There are a variety of factors which may result in a baby having flattening of the bones in their head.  A common thread through these factors is restriction of the bones by outside forces or restriction of movement of the head.  Before getting into more detail, let’s start with a few definitions.  

Explanation and definition of terms

Flattening alone may not be a cause for concern.  It depends on the amount of flattening and whether the alignment of the jaw, ears, and eyes are affected. 

If the flattening is combined with asymmetry, this is called plagiocephaly.  If the plagiocephaly is significant, it can affect the symmetry of the jaw, ears, and eyes. 

If the flattening goes across the back of the head and is symmetrical, this is called brachycephaly. With brachycephaly, the lower jaw may be shifted forward and the oral structures may also be skewed creating the potential for sleep apnea later in life.  

Both of the above conditions may involve muscular restrictions which limit full movement of the head (torticollis).  This can lay the foundation for a baby to be unable to fully view the environment and may impact symmetrical development and/or slow milestones. 

It is important for parents to understand that head shape is not isolated from overall development.  Flattening of the skull bones is common.  It is also common for there to be an underlying muscular imbalance which can impact developmental progressions.  It is crucial for parents to understand that this constellation of symptoms correlates with a higher likelihood of language and cognition delays. (Cognitive Outcomes and Positional Plagiocephaly | American Academy of Pediatrics (

An Aside…

You may notice in the list below that some of the factors around flattening of the head shape can be influenced by the parent and other caregivers, but many are out of one’s control.  So even if you notice items in the list that you didn’t know and might have done differently had you known, please try not to blame yourself.  Bypass “Blame Yourself” Street if possible and turn down “Once I Knew Better, I Did Better” Street.  Lift yourself up, pat yourself on the back, and realize you are experiencing a universal aspect of parenting.  That is, parenting has a great deal of course correction involved.   As tremendously experienced occupational and physical therapists who’ve worked with thousands of families over many years, we know this to be true!  You are not alone!

Infants at higher risk of head flattening include:

  1. Infants born prematurely
  2. Infants who had a traumatic birth
  3. Infants who were in a restricted intrauterine environment such as multiple births or maternal fibroids or being carried very low throughout a long portion of pregnancy
  4. Large infants born to mothers with smaller pelvises.
  5. Infants that spend greater than 15 hours/week harnessed into equipment such as car seats, boppy seats, swings, and the Snoo.  This also includes a baby placed on a boppy pillow on her or his back (a baby placed flat on her back with a toy to either side, not always an activity mat, is far preferable to the baby being in a boppy pillow.  A blog post coming on this).  Container Baby Syndrome Physical Therapy Guide to Container Baby Syndrome –
  6. Infants who have a preference for turning in one direction, be it left, right, or center.  Depending on other factors this may be termed torticollis and may affect not only the way the head turns and moves but also hand use, visual exploration, pelvic and ribcage position, and the symmetry of development  (rolling in one direction only, etc.).
  7. Infants who have muscular strength and flexibility imbalances where one side may be tighter than the other.  Sometimes the imbalance is not on either side of the neck but in shortening in both sides and the front of the neck.
  8. Infants who develop more slowly during the first weeks and months of life
  9. Infants in group care situations such as child care centers
  10. Infants with other medical issues that may make repositioning more difficult and slow development such as cardiac issues
  11. Familial tendency to grow quickly with possibly more pliable bones
  12. Infants who have tongue ties
  13. Infants who also have hip dysplasia

Please note the relationships between many of the factors above.  For example, an infant who was premature is more likely to have slower development early on.  Another example is a family who has twins with other medical issues may need to use more equipment (containers).  Another theme to notice is that restriction of movement of the head and body is often involved, whether it is in utero or after birth via equipment usage.  

Note also that while swaddling entails some restriction, it is helpful to soothe and organize many infants in the early weeks of life.  It is important to swaddle correctly (a later blogpost will touch on this, call us if you need the information now) and not to use beyond 2-3 months of age. 

Another important theme to note is that which is helpful for development is also helpful for head shape.

If your baby has one or more of these risk factors, what should you do?

If you notice flattening of the skull bones or a preference to turn one way, address it quickly.  The way to address is varies infant to infant.  It could be increasing tummy time; repositioning head during sleep; and reducing equipment.  It could mean occupational or physical therapy.  The idea is to first halt further flattening, then possibly begin improvement of the head shape.  By addressing flattening as soon as it is noted, the least amount of intervention, time, and cost will be needed.  Not only will your infant’s head shape be improved, their developmental progressions will be improved.  A newborn to 8 week old infant will need far less intervention than a similar baby who did not receive intervention early.  Of course, there are varying levels of initial severity and involvement.  A conservative approach in this scenario is to lean towards having an evaluation with an occupational or physical therapist highly skilled in this area who has manual therapy training.

To expand upon what was discussed earlier, some factors may be within in your control, while many are unavoidable.  Throughout our many years of working intensely with infants and their parents it is evident that parents love their infants and want to do right by their baby.  Parents of young infants are at a vulnerable time of life and marketers of baby equipment prey upon this vulnerability.  

While Google is a great source of general information, it is best to talk to your pediatrician or a pediatric occupational or physical therapist if you have any questions about how to influence the factors above or about your baby’s head shape or development.  Questions or want to make an appointment?  Please reach out to us at 704-379-7773 or [email protected]

Dedicated to the caring parents and infants in our clinic who so often have lamented,If only I had known”.  Thank you.