Plagiocephaly (play-gee-oh-kef-a-lee) is a very common craniofacial (skull and face) problem. Deformational plagiocephaly, also known as positional plagiocephaly, means a misshapen, flat or asymmetrical (uneven) head shape. Plagiocephaly does not usually affect the development of a baby's brain, but if left untreated it may change their physical appearance by causing uneven growth of their face and head. 

Plagiocephaly occurs because the bones of a newborn baby's head are thin and flexible, so the head is soft and may change shape easily. Flattening of the head in one area may happen if a baby lies with their head in the same position for a long time. When the head has a flat spot at the back of the skull, this is called brachycephaly (brak-ee-kef-a-lee).

There is another type of plagiocephaly caused by abnormal closure of the skull bones. This is called synostotic plagiocephaly, and is not addressed in this fact sheet.

Signs and symptoms of plagiocephaly

It is quite common for a newborn baby to have an unusually shaped head. This can be either related to their position in the uterus during pregnancy, or caused by moulding (changing shape) during labour, including changes caused by instruments used during delivery. Depending on the cause of the unusual shape, most babies' heads should go back to a normal shape within about six weeks after birth.

Sometimes a baby's head does not return to a normal shape, or they may have developed a flattened spot at the back or side of their head. Sometimes a flat spot develops when a baby has limited neck movement and prefers resting their head in one particular position.

How to prevent plagiocephaly

A baby's head position needs to be varied during sleep and when they are awake to avoid them developing deformational plagiocephaly.

• Sleeping position: Your baby must always be placed on their back to sleep to reduce the risk of SIDS (Sudden Infant Death Syndrome or Cot Death). Do not use pillows in the cot for positioning.  
• Head and cot position for sleep: A young baby will generally stay in the position they are placed for sleep, until they can move themselves. Alternate your baby’s head position when they sleep. Place your baby at alternate ends of the cot to sleep, or change the position of the cot in the room. Babies often like to look at fixed objects like windows or wall murals, so changing their cot position will encourage them to look at things that interest them from different angles.  
• Play time: When your baby is awake and alert, play or interact with them facing you (face time) or place them lying down on their front (tummy time) or on their side from as early as one or two weeks of age. Place rattles or toys (or other people’s faces) that your baby likes to look at in different positions to encourage your baby to turn their head both ways.  Even at two weeks of age your baby can follow your voice or eyes (maintain eye contact) and turn their head themselves each way if you support their head in your hands while they are awake and alert.
• Vary your holding and carrying positions of your baby: Avoid having your baby lying down too much by varying their position throughout the day, e.g. use a sling, hold them upright for cuddles, carry them over your arm on their tummy or side.

When to see a doctor

If you have concerns about your baby's head shape or if you notice that your baby only turns their head to one side when lying on their back, see your Maternal and Child Health Nurse or GP.

Treatment for plagiocephaly

Most babies with deformational plagiocephaly do not need any treatment at all, especially if they are active and you have plenty of one-on-one interaction with them. Plagiocephaly usually improves naturally as your baby grows and gains head control and can move their head by themselves. The plagiocephaly will get better if you encourage your baby to turn their head themselves when they are awake. From the age of two weeks, while you are supporting their head in your hands, your baby can slowly follow your eyes or voice around, even if one way seems harder at first.

If treatment is necessary, you may be referred to a specialist clinic where your baby will be treated by a team that may include a paediatrician, plastic surgeon, physiotherapist and orthotist.

The most common treatment is provided by the physiotherapist who will encourage active movement, and teach parents how to position their baby and do exercises with them to help improve the head shape.

A very small number of babies with plagiocephaly (less than one in 10) have a severe and persistent deformity, and they may need to be treated with helmet therapy.

Helmet therapy

A lightweight helmet is made by an orthotist using 3D images and fitted for your baby. The helmet helps to reshape the skull by taking pressure off the flat area and allowing the skull to grow into the space provided.

Helmet therapy is most effective if treatment starts between six and eight months of age and is completed before 12 months, as this is the time of rapid growth of the skull.

Wearing the helmet doesn't hurt and babies usually get used to it very quickly. Parents can sometimes feel quite emotional when their baby first wears the helmet. It can be helpful to know this is a common feeling and to remember treatment is temporary and outcomes are normally very good. 

When your baby first gets their helmet, it will usually be worn for a two-hours-on/two-hours-off cycle for the first two days. This will allow you to monitor your baby's skin and give your baby time to get used to the helmet. Following a review around two days after fitting, your baby will start wearing the helmet 23 hours a day. The orthotist will then review your baby about every three weeks.

Caring for your baby during helmet therapy:

• There should be some space in the helmet for your baby's ears. Make sure their ears sit comfortably in these spaces and the helmet is not twisted.
• When you take the helmet off, check your baby's skin to make sure there is no rubbing, blisters or broken skin. Mild redness over the high spots of the head is normal. 
• You can put sorbolene cream on dry skin or mild rashes. You can buy sorbolene from a chemist or larger supermarkets. If the dry skin or rash does not get better, call your baby's orthotist. 
• Rather than taking the helmet off during hot weather, it is better to dress your baby in light clothing to keep them cool.
• Your baby's head will become sweaty under the helmet. You should wash their hair daily and clean the inside of the helmet with a soft nailbrush or face washer and warm, soapy water. Rinse the helmet well and towel dry.

Key points to remember

• Lie your baby on their back for sleep and do not use pillows in the cot.
• Vary the position of your baby’s head when putting them down to sleep, and your baby’s position when they are awake and alert. Give your baby face time and tummy time.
• Talk to your Maternal and Child Health Nurse or GP if you are worried about your baby's head shape.
• Plagiocephaly usually improves over time if your baby is active and has lots of one-on-one interaction.
• If helmet therapy is needed, it won’t hurt your baby and the outcomes are normally very good.

For more information

• Dr Margie: What causes plagiocephaly, and how can it be treated?
• The Royal Children's Hospital Physiotherapy department: Baby’s head shape
• See your GP or Maternal and Child Health Nurse.
• Contact your baby's orthotist if you have queries about your baby's helmet therapy.
  

Developed by The Royal Children's Hospital Plastic and Maxillofacial Surgery, General Medicine, Physiotherapy and Orthotics departments with the University of Melbourne. We acknowledge the input of RCH consumers and carers. 

Reviewed June 2020.

Kids Health Info is supported by The Royal Children’s Hospital Foundation. To donate, visit www.rchfoundation.org.au.