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How to Prevent Flattening of Your Baby’s Head
In 1992, recommendations were made to put babies to sleep on their backs to prevent Sudden Infant Death Syndrome (SIDS). Since then, infant deaths have been reduced by one-half. However, at the same time, there has been an increase in babies developing some flattening of the back of their heads (known as plagiocephaly). Here’s what you need to know about it.

Should I put my baby to sleep on his side or tummy to prevent head flattening?
No. Experts insist that sleeping on the back is the safest position for most babies. The concern about a slightly misshapen head is minor compared to the risk of SIDS. Most head flattening can be prevented. And if your baby does develop some head flattening, it’s most likely to resolve between 6 and 12 months of age, once he spends more time sitting up and crawling. Most experts agree that mild flattening of a baby’s head does not affect the child’s brain growth, vision, hearing, or development.

What causes the flattening of a baby’s head?
Babies’ skull bones are naturally soft and flexible so they can squeeze through the birth canal during childbirth. Many babies born by vaginal delivery come out with slightly pointed heads. During the newborn months, the skull can become flattened when the back of the baby’s head rests for many hours against a firm surface such as a mattress, car seat, infant carrier, bouncy seat, stroller or swing. You may also notice that your baby’s hair is worn off on the flattened side; or her face, eyes or ears may appear slightly asymmetrical. These changes can happen to any newborn baby, but it is more common for premature babies who have softer skulls, babies whose neck muscles are tighter on one side than the other, babies with large heads that are harder to turn, and babies who are “good sleepers.”

What can we do to prevent this?
The key to preventing flattening of your baby’s head is to hold your baby and lay her down in different positions over the course of each day.

For Sleep Time (Naps and Night-time):
Always put your baby to sleep on her back, unless your doctor recommends a different position. But try alternating your baby’s position in the crib each time you put him to sleep. One night, put him to sleep with his head at the head of the crib; the next night, with his head at the foot of the crib. Babies naturally turn their heads toward the door (to look for you coming into the room), the window (to see the light) or a mobile (to see interesting objects)—this will give your baby practice turning his head equally in both directions.

For Awake Time:
1. Play: The new recommendation is “Back to Sleep. Tummy to Play.” When your baby plays on her tummy, it helps take the pressure off the back of her head. It also helps her strengthen her neck, arms and upper body, and will help her learn to roll over, sit up and crawl. You can start tummy time for play even with a newborn. When your baby is awake and alert, try playing with her on her tummy, several times a day. Good times are after a feeding and diaper change, nap or bath, when your baby is alert and comfortable. At first she may fuss a bit with this new position, but over time she will enjoy it more and you can do it for longer periods of time. Your baby will enjoy playing on her tummy when she can see and hear you and other interesting things, for example:
• Lie on your back with your baby on top of you, tummy down, with her head on your chest. Talk and sing to her. She’ll want to pick up her head to see you and play with your face.
• Lie on your back with your knees up and your baby tummy-down along your shins, with her head at your knees. Hold onto her and bounce your legs gently up and down. Talk and sing to her, and bring your knees and head forward to kiss her.
• Lay your baby on her tummy on the floor, with a small cushion or rolled up towel under her chest to prop her up. Lie down in front of her to play with her, and set out toys within her reach. Make funny faces, show your baby the toys, talk and sing to her, and encourage her to reach out. Show her interesting things above her head—such as your face, a mirror, a rattle or a stuffed animal—to encourage her to lift her head and push up with her arms. Have a young child play gently with the baby while you supervise—they can easily get down on the floor and capture a baby’s interest in a special way.
• Place your baby tummy-down on a blanket. Lift up the front two corners and pull her around the room making motor sounds.
• Considering getting your baby an infant activity mat designed for tummy-time play.
• Ask your friends what tummy time activities have worked for them. And invent your own.

2. Resting: Parents find that baby carriers, bouncy seats and swings are helpful to keep babies resting calmly and safely. However, if you leave your baby seated for a long time, the seat puts pressure on the back of your baby’s head, which can cause head flattening. Health experts recommend that you don’t leave your baby in a car seat, baby carrier, bouncy seat or swing for “extended periods of time.” While they don’t specify how long is too long, it’s best to use common sense—imagine how long you would feel comfortable sitting in exactly the same position, without turning to look at something new, stretching your arms and legs, or getting up to move around. Although your baby must always be in the car seat when you’re driving, think about times when you could walk instead of drive, and carry your baby in a front-pouch, backpack or stroller. Also, when you’re at home, take your baby out of the seat and spend time holding and cuddling him, and doing your chores with him in a front-pouch.

3. Feeding: When you breastfeed your baby, you feed her on both breasts—this naturally gives her the chance to turn towards you in both directions, exercise her neck muscles equally, and rest a different part of her head on your arms—this helps prevent flattening of the head. If you bottlefeed your baby, also try to alternate sides with each feeding—at one feeding, hold your baby in your left arm and the bottle with your right hand; and the next feeding hold your baby in your right arm and the bottle with your left hand.

How can we make sure our baby’s skull shape is okay?
Over the first few months of your baby’s life, observe the shape of her head, her neck position, and symmetry of her eyes and ears. If you have any concern that there might be some flattening or asymmetry, take photos of your baby’s head from all sides—the front, back, top, and each side. Ask your baby’s doctor to check her head and neck at every well-baby visit. The doctor will tell you whether you need to be concerned or take any special measures. Usually an exam is sufficient, but if the doctor is concerned, she might order an X-ray or CT scan of your baby’s head. Rarely, a referral to a specialist for evaluation and treatment may be recommended.

Remember, it is very common for babies to have slightly misshapen heads, and this usually resolves within the first year. For children whose heads remain a little misshapen, there is treatment to correct it. Most differences in the shape of your child’s head will probably not be noticeable by school-age, once he has more hair. If you have any concerns, talk with your doctor.

(Article written February 2012)
Karen Sokal-Gutierrez M.D., M.P.H. Pediatrician