Brachycephaly: 10 Things You Need to Know

As a mom and occupational therapist with a child that had “flat head”, this topic is very dear to my heart. My purpose behind this article is to raise awareness in the treatment and prevention of brachycephaly and other forms of “flat head”. New parents need to be educated on three things: 1) the occurrence of brachycephaly, 3) how to prevent brachycephaly, and 2) the options available to fix brachycephaly without a cranial helmet.

Brachycephaly, is another head shape change in addition to plagiocephaly. “Flat head” and brachycephaly have become more known to new parents due to the rise in the usage of cranial helmets to correct head shape changes. Brachycephaly is defined by the changes in head shape on the very back of the head due to the infant laying on the center of their head more often than other areas. This back flattening is caused by prolonged pressure on the back of the head when a baby lays on their back. This often presents in infants with a preference to sleep in the very center without turning their head very much at all at night. This type of head shape change can develop very quickly and I want to provide you with a list of 10 Things You Need to Know About Brachycephaly.

Download our free “flat head” guide here to learn more about preventing & correcting “flat head” with your baby.

#1: Brachycephaly is the flattening on the back of the head

Brachycephaly is defined as flattening on the back of the head due to prolonged pressure from a surface. This is often due to a baby’s sleeping position and presents as the back of the head appearing flattened and the head appearing “tall”. The flattening on the back causes bulging on the sides and top of the head due to the redistribution of mass. If you think of a baby’s head like a balloon, brachycephaly is just a shift in “air". The shifting of “air” from a contact with a surface, results in the flattening on the back when the baby prefers to lay on the center of their head more often than other areas. When assessing brachycephaly, one way to assess is viewing your baby from the very side. This ensures that a proper assessment can be made when comparing the difference in the head and neck. We want to see a clear difference from where to head begins and the neck ends when looking at our baby from a profile view. If flattening is present, the head may look flat on the very back with no clear curvature of the head. The head may also look tall and there may be an increase in angle from the forehead to the back of the head. See the photo on how to view your baby’s head to indicate if brachycephaly is present. A good rule of thumb is to note where the head ends and the neck begins to evaluate if brachycephaly is present. You can also view the baby from the very top, to note any width changes in the baby’s head. We want to widest part of the head behind the ears, so if that is not the case your baby may be at risk for brachycephaly. I am also happy to assess your baby’s head through a free evaluation if interested!

#2: Babies that sleep on their back are at a higher risk for brachycephaly

Back to sleep, which was introduced in the late 1990s, encouraged parents to place babies on their back to reduce the risk of Sudden Infant Death Syndrome (SIDS). Although back to sleep has significantly lowered the risk of SIDS, back sleeping significatly increases the risk of plagiocephaly. This is due to the constant pressure on the back of the head. It’s a good lesson in physics - a baby’s head is very soft so when they sleep on their back, pressure is applied to those soft areas. This can cause a shift in mass (as discussed above), so flattening on the back of the head if the baby sleeps to the center every night. This can also occur if baby does not move their head very much during sleep. Be sure to monitor your baby’s sleeping position when they are on their back and avoid baby sleeping on the same area of the head every night. Interested in seeing if your baby is at risk for brachycephaly? Take this quiz!

#3: 1 in 10 babies are affected by brachycephaly

As discussed above, The Safe to Sleep initiative strongly encouraged parents to place babies on their backs to sleep to minimize the risk of SIDS (Sudden Infant Death Syndrome). Although the risk of SIDS has gone down significantly (which is SO IMPORTANT), the risk of brachycephaly has increased. Read more about the rise in brachycephaly here. This is not necessarily a bad thing, but a topic that needs to be prioritized when discussing the many things to prepare for when bringing a new baby home. New parents are strongly encouraged to place their baby on their back to sleep, so they should be strongly encouraged to monitor their baby’s head shape and implement strategies to prevent brachycephaly. A baby that sleeps on their stomach is not placing pressure on the soft areas of the head. Although back sleep is THE SAFEST POSITION, preventing brachycephaly must be a topic of conversation with new parents. This brings me to the next thing you need to know about brachycephaly.

#4: Preventing brachycephaly is something every parent should be aware of

Preventing brachycephaly can significantly reduce the risk of your baby developing flattening on the back of the head. Preventing sounds simple right!? Take recurrent pics of your baby’s head every other week, make sure they don’t lay on the very back of the head more than the other areas, etc… But, it’s really more complex than that. Preventing brachycephaly not only involves those things, but also many more. Preventing brachycephaly involves strategies positioning, stretching, strengthening, monitoring, and whole body stretches. Positioning includes making sure your baby does not spend a prolonged amount of time on the back of their head at any given time. Babies tend to do 7-9 activities recurrently throughout the day, so it’s important to monitor their head position during all of these activities. Stretching is also important in preventing brachycephaly. The presence of brachycephaly often indicates tightness in the neck (see point #5 for more information), so stretching your baby’s neck is very important in reducing the risk of brachycephaly. Download my Neck Stretches to Prevent and Correct “Flat Head” for more information. Neck tension can also lead to full body tension, so it’s very important to stretch your baby’s whole body to prevent brachycephaly and also milestone delays. Lastly, strengthening your baby’s neck will ensure that the muscles are balance and baby can turn and move head in all directions equally. This will leads to equal distribution of pressure and NO BRACHYCEPAHLY. YAY! Brachycephaly develops quickly, so be sure to monitor your baby’s head shape by taking photos every couple weeks. 

#5: Brachycephaly may be due to neck tightness

As stated above in point #3, brachycephaly is often due to neck muscle tightness. When a baby is in-utero, they are very crowded and have limited areas to move, stretch, and reposition. Once a baby is born, they exhibit a synergistic flexion pattern where they keep all of their limbs in a bent position. When a baby is placed on their back to sleep, they are able to maintain this flexion pattern, and may not move or elongate their body very much. This may lead to tension in the neck and whole body. When a baby is placed on their belly to sleep, the arms are often up in an extension pattern and the head is rotated one way or another. This leads to a prolonged stretch of the neck and upper body, which leads to less body tension. Placing a baby on their back to sleep is THE MOST SAFE POSITION, but when doing so we should offer our babies a stretch of the neck and body to avoid muscle tightness. When a baby sleeps on their back with their head in the center every night, this baby may not turn their head to the sides easily. This is due to neck tightness due to sleeping in one position every night. This preference to sleep in the center leads to tightness of the neck, which leads to a significant increase in brachycephaly. This is why it’s very crucial to address neck and body tension, as well as neck strength and mobility when preventing and correcting brachycephaly. Does your baby exhibit a preference by keeping their head in the center while they sleep? Submit a form here for a FREE head shape assessment, so if any flattening is present you can begin correcting ASAP.

Download our free “flat head” guide here to learn more about preventing & correcting “flat head” with your baby.

#6: Early detection of brachycephaly often occurs at “well checks”

When your baby is born, you are so excited to take them home and begin your life as a parent. Shortly after returning home, you will schedule your baby’s check in at the pediatrician, or family doctor’s office. This appointment, in the United States, often occurs at the 2 month mark. This is the first time, unless otherwise indicated, your baby visits to pediatricians office for a “well check". At this check, many measurements are taken, including head circumference. The pediatrician will also check your baby’s head shape, from a bird’s eye view (as discussed above) and a profile view. This check may indicate flattening developing on the back of the head if baby prefers to sleep to the center every night. Your doctor may suggest more tummy time and may revisit the flattening, if present, at the next visit. If flattening is still present at the 4 month check, your doctor may recommend physical or occupational therapy, or conservative treatment for the flattening. Helmet referrals are often made at the 4 month check, but they are not the only option in correcting brachycephaly or other head shape changes. More on this topic in point #10. If your pediatrician has indicated flattening of your baby’s head, I am happy to take a look and help you navigate next steps through a free head shape evaluation here.

#7: Brachycephaly is measured through cephalic index (CI)

Brachycephaly measurements are taken to rate the severity of the flattening on the back of the head. This measures the length compared to the width of the head. When measuring brachycephaly, CI can be taken manually or through a 3D scanner at a cranial orthosis clinic. CI is the gold standard in brachycephaly measurements and determines the amount of flattening on the head based on the width. Refer to the chart for specific measurements of CI and their rating category. Also, read a recent research study completed at Children’s Healthcare of Atlanta (CHOA) on the evidenced around these measurements. Read a recent blog post regarding Head Shapes and Helmets where I chat with this trusted orthotist, Becki, who specializes in infant cranial helmets.

#8: Certain baby gear leads to increased risk of brachycephaly

There is a TON of baby gear on the market, most things functional for new or seasoned parents. But, there are certain baby gear options that can increase your baby’s risk for plagiocephaly. A few of these items include the Snoo bassinet, Merlin Sleep sack, weighted sleep sacks, swings, bouncers, and overhead play gyms. These items encourage baby to stay in one position, on their back, which is the safest sleeping position but we do not want these items to hinder baby’s movements. We want baby to move freely and reduce constant pressure on any one area of the head, and these items do not encourage that. Although the Snoo is great for soothing and keeping baby on their back, the included swaddle does not allow baby to move freely. Additionally, the Merlin sleep suit is wonderful for encouraging independent and long windows of sleep, but the suit does not place baby in a nature resting position. This resting position, that the suit encourages, may not allow free movement. Weighted sleep sacks can be thought of similarly to the Merlin suit as this weighs baby down and does not encourage natural, free movement and repositioning. Containers and swings may be used in moderation if needed, but it’s very important to be mindful of baby’s head position in these places. This can lead to plagiocephaly very quickly if not monitored. Lastly, a play gym is wonderful for visual input and hand exploration but while baby is mesmerized with the toys above head, they are not motivated to move and reposition themselves. When thinking of baby gear and plagiocephaly prevention, think items that 1) allow free movement and 2) avoid constant pressure on the head.

#9: Some babies are at a higher risk for brachycephaly

Some babies are at a higher risk for brachycephaly and other head shape changes and that is okay! We just have to be mindful of this and be proactive in preventing this from occurring in our infants. Babies that are at a higher risk for brachycephaly includes, but are not limited to, breeched babies, multiple births, pre-term infants, and babies born of small, petite women. Breeched babies are very crowded in utero, which may lead to increased tension and tightness in their body. This can lead to a side preference or torticollis, which can lead to brachycephaly. Multiple births can also lead to brachycephaly due to in-uterine crowding and difficulty repositioning. The parent to multiple babies is also busy and may have difficulty making time to monitor the head shape. We all know one baby keeps us BUSY, but what about more than one!? Pre-term infants are also higher risk for brachycephaly due to more time spent on their back after birth. A baby born pre-term may spend 3 or more weeks lying on their back to sleep compared to a full term infant. No wonder brachycephaly may occur more easily, due to the constant and increase amount of time on the soft skull. Lastly, what I have found from my experience, is brachycephaly is more common in babies who have a small, petite mother. If the mother is small, the uterus may not allow optimal room for baby to move and reposition. This difficulty with repositioning can lead to in-uterine crowding and tightness in the body once baby is born. It’s so important, in all of these cases to prioritize preventing brachycephaly from day one.

#10: Helmets are not the only way to correct brachycephaly

I am saving the BEST FOR LAST. If you know me, you know I am so passionate about keeping babies out of helmets and raising awareness around preventing and correcting brachycephaly and all head shape changes. Helmets are a popular option when correcting brachycephly, but they are not the only option. I have created a very strict program for correcting brachycephaly without a helmet through repositioning, stretching the neck and the whole body, and addressing any muscle imbalances present. The research shows that babies with mild to moderate flattening, in all ages of infancy, can be corrected through repositioning strategies without a helmet. The article states that if repositioning strategies continue to improve the shape, a cranial helmet is not required. In severe cases, a helmet is indicated, in which severe cases are less common. Lots of therapist educate parents on repositioning in simple ways, like the changing table, feeding baby, and how to baby sleeps, but they are not most affective sometimes due to the many other places baby spends time on their back. I have made it my mission to raise awareness among parents and therapist that helmets are NOT THE ONLY OPTION. Strict repositioning should be completed before helmets are considered. Email me at [email protected] or submit a FREE head shape form here if you are interested in my services.

I hope you leave this article knowing more about brachycephaly and how to prevent or correct this in your infant!

Download our free “flat head” guide here to learn more about preventing & correcting “flat head” with your baby.

Have a great day,

Brooke, OTR/L

Owner of Infant Insights, LLC

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