Flat head in babies and how much tummy time a baby needs

A flat spot on the back or side of a baby's head is very common and usually mild. It comes from lying in one position while the skull is soft. Most flat heads improve with changes in position, daily tummy time and time. Keep putting your baby to sleep on the back, and aim for at least 30 minutes of awake tummy time a day, spread out. A few babies need a physiotherapist or a specialist.

Why is my baby's head flat on one side?

A flat spot usually forms because a baby's soft skull rests in the same position for many hours. Doctors call this positional plagiocephaly (flattening from position).

It is very common. In a Canadian study of 440 healthy babies aged 7 to 12 weeks, 46.6% had some flattening, and most (78%) was mild.¹ Babies were more likely to have a flat head if they always turned the head to one side, slept on the back, were boys, or were born with vacuum or forceps help.²

Is it still safe to put my baby to sleep on the back?

Yes. Always put your baby to sleep on the back. This lowers the risk of sudden infant death.³

A flat head is a shape problem. Sudden infant death is a life-or-death problem. So we keep back sleeping and prevent flat spots in other ways: turning the head, tummy time while awake, and less time lying in seats. The American Academy of Pediatrics also advises a firm, flat sleep surface with no soft bedding.³

Will a flat head correct itself?

Most flat heads get better, especially mild ones. As babies learn to roll, sit and hold the head up, they spend less time on one spot, and the skull keeps growing.

Changing position helps almost every baby with some degree of improvement.⁴ In a Dutch trial of babies with moderate to severe flattening, the head shape at 2 years was the same whether or not the baby wore a helmet.⁵ Full correction is not guaranteed. In that trial about a quarter of babies had a perfectly round head by 2 years in either group.⁵ For most children, any small difference left is hidden by hair.

How can I prevent or fix a flat spot?

Change your baby's head position many times a day while awake and asleep, and give plenty of tummy time.

Simple steps that help: - Alternate the end of the cot where your baby's head lies, so they turn to look at the door or light from both sides - Switch the arm you hold your baby in for feeds - Put toys and talk from the side your baby turns to less - Limit time in car seats, bouncers and rockers. The WHO advises that babies should not stay strapped in a seat, pram or carrier for longer than an hour in one go.⁶ - Hold and carry your baby upright often

If the flat spot is not improving, a physiotherapy programme works better than position advice alone.⁴

Does my baby need a helmet for a flat head?

Most babies do not. A helmet is worth discussing only for severe flattening that has not improved with position changes and physiotherapy.

The evidence is mixed. In the Dutch trial, helmets did not give a better result at 2 years than leaving the head to change naturally, and all parents reported side effects such as skin irritation.⁵ On the other hand, a review of mostly non-randomised studies found helmets can correct shape faster, especially in severe cases started early.⁷ Helmets are costly and must be worn for most of the day for months. In her practice, Dr Dutta seldom suggests one.

Do head-shaping pillows work?

Dr Dutta does not recommend them. Soft pillows and positioners in the sleep space can raise the risk of suffocation.

The American Academy of Pediatrics advises against soft objects and pillows where a baby sleeps.³ A neurosurgical guideline panel agreed, and recommended physiotherapy over any positioning device.⁴ Many "rai" or mustard seed pillows sold to families in India fall into the same category. Keep the cot bare.

What is torticollis in a baby?

Torticollis is a tight neck muscle on one side, so the baby tilts the head to one side and turns the chin to the other. Doctors call it congenital muscular torticollis.

It is one of the most common muscle and bone conditions of infancy.⁸ Sometimes you can feel a small, firm lump in the neck muscle in the first weeks. A baby with torticollis always looks one way, so the head often flattens on one side. Strong head turning to one side was a major risk factor for flat head.²

How is torticollis treated?

With gentle stretching exercises and positioning, usually guided by a paediatric physiotherapist. Start early, ideally in the first weeks.

In a review of 100 trials, most from China and many using Tuina massage, adding hands-on (manual) therapy to usual care improved neck turning and head position in the short term. The certainty of this evidence was very low to low.⁸ A physiotherapist will teach you stretches to do at each nappy change. Surgery is considered only when therapy has not worked.

How much tummy time should a newborn get?

Aim for at least 30 minutes of tummy time a day, spread across the day, while your baby is awake and watched. This is the World Health Organization advice for babies who cannot yet move about.⁶

Start in the first days at home with 1 to 2 minutes at a time, several times a day. Build up as your baby gets stronger. The American Academy of Pediatrics also recommends supervised, awake tummy time.³ Never let your baby sleep on the tummy.

Why is tummy time important?

Tummy time builds neck, shoulder and back strength, which babies need to roll, crawl and sit. It also takes pressure off the back of the head.

A review of 16 studies found that tummy time was linked with better gross motor skills (big movements) and overall development, and with less flattening across the back of the head.⁹ It was also linked with rolling and crawling skills, and with a lower body mass index score.⁹

My baby hates tummy time. What can I do?

This is very common, especially in the early weeks. Short, frequent sessions work better than one long battle.

Ideas that help: - Lay your baby on your chest while you recline. Your face is the best toy - Lay your baby across your lap and rub the back - Put a rolled small towel under the chest and armpits - Get down on the floor at eye level, or place a baby-safe mirror in front - Try after a nappy change, not straight after a feed - Let grandparents and siblings take turns entertaining

Stop when your baby is upset and try again later. A few minutes many times a day adds up.

When is a misshapen head a sign of craniosynostosis?

Craniosynostosis is early fusion of one or more joints between the skull bones. It is much rarer than positional flattening, and it does need a specialist because some types need surgery.¹⁰

Signs that point to it rather than simple flattening:¹⁰ - An odd head shape present at birth that gets worse instead of better - A hard ridge along a skull joint - A long, narrow head, a triangle-shaped forehead, or one side of the forehead pushed back - The soft spot closing very early

Does my baby need an X-ray or CT scan for a flat head?

Usually not. A doctor can diagnose positional flattening by examining the head.¹¹

Imaging is kept for unclear cases.¹¹ CT scans should not be used to diagnose positional flattening, but may be needed if the doctor suspects craniosynostosis.¹¹ This avoids unnecessary radiation for most babies.

How do I keep floor play safe for my baby?

Give your baby lots of floor play on a clean mat, always within your sight. Floor-based play is the main way babies under 1 should be active, according to the WHO.⁶

Keep the floor clear of small objects, coins and plastic bags. Keep away from stairs, fans, heaters and hot drinks. Screen time is not recommended for babies.⁶ Do not leave your baby on a bed or sofa, even for a second. Babies roll earlier than parents expect.

When should I see a doctor about my baby's head shape?

See your doctor or paediatrician if: - The flat spot is getting worse after 2 months of good repositioning and tummy time - Your baby always turns or tilts the head one way, or you feel a lump in the neck⁸ - You feel a hard ridge on the skull, or the head shape was odd from birth¹⁰ - The forehead, eyes or ears look uneven - The soft spot seems to have closed early¹⁰ - Your baby still cannot lift the head during tummy time after a few months of practice - Your baby seems to be losing skills, or is very floppy or very stiff

Go to hospital the same day if the soft spot is bulging or tense while your baby is calm and upright, especially with fever, vomiting, a high-pitched cry or unusual sleepiness. This can mean infection or raised pressure inside the skull.