Shaping Up: Support for Babies with Flat Heads

A baby smiles whilst wearing a helmet used for treating flat head conditions in babies.
Photo by jenjen42 (iStock photo)

 

 

By Simon Yap and Sarah Russell

 

Positional Head Shape Deformities

Positional head shape deformities (PHDs) have become more prevalent since the Safe to Sleep campaign was introduced in 1994 as a means to reduce the risk of sudden infant death syndrome (SIDS) (1,2). While SIDS has significantly reduced, sleeping babies on their backs has led to a rise in PHDs such as plagiocephaly and brachycephaly (see Figure 1) (3,4). This rise has been reported to be as high as 600% (2). 

Positional head shape deformities are most likely to occur during the first few months of life, when babies spend a significant amount of time on their backs, and their heads are soft and rapidly growing (3). Flat head shapes may also result from conditions and factors including a limited ability to rotate the neck (torticollis), premature birth, multiple birth, and intrauterine constriction (2,5)

 

What are the risks associated with a flat head?

Commonly, parents want to understand whether a PHD might be connected to their baby’s development. A 2017 study suggested that PHDs are “a marker of elevated risk of developmental delays” (6), meaning there may be a link between PHDs and developmental delay. Motor delays were reported to be the most commonly affected area of development. Additionally, it is thought that babies with a PHD may be less active than other babies the same age (2).

 

What do I do if I notice a flat spot on my baby’s head?

If your baby has a flat spot and you’re either worried about it or you notice the flatness getting worse, we recommend that you consult a clinical professional with expertise in this area, such as a physiotherapist, occupational therapist, or orthotist. These professionals will be able to offer some insight by undertaking a comprehensive assessment, which may include taking measurements and 3D images to accurately understand the precise location and severity of the flatness.

 

Treatment for PHDs

There are two main approaches to treating a baby that a clinical professional has determined has a PHD: physical therapies and a customized helmet. Research suggests that a physical therapy program should be implemented first (2). 

Physical therapies: Occupational therapists and physiotherapists are allied health professionals who can assess and treat babies with head shape deformities through the use of physical therapies. Referrals to occupational therapists and physiotherapists commonly come from pediatricians and child health nurses, though a growing number of parents are starting to seek support independently.

Assessment involves uncovering underlying reasons for head shape deformity, exploring physical (e.g. development and muscle tone) and environmental factors (e.g. sleep position, tummy-time exposure). Following the initial assessment, treatment involves a combination of caregiver education, physical therapies, and repositioning or counter-positioning.

Early intervention is strongly recommended when physical therapies are the most suitable option for your baby. This is because treatment is most effective when started as early as possible (7). You can find recommendations on how to minimize the risk and assist in the management of PHDs in Sarah Russell’s article, “Head Shape Deformities in Babies” in the February 2022 issue of BAMBI Magazine (8). 

 

Helmets: Some babies require further, more intensive treatment for a PHD, such as a customized helmet. Best practice guidelines suggest mild presentations of PHD benefit from physical therapies while a helmet is the superior treatment option for serious or severe presentations, prevalent at six months or older, or for babies with severe PHD regardless of age (2,9). 

Helmets used for PHDs are typically custom-made by an orthotist. Advancements in technology, including 3D printing (see Figure 2), have enhanced the materials available, the weight, and the overall comfort of helmets. Helmets typically consist of a rigid outer shell and a foam or fabric inner layer that provides a cushioning barrier between the baby’s head and the outer shell. 

 

How do helmets work to fix flat spots?

Helmets work by applying persistent pressure and force to area(s) of the head that are “prominent or bulging”, or are otherwise not flat or less flat. This inhibits growth in those areas and encourages it in the flatter areas. The baby is closely and regularly monitored so that adjustments to the helmet can be made as their head grows, ensuring that the helmet is appropriately addressing their changing head shape.

  

How many hours a day does a baby need to wear their helmet? 

For the best outcome, it is widely accepted among clinical professionals that a helmet be worn for 23 hours a day. The helmet can be removed for one hour a day, typically for activities such as showering, swimming, or special occasions.

 

How long will my baby need to wear the helmet? 

The length of time babies need to wear a helmet depends on their individual needs, which are assessed and closely monitored by a professional such as an orthotist. Factors such as the age of the baby, the severity of the PHD, and how the head shape is responding to the helmet will determine the duration of time the helmet is required.

Typically, helmet therapy begins when a baby is between four and 12 months old, with a common wear-time of three to four months. Some wear-times may be longer or shorter, depending on individual physical factors. The earlier helmet therapy begins, the more effective it has been shown to be (2). Typically, intervention around four to six months of age is ideal because babies’ skulls are still soft and growing rapidly, which means they are receptive and responsive to being remo

ulded.

 

Are helmets effective?

There is some debate in the research on the effectiveness of helmets for treating PHDs. The NHS, the UK’s public healthcare system, does not recommend the use of helmets, stating “there is not clear evidence to suggest they work” (10). However, a systematic review of the effectiveness of conservative treatment for PHDs—which included helmets—summarizes a number of robust studies in support of helmet therapy for PHDs (2). One study in the systematic review reported that 95% of infants in the group receiving helmet therapy achieved complete correction (11). 

The bottom line is there is a good amount of research to suggest that helmets are worth exploring for severe PHDs and head shapes that have not made improvement following physical therapies. 

 

Take home points

  • Occupational therapists, orthotists, and physiotherapists can all play important roles in treating babies with PHDs.
  • Early identification of PHD is associated with improved outcomes. If you notice any change to your baby’s head shape, seeking advice as soon as possible from a professional with experience in this area is strongly recommended.
  • Research guidelines inform that physical therapies are appropriate as an initial treatment, and that helmets should then be considered if no improvement is seen or if the PHD is severe.
  • Helmets have been shown to be an effective treatment option in helping to correct head shape deformities if treatment is started between four and 12 months of age.
  • Helmets today are made from various lightweight materials. These make wearing the helmet more comfortable and likely to be tolerated.
  • Your baby will require time to adjust to the helmet as they would any new addition to their body. After this period of adjustment, babies generally tolerate helmets well and appear to find them comfortable even when sleeping.
  • If your baby requires a helmet, you as a parent or caregiver are not at fault. There are many reasons why a head can become misshapen. The ideal approach is to seek appropriate advice and move forward confidently with a plan.

 

Helpful terms

SIDS: The sudden unexplained death of an infant younger than one year old

Positional head shape deformity (PHD): Also known as flat head shapes; refers to changes in a baby’s head shape that occur when their head rests in the same position over a prolonged period of time

Plagiocephaly: A specific type of flat head shape where one side of the head is flatter than the other

Brachycephaly: A head shape where the flat spot is noticed at the back of the head. The head often appears wider than normal.

Orthotist: A healthcare professional who provides assessment, measurement, design, and fabrication of external braces like custom helmets for the human body, and offers ongoing support such as education, fitting, and adjustment to the people using them.

Pediatric occupational therapist: A healthcare professional who works with children to develop important skills for daily activities. In the context of head shape concerns, they may provide education to parents and caregivers, suggest exercises and discuss techniques such as different ways to hold and position your baby for feeding, sleep, and play to help with your baby’s development and head shape concerns.

 

Disclaimer: The information within this article does not constitute health advice and should not be used to diagnose or treat any health condition. Please consult with healthcare specialists to ensure this information is right for you or your child.

 

References

  1. Safe To Sleep (2021) Ways to reduce baby’s risk. safetosleep.nichd.nih.gov/reduce-risk/reduce
  2. Blanco-Diaz, M et al. (2023) Effectiveness of conservative treatments in positional plagiocephaly in infants: a systematic review. Children (Basel). 10(7):1184.
  3. Hutchison BL, Stewart AW, & Mitchell EA. (2011) Deformational plagiocephaly: A follow-up of head shape, parental concern and neurodevelopment at ages 3 and 4 years. Arch Dis Child. 96(1):85–90
  4. Hutchison BL et al. (2010) A randomised controlled trial of positioning treatments in infants with deformational plagiocephaly. Acta Paediatr. 99(10):1556–1560.
  5. Bialocerkowski AE et al. (2008) Prevalence, risk factors, and natural history of positional plagiocephaly: a systematic review. Dev Med Child Neurol. 50(8): 577–86.
  6. Martiniuk AL et al. (2017) Plagiocephaly and Developmental Delay: A Systematic Review. J Dev Behav Pediatr. 38(1):67–78
  7. Looman WS & Kack Flannery AB. (2012) Evidence-based care of the child with deformational plagiocephaly, Part I: assessment and diagnosis. J Pediatr Health Care. 26(4):242–250
  8. Russell S. (2022) Head Shape Deformities in Babies. BAMBI Magazine February 2022. bambiweb.org/news/head-shape-deformities-babies 
  9. Aihara Y, Chiba K, Kawamata T. (2024) Helmet therapy efficacy and its prediction in Japanese infants with positional plagio- and brachycephaly, Childs Nerv Syst. 40(7):2135–2144.
  10. NHS (2022) Plagiocephaly and brachycephaly (flat head syndrome). nhs.uk/conditions/plagiocephaly-brachycephaly 
  11. Steinberg JP et al. (2015) Effectiveness of conservative therapy and helmet therapy for positional cranial deformation. Plast. Reconstr. Surg. 135:833–842.

 

About the Authors

Simon has worked in the orthotic and prosthetic healthcare industry across Asia Pacific since 2009. Contact: simon.yj.yap@gmail.com, www.linkedin.com/in/simonyap87

Sarah is an Australian trained pediatric occupational therapist who has worked in Southeast Asia since 2014 in international schools, private practice, and consulting. Contact: stamburrini@gmail.com