Flattening/asymmetry of the head & restricted neck movement
The following text is a review of the literature on flattening/asymmetry of the head and restricted neck movement and is for educational purposes only. Before following ANY advice on the management of a particular condition you should first consult an appropriate healthcare professional to avoid risk of injury or health complications. Whilst every effort has been made to make this advice safe and clearly explained, it is impossible for this type of generic advice to be complete, safe and effective in every individual case.
Flat head syndrome: Plagiocephaly & Brachycephaly
Plagiocephaly
Plagiocephaly is a condition whereby the baby’s head is flattened on one side causing it to look asymmetrical, with sometimes the forehead and face bulging a little on the flat side. It can present at birth or during the first few months of life when the baby’s skull is soft and pliable. A certain level of skull misshaping is quite normal as babies heads are soft and subject to forces in the womb and during childbirth. This more ‘normal’ flattening/asymmetry usually resolves after a year or so.
If your baby has been diagnosed with deformational or positional plagiocephaly, which is a vast majority of cases, then treatment is aimed at reducing the tension and pressure on the head (refer below, ‘Practical advice to reduce flattening/asymmetries & improve neck movement’). Reducing the pressure and tension on the head allows it to start growing back towards its normal, natural shape.
If your baby has been diagnosed with craniosynostosis (or synostotic plagiocephaly), which is a rarer condition, that can cause a variety of abnormal head shapes, then medical treatment through your doctor is advised.
Brachycephaly
Brachycephaly is when the back of the head becomes flattened, causing the head to widen, and occasionally the forehead may bulge out.
If your baby has been diagnosed with positional or deformational brachycephaly, which is a vast majority of cases, then treatment is aimed at reducing muscle tension and pressure on the head (refer below, ‘Practical advice to reduce flattening/asymmetries & improve neck movement’). Reducing the pressure and tension on the head allows it to start growing back towards its normal, natural shape.
If your baby has been diagnosed with brachycephaly due to craniosynostosis (synostotic brachycephaly), which is more rare, then medical treatment through your doctor is advised.
In most cases of plagiocephaly or brachycephaly there is no major cause for concern as there is no pain and no effect on brain function or development and the shape of the head often improves by itself over time.
What causes positional or deformational plagiocephaly & brachycephaly?
Temporary deformities can occur due to restricted space in the womb or as the baby travels through the birth canal. These temporary cranial deformities don’t need any treatment as they usually improve as muscle imbalances are corrected with movement of the head and neck from feeding, crying and as the baby explores its world. However, these deformities are less likely to resolve naturally if the baby’s neck movement is restricted or if they are consistently positioned in a way that exerts pressure on one particular area of the head. Obviously this is NOT a reason to stop lying babies on their back in an EMPTY cot when asleep as this reduces the chance of Sudden Infant Death Syndrome (SIDS) and other measures can be used to reduce pressure on the head (refer below, ‘Practical advice to reduce head flattening/asymmetries & improve neck movement’).
Torticollis & restricted neck movement
This is a typical posture of a baby whose muscles on the left are tight causing their head to naturally tilt to their left
Torticollis is a twisted neck whereby the head is tipped to one side, while the chin is turned to the other. It occurs when the neck muscles (usually the sternocleidomastoid) goes into a spasm and may develop nodules. Correct treatment early on aims to reduce this muscle tightness, that, within itself, can lead to flattening and asymmetries in the head.
Not all restricted neck movement is caused by torticollis. Accumulated muscle tension from how the baby was laying in the womb or forces from childbirth can cause more generalised, but not so serious, muscle tension. The Osteopathic Centre for Children (OCC) identifies seven clues that suggests your baby may have some neck tension:
Does your baby prefer feeding from one breast or sleep/lie with the head always turned to one side?
Does your baby appear to have tension in one shoulder, making it more difficult to get that arm into clothes?
Do you/your baby have difficulty getting the head into the right position to get the nipple into the mouth?
Does your baby struggle to open the mouth wide enough for the breast? Does your baby ‘stop-start’ feed, or appear to ‘choke’ on milk flow?
Does your baby break seal during feeding: is there ‘clicking’ during a feed, nose congestion/snoring or noisy breathing?
Does your baby appear to be swallowing air as well as milk (hiccups or big burps after a feed)?
Are you uncomfortable during or after feeding, is it worse on one side?
Practical advice to help correct head flattening/asymmetries & improve neck movement
Despite some advice on the internet your baby should ALWAYS sleep on its back in an empty cot to ensure that its airway is kept clear as to prevent Sudden Infant Death Syndrome (SIDS). Obviously, if your baby falls asleep in your arms that’s fine because you can supervise it, but, if you feel yourself getting tired place the baby on its back in its empty cot so you don’t fall asleep holding the baby.
1. During tummy time distracting your baby to lift and turn their head, especially to the restricted side, helps stretch out and condition muscles to readdress any muscle imbalances.
Whilst this advice aims to encourage movement of the baby’s neck to the ‘restricted side’ if your baby’s neck movement isn’t restricted in one particular direction the advice can still improve general neck movement in all directions with the aim of reducing general muscle tension and improving feeding. Your baby shouldn’t experience any discomfort when following any of this advice, and if you feel they are experiencing discomfort, or it is beyond their tolerance, then you should stop what you’re doing.
Supervised ‘tummy time’. As mentioned above your baby should NEVER sleep, or be left unsupervised on their tummy, but supervised play on their tummy, can encourage them to lift and turn their head by, for example, distracting them with toys, lights and sounds. Encouraging them to lift and turn their head to both sides, but obviously to the restricted side more, can help address muscle imbalances.
Car seats are for cars - and for giving parents a temporary break! Obviously a car seat should always be used when a baby is travelling in the car, but outside of the car, unless the baby is asleep and you feel as though you need a bit of a rest, take the baby out of the car seat. Car seats restrict neck movement and place pressure on the back of the head.
Carrying your baby in different positions encourages their neck to rotate in different directions. This should NEVER be a forceful movement but aims to encourage the movement of their neck to the restricted side. A baby that is restricted when looking to their right can be held in these positions, shown in the pictures, when not too uncomfortable, as to stretch their neck in that direction.
3a. This carrying position encourages the baby to look to their right. Carrying the baby on the other side will encourage them to look to their left.
3b. This carrying position also encourages the baby to look to their right. Carrying the baby on the other side will encourage them to look to their left.
If a baby doesn’t like bending their neck to the left (moving their left ear to their left shoulder), they can be held facing away from you, in a side lying position, with the baby’s RIGHT ear resting against your RIGHT forearm. When holding a baby like this place your LEFT arm between the baby’s legs and support their body (refer to the picture below).
Obviously this can be performed the other way with the baby facing away from you, in a side lying position, with their LEFT ear resting against your LEFT forearm. This encourages the baby to bend their neck to the right (lowering their right ear to their right shoulder).
3c. Due to the rigid nature of the doll you can’t see how the neck would normally bend to the left when holding a baby in this position.
4. Alter feeding positions to encourage rotation of the neck. When breast feeding, if possible, try to encourage the baby to feed from both breasts. If this is not possible you can use the other exercises mentioned here to encourage neck movement.
4a. Feeding to encourage the baby to look to their right by moving the bottle away from the parent. Using a similar technique, but feeding in the opposite arm, can encourage the baby to look to their left.
4b. Feeding to encourage the baby to look to their left by holding the bottle as close to the parent as possible. Using a similar technique, but feeding in the opposite arm, can encourage the baby to look to their right.
5. Try to place as many different distractions in the room as possible to encourage the baby to turn their head to the restricted side. Obviously, you can’t have every distraction in one side of the room but for instance, in their bedroom, you can place the cot so the sounds coming in from the doorway or from a radio, or the visual stimulus from a light, naturally encourages the baby to turn their head towards the restricted side.
5a. Try and locate any stimulus, e.g. lights and sounds, so that it encourages the baby to turn their head to their restricted side.
5b. Use distractions, e.g from toys, lights and rattles, to encourage head rotation to the restricted side.
6. The Labyrinthine Head Righting Reflex (LHRR) starts to develop after two months of age and is an excellent way to address the muscular imbalances that can cause restricted neck movement and flattening of the head.
Whilst sat on your leg gently tilt your baby slowly to the left. To stop their head flopping to the side the baby will have to use their neck muscles so they can keep looking directly forwards. The converse is true when gently tilting your baby to the right.
6a. Initiating the LHRR by gently tilting baby to the left.
6b. Initiating LHRR by gently tilting baby to the right.
6c. This is an example of LHRR ‘in action’. In this picture the baby is tilted over to their left by leaning them over towards their mother. To stop their head from flopping over to their left the baby has to use their neck muscles to keep looking directly forwards.
7. Switch your baby between a sloping chair, a sling and a flat surface to ensure there is not a constant pressure on one part of their head.
8. Reduce the time your baby spends lying on a firm flat surface, such as car seats and prams – try using a sling or front carrier when practical. However, your baby should ALWAYS sleep on its back in an empty cot to ensure that its airway is kept clear as to prevent Sudden Infant Death Syndrome (SIDS), it should NEVER be left unsupervised when on its front, and, if when holding the baby you feel tired the baby should always be placed on its back in an empty cot in case you fall asleep whilst holding the baby.