Plagiocephaly (Flat Head Syndrome) & Reposition Therapy

An infant’s skull is made up of several relatively moveable bones that are separated by sutures (where the bones join). The sutures allow the skull to mould (bones folding underneath each other) during labour to make the head small enough to pass through the birth canal and later to expand as the brain grows. While most infants have a ‘funny’ head shape straight after birth, most will correct themselves within two-six weeks following the birth. When an abnormal head shape persists or is not noticed until after six weeks, it is important to find out why and take steps to correct it sooner rather than later.

The most common cause is Positional Plagiocephaly. This is caused when repeated external pressure is applied to one side of the occiput (the back of the head) and a flat spot forms[1,2]. The side of the occiput that is flattened will sometimes be accompanied by a prominent forehead, which when viewed from above will give the head a parallelogram shape instead of a normal symmetric oval shape. It is also common for an infant with Positional Plagiocephaly to have misaligned ears (the ear on the affected side may be pulled forward and down and be larger or stick out more than the unaffected ear) and facial asymmetry, with the affected side of the face having a fuller cheek, and a more prominent appearance. Facial asymmetry on the affected side can also include a jawbone that is tilted, and an eye that appears displaced and mismatched in size.

<- The two most common forms ->









                              Fig 1.Plagiocephaly                                                         Fig 2. Brachycephaly

When deciding on a treatment for Positional Plagiocephaly it is best to do this in conjunction with a knowledgeable specialist. However, since Repositioning does not require any custom fitted items, most parents will begin repositioning their child while they are waiting for their appointments with doctors. However, it is important to note that if your child has Torticollis (a condition which causes contraction of a neck muscle), Repositioning can be very frustrating. If you suspect that your child has Torticollis, please raise your concern with your doctor so that stretching exercises and/or other therapy can be implemented, as this will be greatly beneficial to your Repositioning efforts.

Repositioning is the concept of keeping the baby off of the flat spot, but it is actually much more than that. Repositioning is actually a mindset and is a 24 hour, 7 day a week job, especially in the beginning. However, do no let this deter you, as the benefits of Repositioning can be tremendous. Some babies respond so well to Reposition Therapy that no further treatment is needed, while others will receive a decent amount of correction, but may need further treatment.

While repositioning it is very useful to take picture of your child, at the same angle each time, so that you can monitor progress. Take pictures of both sides of your child’s head, the back, the top (you may have to stand up on a chair to do this) and a full facial shot. Since you see your child every day, it may be difficult to see change in your baby’s head shape. Taking weekly pictures will allow you monitor progress much easier and see subtle changes.

Repositioning During the Day


Tummy Time – when the baby is awake and supervised is one of the most important techniques of Repositioning. However, Tummy time is something that must be done in small increments several times a day for most babies until it become enjoyable. Since most babies do not have the muscle strength in the beginning to lift their heads up and prop themselves up on their arms, Tummy Time can be very frustrating for them. Do not let this deter you. Use different items such as a Tummy Time Mat, a bean bag, flexible soft mirrors, and any favourite toys, to try and make Tummy Time enjoyable. Make sure you get down on the floor/bed with them and cheer your baby on. Putting baby in new places may also help encourage Tummy Time to be more pleasurable. The more minutes, baby spends on his tummy, the more the muscles will strengthen and the more enjoyable these sessions will become. If you have some time and were planning on watching some TV, or relaxing, laying in a reclined position and letting baby lie face down on your chest/stomach, is also a way to sneak in some Tummy Time.

Car Seats – There is no denying that a baby needs to be in a car seat while in the car. However there are some steps that you can take to keep the baby off the flat spot while travelling. Positioning the Car Seat – Take some time to notice where you baby focuses the majority of his attention while in the car. If you baby likes to look out the window, position the car seat on the side of car so that the baby has rest on the rounded side of the head to look out the window. If your baby likes to look into the car, then position the seat on the side of the car so that the baby has to turn to rest on rounded side of the head to look inside of the car. If your baby has no preference, you can always help encourage the baby to rest on the rounded side by hanging some toys on back rest of the car’s seat or using a suction cup type mobile and sticking it on the window.

Car Seats As Carriers/Strollers – The baby product industry have made too many convenient products. We now have those nifty strollers that are car seat and stroller in one, as well as car seats that snap right into shopping carts. Do not let these items of convenience tempt you. Too many babies are spending FAR too much time strapped into their car seats while they are being shuttled around during errands and shopping. Of course a baby needs to be in a car seat while in the car, however it can be detrimental to leave a baby for extended periods in a car seat. Instead, put the baby in a soft carrier or sling and “wear” your baby as much as possible while running errands. This can be uncomfortable for you, and can be hard on your back. However, it will be very beneficial for the baby and your muscles will strengthen as time goes by.

Strollers – While it is preferable to use soft slings and carriers for a baby that is being repositioned, it is absolutely impossible for this to be done all the time, especially on long outings and on errands where you need both hands free and baby not right in front of you.

Using a Fashioned Wedge – Many parents have great success in using a rolled up blanket under the shoulder of the flattened side to prevent the baby from resting on the flattened side of the head. In some cases where the baby is too big try using a bit of foam cut to suit.

Toys on the Stroller – Although it is much harder to encourage baby to look in one direction when in a stroller because there is so much to look at, you can try to encourage your baby to look in the direction opposite the flattening by hanging some toys on the stroller on the side that you want her to look.

Infant (bouncy/cradle) Seats and Swings – Just like the infant car seat, infant swings and infant seats are very tempting to parents, and many babies are spending too much time in them. There are times when a swing or vibrating bouncy seat is the only thing that will soothe him, but don’t be tempted to let baby be in them too much.

Placement of the Swing or Seat – Promoting a child to look in the direction opposite of the flat spot is much easier to do in an infant swing or seat. Be sure to position the swing or seat so that a blank wall is on the same side as the flattening of the head. Since babies like stimulus in their environment placing a boring blank wall on the side of the flattening will encourage baby to rest on the rounded side of the head to see all the action in the room.


Holding Baby and Feeding Time


While you are holding baby you can also be repositioning. If your baby can not hold the bottle on her own or is still nursing, you can use feeding time as another opportunity to keep baby off the flat side of the head. If you use formula feeding make sure to change sides, just as you would if you were breast feeding.

Holding Baby – If you are just relaxing out and cradling your baby, be sure that baby is resting in the crook of your arm off the flat spot. If you have baby sitting up, try and promote her to look in the direction opposite the flat spot by having a blank wall or a low stimulus area on the side of the flattening. Even though there is no pressure on the back of the head while the baby is being held up, promoting her to look in the direction that you want will get her more accustomed to looking in the direction and help “train” her to stay off the flat spot.

Holding Baby While Giving a Bottle – When holding your baby during feeding time be sure that the rounded side of the head is resting in the crook of your arm. This may require you to switch your usual feeding arm and can be a little awkward at first. However, given time you and baby will get accustomed to the new position.

Holding Baby While Nursing – Although keeping the baby off the flat side while nursing is a little more complicated then when bottle feeding since you can’t just switch arms, it is still very possible by changing nursing positions. Using the “football hold” on the side where your baby would typically rest on the flat spot may be a solution. If you are having trouble finding a comfortable position, perhaps speak to your GP, Health Visitor, or Paediatric Physiotherapist/Chiropractor/Osteopath  (if your child has one) to seek out other positioning options.


General Day Time Tips


Nappy Changes – When you change baby’s nappy, do it from the side of the head that is rounded, so that baby is looking at you and is relieving pressure off the flat side of the head. If you use a changing table and a flexible mirror can be secured to the side of the table, this will also be helpful to promote baby to looking in the direction of the rounded side of the head.

Repositioning at Night – It must be stated that we are 100% supportive of the Back To Sleep Campaign. It is also important to note that parents must always be cautious about items that they place in the cot as to not create a suffocation hazard in the cot; therefore parents need to pay particular attention when baby has the ability to roll. We recommend you discuss all ideas with your GP or Health Visitor to ensure the safety of your child.

“Spooning” – For those that are not averse to sharing the family bed, the practice of “spooning” can be used to secure baby off the flat side of the head. By having baby lay along side of you, on the rounded side of the head, you will be able to reposition baby.

Changing cot/baby placement – Most babies like to look into the centre of the room instead of looking at a wall. If baby has to lie on the flat side of the head in order to look into the centre of the room, change the position of baby so that her head is where the foot of the cot is. This will force baby to have to lie on the rounded side of the head in order to look into the centre of the room. If the idea of having baby’s head pointed where her feet should go, does not appeal to you, you could also change the placement of the cot so that baby’s head is where the head belongs, but so that she has to lay on the rounded side of the head in order to look in the centre of the room.

Changing the outlay of the cot – A very helpful tool for repositioning your baby in the crib is to change all the stimuli (i.e., toys) in the cot so that baby has to rest on the rounded side of the head in order to see them. Be aware of which way baby tends to look. If she tends to look into the centre of the room, it would be more beneficial do the previous tip (changing cot/baby placement) and then place all the toys on the side of the cot that is in the centre of the room.

Adding more stimuli – Adding items such as flexible cot mirrors, mobiles and hanging cot toys to the side of the cot where baby has to rest on the rounded side of the head, should also be of great benefit. If you are concerned about the items being in the cot, they can be secured on the outside of the cot as well.


If you have any worries about the shape of your baby’s head and would like to know more about reposition therapy, we recommend contacting your local Paediatric Physiotherapist/Chiropractor/Osteopath



Special thanks to Elisabeth Davidson, MSc (APP), BSc(Chiro), DC, FRCC(Paeds)