babies with severe head-shape deformities, therefore, affected babies may not be hearing or seeing the world in a normal way.
Signs and Symptoms
The signs of plagiocephaly, brachycephaly, and scaphocephaly are the visible flattening of the skull on the side of the back of the head, the back of the head, or the side of the head, respectively.
How Is It Diagnosed?
Parents may be the first to notice that the baby’s skull is becoming flattened on the back or on 1 side. They may also notice that the baby keeps the head tilted to 1 side because of muscle tightness.
CAUTION: If you see these problems, seek medical help immediately!
Your physician will evaluate your baby’s head to determine the cause and extent of skull flattening. Your physician may refer your baby to a physical therapist for treatment.
Your physical therapist will conduct a thorough evaluation that includes taking the baby's health history. The physical therapist also will ask you detailed questions about how the baby is handled and the baby's activity level each day, and gently test for signs and symptoms of common plagiocephaly, brachycephaly, and scaphocephaly problems, such as:
- Flattened skull: The back or the side of the head is abnormally flat.
- Torticollis: The baby has difficulty turning the head to 1 side, or keeping the neck and head straight due to muscle tightness on 1 side of the neck.
- Facial asymmetry: The sides of the baby's face may appear unequal as a result of the skull deformity and flatness.
Your physical therapist will examine:
- The shape of the skull and face
- The baby’s muscle development
- The baby’s neck, trunk, arm, and leg movement
- How your baby holds the head and neck
- How your baby moves the head, body, and limbs
- How well your baby can lift the head and limbs when lying on the tummy
- How well your baby can roll over, crawl, and change body positions
- How well your baby can track objects with the eyes
Your physical therapist will likely also test for problems that can possibly occur in babies with severe plagiocephaly, brachycephaly, and scaphocephaly, such as:
- Delayed muscle development. The baby may not be able to roll, sit up, crawl, or lift the head or reach out with the arms when on the tummy in a way expected for the baby’s age.
- Sensory problems. The baby may show a delay in the development of vision or hearing skills. The baby may have depth-perception problems, and problems tracking moving objects with the eyes.
- Delayed cognitive development. The baby may have delayed development of certain thinking and language skills.
Your physical therapist will likely collaborate with a physician or other health care provider to make a final diagnosis. Further tests may be necessary to confirm the diagnosis, and to rule out other problems.
If your physician notices signs of plagiocephaly, brachycephaly, or scaphocephaly before you do, the physician may refer your baby to a pediatric physical therapist for evaluation and treatment.
How Can a Physical Therapist Help?
Based on the findings during the examination, your physical therapist will develop and implement an individualized treatment plan to address your baby's specific needs.
Physical therapy for any skull deformations should be started early, often prior to the baby being 3 months old, but a physical therapist can also help a child who is older regain strength and well-being. Your physical therapist will help improve your baby's:
Skull shape. Your physical therapist will help your baby achieve and stay in certain positions that will give the skull a chance to become more normally rounded. Physical therapists teach parents this “repositioning therapy,” so it can be done at home. Repositioning therapy is the first line of home treatment. Your physical therapist will teach you how to reposition your baby in ways to aid in developing more normal movements, strength, and skull shape. This therapy usually consists of increased floor time and “tummy time,” and increased times of sitting upright.
Parents are encouraged to hold their baby more, and to perform other activities to encourage movement. Recent guidelines recommend tummy time 3 times a day, with constant adult supervision. Your physical therapist will design a safe program to gently treat your baby's particular symptoms.
Based on each child's condition, the baby’s pediatrician may prescribe an orthotic device, such as a remolding helmet, to gently redirect the growth of the baby’s skull.
CAUTION: Babies should not sleep in carriers or strollers at night unless instructed by a pediatrician.
Motion. Your physical therapist can help loosen any tight neck muscles your baby may have by using specific stretching motions, positions, and hands-on techniques called “manual therapy.” These techniques gently help the tight muscles relax, which allows the baby to regain more movement in the neck.
Strength. Your physical therapist can work on specific skills your baby needs to develop. The therapist may use toys, games, and songs to encourage your baby to learn new movements and strengthen underdeveloped muscles. The program will progress to match the growing skills and strength of your baby.
Your physical therapist can help improve your own:
Knowledge. Your physical therapist can educate you about the causes of the flattened skull, and teach you healthier ways to position, feed, and provide safe nap and play times for your baby.
Preventive skills. You'll learn how to safely place your baby on the tummy (eg, on the floor or in a playpen) after every feeding, nap, diaper change, and whenever the baby is awake and alert. Holding the baby for feedings, rather than feeding the baby in a carrier or stroller, allows the baby to look around, which improves neck and eye movement. A playpen is a good way to allow the baby to be active and safe while giving the parent some time to get chores done, without confining the baby to a container. Changing the position of toys and mobiles in the crib encourages babies to turn their heads in different directions.
Can this Injury or Condition be Prevented?
Parents can prevent the development of acquired (after-birth) plagiocephaly, brachycephaly, and scaphocephaly by:
- Providing sufficient tummy time during the day, when the baby is awake, starting soon after birth.
- Varying the position of the baby frequently.
- Allowing the baby to lie or sleep on its tummy, while supervised (with pediatrician approval).
- Limiting the time the baby spends sitting in or being propped up by containers, such as car seats, strollers, rockers, and nursing cushions. Car seats should only be used during transportation in vehicles for safety.
- Holding the baby in their arms or a sling for short periods, instead of leaving the baby in a container.
- Allowing the baby to play freely in a playpen.
- Allowing the baby to frequently play on the floor on a blanket (with adult supervision).
Congenital (prebirth) forms of these conditions cannot be prevented, but early treatment will yield the quickest and best results in correcting skull shape.
Real Life Experiences
Taylor was born slightly underweight, but otherwise healthy. After a few days of careful feeding in the hospital, Taylor reached a healthy birth weight, and was released home. Taylor’s parents, cautious about handling their delicate baby, felt Taylor looked very secure in her car seat and decided to place her in it to sleep at night. After a couple of weeks, Taylor’s mother noticed that the back of her baby’s head wasn’t rounded, like other baby’s heads. It was somewhat flat.
Taylor’s mother mentioned this to her pediatrician during Taylor’s next checkup. The physician examined Taylor’s head and saw signs of flattening on the back of the skull.
Taylor’s physician explained that Taylor’s head shape flattening was probably caused by her sleeping in her car seat at night. He immediately referred Taylor to a pediatric physical therapist, explaining that Taylor should start physical therapy treatments as quickly as possible for the best results.
Taylor’s physical therapist conducted a full physical evaluation, and confirmed the physician’s suspicions: Taylor had developed brachycephaly. She assured Taylor’s parents that treatment at this early stage could be very effective.
Taylor’s physical therapist explained that Taylor’s treatment would focus on clinical and home treatment techniques. She said that if improvement did not occur quickly enough or fully by 6 months of age, there was an option to use a cranial remolding helmet to gently reshape Taylor’s skull.
Taylor’s physical therapist taught Taylor’s mother how to safely place Taylor on her back to sleep in her crib. She explained how to keep the crib clear of objects, such as pillows and blankets, so it was free of objects that could impede Taylor’s breathing while she slept.
The physical therapist explained to Taylor’s mother that when Taylor was not asleep, she should be placed in positions other than on her back, as much as possible, as long as she was supervised by an adult. She encouraged her parents to lay Taylor on her side sometimes, and on her tummy sometimes, and to combine that with active playing and lots of interaction with an adult.
Taylor’s physical therapist placed Taylor on her belly and performed some gentle hands-on exercises in that position. Taylor was somewhat fussy being on her belly during this first session, as she was not used to it, but her physical therapist gave her lots of little breaks to lay on her side and back, and used toys to make the time on her tummy fun and entertaining. She taught Taylor’s mother about “tummy time,” how often to have Taylor do it, and how to do it safely.
The physical therapist explained that putting Taylor in a playpen was better for Taylor’s development than putting her in a container, such as a car seat or swing at home. She also encouraged Taylor’s mother to carry Taylor in her arms at home, holding her upright or on her tummy, rather than using a carrier or stroller, as arm-carrying encourages babies to use and develop neck muscle strength. Taylor’s mother was excited to learn that using neck muscles to hold up the head can help restore the natural rounded shape of a baby’s skull.
Taylor’s physical therapist reminded her mother to not use a car seat except when Taylor was actually traveling in a car. She urged her to also avoid using any other kind of baby “container,” such as a stroller, rocker, nursing cushion, bouncy seat, or vibrating chair, as these devices limit head movement and muscle development.
Taylor’s mother applied the home treatments she had learned over the next few weeks. Taylor became adjusted to spending time on her tummy, and enjoyed playing with some of her toys that way.
After 7 weeks, Taylor’s skull flatness had almost completely vanished.
Because Taylor’s mother had sought treatment early, Taylor was able to make a full recovery without the use of a cranial remolding helmet. Being allowed to move around more, outside the car seat, Taylor seemed more awake and engaged, and frequently giggled and laughed like a very happy baby!
This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.
What Kind of Physical Therapist Do I Need?
Many physical therapists are prepared through education and experience to treat children who have plagiocephaly, brachycephaly, and scaphocephaly. You may want to consider:
- A physical therapist who is experienced in treating children (pediatrics).
- A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in pediatric physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to this condition.
You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you’re looking for a physical therapist:
- Get recommendations from family and friends or from other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapists’ experience in helping this condition.
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.
The following articles provide some of the best scientific evidence related to physical therapy treatment of plagiocephaly and brachycephaly. The articles report present research and give an overview of the standards of practice for treatment both in the United States and internationally. The article titles are listed by year and linked either to a PubMed abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
Kaplan S, Sargent B, Coulter C. Congenital muscular torticollis and cranial deformations. In: Palisano RJ, Orlin M, Schreiber J, eds. Physical Therapy for Children. 5th ed. Philadelphia, PA: WB Saunders; 2017.
Binkiewicz-Glińska A, Mianowska A, Sokołów M, et al. Early diagnosis and treatment of children with skull deformations: the challenge of modern medicine. Dev Period Med. 2016;20:289295. Free Article.
Cabrera-Martos I, Valenza MC, Valenza-Demet G, et al. Effects of manual therapy on treatment duration and motor development in infants with severe nonsynostotic plagiocephaly: a randomised controlled pilot study. Childs Nerv Syst. 2016;32:2211–2217. Article summary in PubMed.
Baird LC, Klimo P Jr, Flannery Am, et al. Congress of neurological surgeons systematic review and evidence-based guideline for the management of patients with positional plagiocephaly: the role of physical therapy. Neurosurgery. 2016;79:E630–E631. Free Article.
Cabrera-Martos I, Valenza MC, Valenza-Demet G, et al. Repercussions of plagiocephaly on posture, muscle flexibility and balance in children aged 3-5 years old. J Paediatr Child Health. 2016;52:541–546. Article Summary in PubMed.
van Vlimmeren LA, van der Graaf Y, Boere-Boonekamp MM, et al. Effect of pediatric physical therapy on deformational plagiocephaly in children with positional preference: a randomized controlled trial. Arch Pediatr Adolesc Med. 2008;162:712–718. Free Article.
Coulter-O'Berry, C, Lima, D. Tummy time Tools. MoveForwardPT.com website. Published 2007. Accessed September 21, 2017.
*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.
Authored by Andrea Avruskin, PT, DPT. Reviewed by the editorial board.