Abnormal head shape is common in babies, but for some, a more rare condition can be the cause.

Nearly half of all babies born in the United States will have abnormal head shapes as newborns, but 1 in 2,000 babies have a condition called Craniosynostosis. Here, we highlight the basic differences and explain treatment options for your baby’s head shape.

First, it’s important to understand the basics about a newborn’s skull, which has several bones with open seams or sutures between them. These not only allow the baby to pass through the birth canal but also allow the rapidly expanding brain to grow freely. Brain growth drives skull growth.

Here are some abnormal baby head shape guidelines to help understand the key differences and treatments:

What is Plagiocephaly?

This common condition is when a baby develops a lasting flat spot on one side of the head or the entire back of the head. It happens when a baby sleeps on its back or in a car seat without changing positions for a long period of time and the skull bones are not fused. This condition:

• Is increasingly more common with the Back to Sleep campaign, which encourages parents to put their babies to sleep on their backs to reduce the incidence of Sudden Infant Death Syndrome before 1 year of age.
• Can be related to muscular torticollis (tightening or shortening of the neck muscles), premature birth, birth complications, prolonged stay in the Neonatal Intensive Care Unit, multiple (twin) birth, preferred head position and not enough tummy time.
• Is more likely if a baby is a first-born or male or is born with the help of forceps or vacuum extraction.

Symptoms

The flattening of the head may not be present at birth, but may develop over first few months of life.

Common head shapes include:

• The head is evenly flat across the back with bulging above the ears.
• The head is unsymmetrically flat in the back on one side. The forehead is more prominent on one side and head shape appears like a parallelogram when viewed from above, with the ear shifted forward on the flat side.
• A long, narrow head is common in preemies who spend several months in the NICU.

How is plagiocephaly diagnosed and treated?

Diagnosis is made by visual exam as well as feeling the child’s head and suture lines.
Positional skull deformities do not require surgery. Treatment depends on the baby’s age and the severity of their symptoms, but babies with mild cases do not need treatment. Your baby’s head shape may improve and round out as they become more active, start sitting up and spend less time on their backs.

Other babies who have moderate to severe flattening, have a difficult time tolerating tummy time, or have other medical conditions may benefit from a cranial helmet. This involves a referral to a local helmet clinic where a certified orthotist fits the child for a device that helps round out the baby’s head shape over several months.

The average treatment time with a helmet is about 3-6 months and depends on the age when helmet therapy begins. The ideal time frame to start in a helmet is before 6 months old. If your baby’s head shape is not improving while using the helmet, then it may be time to refer for a different diagnosis.

How can I prevent my child from having a flat head?

• Let your baby have tummy time while you are watching.
• Decrease the amount of time your baby spends in car seats and baby carriers.
• Hold your baby, providing time to be upright.

What is Craniosynostosis?

This is when a cranial suture in the skull closes too early, which can happen before or after birth. This can happen by chance or may be inherited, or may be associated with a craniosynostosis syndrome such as Crouzon, Pfeiffer or Muenke syndrome.

This leads to two problems:

1. A constriction in one part of the skull from craniosynostosis will force the brain to grow in an abnormal direction, deforming a different part of the skull. This in turn can lead to abnormal eye and head shapes.
2. Early suture fusion can increase the risk of developing increased pressure inside the skull, which can lead to developmental delay, vision changes and headaches.

What do the most common forms of craniosynostosis look like?

• Sagittal Craniosynostosis is a long, narrow head shape. The forehead may bulge and the back of the head may narrow.
• Metopic craniosynostosis presents as ridging along the forehead, which is angled instead of flat. Eyebrows are pulled back and eyes can appear closer together. The head appears triangular when looking from above.
• Coronal synostosis presents as a flattened forehead on the side of the skull where one of the sutures, which run from each ear to the top of the head, closed early. The eye socket on that side may be raised up and the nose could pull toward that side.
• Lambdoid synostosis presents as flattening on the back side of the head which appears like a trapezoid rather than a parallelogram (as in a positional case).

How do we diagnose and treat craniosynostosis?

• An ultra-low dose radiation CT scan is used to diagnose, usually at the time of the specialists visit. Imaging from the primary care provider doesn’t need to delay referral.
• The main treatment is surgery to fix deformities of the face and skull bones and ensure the brain grows without restriction.
• Most surgeries are done between 10 weeks-8 months, and ideally before age 1.

There are two types of surgeries for craniosynostosis based on the baby’s age:

• Endoscopic-assisted repair: This is for babies 10 weeks-4 months of age. The surgeon operates through small incisions in the skull to remove the fused suture. This surgery lasts one to two hours and typically requires a one-night stay in ICU. The baby will need to wear a custom helmet for six to nine months to help with a normal head shape after the surgery.
• Cranial vault reconstruction/ Fronto-orbital advancement: This surgery involves a hidden incision in the hairline across the scalp. The goal is to reshape the front of the skull, including the forehead and upper portion of eye socket, to create space for the brain to grow and improve the head shape. This surgery lasts four to five hours and typically results in a three- to five-day hospital stay. No helmet is needed after surgery.

This post was written by Clare Gargaro, PA-C, and Dr Michael Golinko of Monroe Carell Jr. Children’s Hospital at Vanderbilt.

Clare is originally from Michigan and worked as a Physician Assistant at University of Michigan (Go Blue!) for 6 years before being recruited to Vanderbilt. In her current role, she is the Cleft & Craniofacial Program Physician Assistant at Monroe Carrell Children’s Hospital At Vanderbilt. She not only is the lead advanced provider for the multi-disciplinary cleft and craniofacial team but also has her own clinic focusing on abnormal baby head shapes.

Dr. Golinko is originally from Brooklyn, NY, and completed plastic surgery training at Emory and then Craniofacial fellowship at NYU. He moved to Nashville with his wife and Golden Retriever in December of 2018 and they have two children, Elliot and Jack. He is the Director of Cleft & Craniofacial Program, Chief of Pediatric Plastic surgery and Director of the Craniofacial fellowship at Vanderbilt.

Have a concern?

If you’re concerned about your baby’s head shape or would like to get in contact with a provider, the Cleft and Craniofacial Program’s team at Monroe Carell Jr. Children’s Hospital at Vanderbilt brings experts from multiple specialties together to treat your child’s cleft lip and palate and other craniofacial disorders.

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