Baby head shapes: What you need to know and when to seek advice

Babies come in many different shapes and sizes, and their heads are no different. Many parents have questions about what is normal, what they should be worried about and when to seek advice. In this blog, the nationally ranked Neurosurgery Team at Riley Children’s Health explains what to expect during your infant’s development and when to be concerned about their head shape or head size.

What is a normal baby head shape?

When babies are born, the skull has flexible spaces between the bones, called sutures. These sutures cause the skull to resemble a “puzzle,” which is very helpful and allows the head to reshape or “mold” as the baby moves through the birth canal (this is why some babies have a “cone-head” shape when they are born that rounds-out after a few weeks). These flexible spaces also allow for enough space in the skull for brain growth. The brain grows rapidly in a child’s first two years, with the most rapid growth occurring in year one.

It is expected that any abnormal head shapes will begin to resolve on their own a few weeks after birth. If there are concerns for prolonged flat spots, soft spots or an uneven head shape, your pediatrician may refer your child to a pediatric neurosurgeon for further evaluation. The nationally ranked Neurosurgery Team at Riley Children’s is highly skilled in evaluating head shape abnormalities and will help determine if an abnormality in the shape of the skull is caused by craniosynostosis or positional plagiocephaly.

Common types of head shape abnormalities

Positional plagiocephaly

Positional plagiocephaly (commonly referred to as “flat head syndrome”) is one of the more common diagnoses seen by the Riley Neurosurgery team. Positional plagiocephaly is a cosmetic flattening (often seen on the back of the head) that occurs when the baby’s skull bones are re-arranged by an external cause, not an early fusion of the sutures. This is usually caused by how the baby is positioned, especially if they are lying in a particular position for extended periods of time, it can result in the skull flattening on one side of the head. This is a non-life threating, non-surgical finding. There is nothing wrong with the underlying brain development and the shape does not affect long-term development or cause delays in developmental milestones.

Common causes

• Infants that have a preference to turn their neck towards one side over the other or history of trauma/injury to the neck at birth.
• If they are a breastfed infant, they have a preference to feed from one breast over the other.
• Infants who do not like “tummy time” or do not spend very much time each day on their tummy.
• Young children or children with motor delays who are not yet able to roll or sit unsupported.
• Children who have head sizes on the higher end of the growth chart (it may take longer for neck-muscles to develop the strength needed to support larger-sized heads).
• Babies born early (prematurely), or who were hospitalized in the Neonatal or Pediatric ICU for a prolonged period.
• Abnormal in-utero positioning (such as breech position) or multiple-gestation pregnancy.
• The use of vacuum or forceps during delivery, or any other reported birth trauma.

How to treat plagiocephaly

Since positional plagiocephaly is caused by external forces, the best treatment is to start repositioning therapy at home as soon as possible. In general, your baby should lie on the side of the head that is not flattened. Once your baby spends more time off the flattened area and changes their head position more frequently, you will start to see improvement in the head shape as the brain and skull continue to grow.

• The American Academy of Pediatrics recommends tummy time two to three times each day.
  • Start with three to five minutes, then gradually increase the time and frequency.

• Promote range of motion of the head and neck.
  • As soon as they are able, help and encourage your baby to sit and play upright.
  • Try to keep your baby off the back of the head as much as possible.
  • Move toys and lights on the floor, play area, or car seat to their less-favored side. This encourages them to lie on the non-flat side to see those items and helps to promote neck range of motion.
  • It is not recommended to stop Back to Sleep (AAP). Continue to place infants “back-to-sleep” for SIDS prevention, but allow more belly and upright time during their awake-times while monitored by an adult.
• If your child has a preference to lay on one side of their head, it may be important for them to be evaluated by physical therapy (PT)/First Steps.
• If your baby prefers to breastfeed on one side over the other, make sure you switch sides when you hold the baby so they don’t spend more time on their preferred side.
• Cranial molding therapy
  • Cranial molding therapy (also known as helmet therapy), is a noninvasive form of management for severe plagiocephaly that can be considered after treatment failure with PT and conservative management.

Craniosynostosis

When babies born with the sutures of the skull already closed or with concerns for early closure (meaning the sutures are no longer flexible enough to allow for rapid brain growth), this is called craniosynostosis. Unlike plagiocephaly, craniosynostosis is not preventable and requires surgical intervention. If left untreated, the deformity will worsen, and can risk damage to normal brain tissue by not expanding to accommodate the growing brain. This may impact or delay normal brain growth and development.

Physical assessment is the first step your pediatrician will take to help differentiate between craniosynostosis and plagiocephaly. If a diagnosis cannot be made on physical exam alone, imaging can be used to obtain better pictures of the skull. The quickest and easiest imaging option is an X-ray which shows if the sutures have closed. At Riley Hospital for Children, a CT scan can also be utilized to provide images with a 3D reconstruction of the skull. CT scans show not only the bone and sutures, but how the brain is fitting inside the skull. These images will show the Neurosurgery team if the sutures remain open, have closed or if there are concerns for early closure of the sutures.

How to treat craniosynostosis

Children with craniosynostosis are managed by the Craniofacial Multidisciplinary Team at Riley Children’s. This team consists of Pediatric Neurosurgery and Pediatric Plastic Surgery specialists that focus on disorders of the face and skull. Many children also see Genetics to look for underlying causes of craniosynostosis, and ophthalmology to assess whether the eye socket shape and vision are developing normally.

Surgical options are dependent on the patient’s age and which suture is affected. Riley Children’s is home to the state’s largest cleft and craniofacial team and is one of the few programs approved by the American Cleft Palate-Craniofacial Association in Indiana. The Craniofacial Team will discuss the condition with you and work with you to create the best personalized plan of care for each individual child.

When to seek advice

Talk to your pediatrician if you are concerned about your child’s head development or shape. They will discuss and review your concerns and refer to Riley Children’s Neurosurgery Team if further evaluation is needed.