Flat Heads... #1. Ask The Right Questions!

Series Information:

1 in 5 babies go through a period of having some flattening of their skull as a result of external forces (the position they are in) which is often called positional or deformational plagiocephaly. In a well baby without developmental concerns, the natural course of this presentation is normally very good. It is a condition though that can cause a lot of stress and worry for parents, therefore I have completed a 3 part series to provide some information and practical tips. If you are concerned, it is important to see your local relevant health professional to best understand exactly what is happening with your bub!

There are 3 articles in this series on Flat Spots / Plagiocephaly:

  1. Flat Heads… #1 Ask The Right Questions!

  2. Flat Heads… #2 Simple Steps for Improvement

  3. Flat Heads… #3 What about helmets?

For other similar articles, please see the Baby and Kids Physio Facebook page or The Movement Team’s Paediatric Physiotherapy Page.

“I am concerned about my baby’s head shape. What do I need to know?”

Any significant asymmetry in a baby’s head shape (where one side is very different to the other) should be considered a firm reason to look more closely and work out why that shape may have developed.

The vast majority of abnormal head shapes in babies are a result of persistent external forces on a babies head and not due to specific internal bone dysfunctions (5).

Most babies with flat spots have extremely good outcomes as a result of natural improvement with age and developmental progression.

So first, a few quick definitions:

  1. Positional Plagiocephaly (or deformational plagiocephaly) describes an uneven flattening on one side of the back of the head and can be associated with ear asymmetry (the ear on the affected side appears to have moved forward), forehead and facial asymmetry. 

  2. Brachycephaly describes a more even flattening at the back of the head.

  3. Craniosynostosis is a structural abnormality of the skull that requires specialist referral but is rare. It involves parts of the skull joining to each other earlier than they should.

Now work through the following questions to help determine why your baby might have developed an altered head shape:

1. Can your baby look both ways?

Check if your baby can turn their head to each side. At any age a baby should be able to look evenly to both sides. All babies should be encouraged to develop head control and to look both directions. 

YES, they can turn both ways evenly and easily – Still complete the rest of the checklist, but no concerns yet!

YES, they can, but they are more likely to look one direction – Many babies develop a preference to turn their head to one side. This may be caused by any number of factors (possibly including the position they were in the womb, a traumatic birth, an abnormality in one of the muscles in their neck, or because something the baby likes to look at is always on one side of them, like a light or television). If your baby can turn to both sides, but simply seems to prefer one side, there is unlikely to be any significant neck restriction or abnormality. Focus on the factors discussed in the ‘avoiding or improving positional plagiocephaly’ section. 

NO, they are not able to turn fully to one side – There are a number of reasons why a baby may not be able to turn their head fully. If your baby has a restriction in their neck, it is likely to affect their head shape. If you notice a consistent limitation in this area, it is advised that you see a Paediatric Physiotherapist or your GP, regardless of whether they have developed a flat spot or not.

2. Does your baby demonstrate age appropriate movement skills?

You can check this by talking to your local Child Health Nurse, Paediatric Physiotherapist, GP or by using the checklist in your red book.

YES – Nice work, keep providing as many chances as possible for your baby to practice tummy-time, rolling, sitting and moving. 

NO, I am worried they are delayed or limited in their skills – Consider seeing a Paediatric Physiotherapist, Child Health Nurse or GP if this is a significant concern. Additionally, ensure that you are giving your child enough opportunities and assistance to practice and develop these skills. If your child has a medical condition or has experienced an adverse medical event and the delay might be associated with this, it may be best to talk about your concerns with the Health Professionals who have previously cared for your baby.

3. Does your baby appear to have any significant asymmetries (differences between sides) in their face, forehead or ears?

YES – This could indicate a slightly more severe presentation. It would probably be worthwhile seeing your GP, Paediatrician or Paediatric Physiotherapist if you haven’t already. In the meantime it is even more important to focus on changing some basic parts of your babies day to help their head grow as symmetrically as possible. Please see the ‘3 Simple Things’ article to help you with this challenge!

No – Small amounts of asymmetry are normal but these are generally not a developmental or medical concern.

4. Could this be the a more concerning abnormality like craniosynostosis?

Baby’s with structural abnormalities (i.e. craniosynostosis) normally have the following features:

  • Their head shape looks odd or asymmetrical from birth

  • They have distinct raised ridge/s on their skull

  • Any ‘flattening’ appears unlinked to their positional tendencies

If you are concerned your baby presents with these symptoms: 

Remember that the chances of your baby having a ‘craniosynostosis’ are still rare, but a discussion with your GP, Paediatrician, Child Health Nurse or Paediatric Physiotherapist is warranted. 

If these symptoms don’t seem to describe your baby’s head shape: 

It is far more likely that your child presents with a positional issue. Work through the strategies to improve your baby’s positioning and gross motor skills and if your concerns persist then see a relevant Health Professional.

If your gut tells you something is wrong or you continue to be worried… always ask for help. Your GP, Child Health Nurse or a Paediatric Physiotherapy service is a great place to start!


*The questions raised in this article have been developed as a result of clinical experience rather than standardised and researched medical questionnaires. Thus this article is designed to assist parents with general information. Please also consider checking out fact sheets on these conditions from places like the Royal Children’s Hospital (Melbourne) or the Raising Children Network which may be updated more regularly.



B.Phty (Hons), G.D. Paed. Neuro. Rehab.

Tim has 10 years of Physiotherapy experience and is experienced in Paediatric (Baby’s and Children’s) Physiotherapy. 

Tim is co-owner and director of The Movement Team. Tim also holds an Advanced Physiotherapist position within a Child Development Service in the public health sector.

Tim has worked across the breadth of paediatric health (acute hospital, disability care, developmental, community and private clinics) and has completed numerous national and internationally recognised education courses in topics including developmental orthopaedics, high risk infant management, respiratory functioning and infant movement.

Tim's formal training consists of:

Bachelor Physiotherapy (Hons) - University of Queensland

Graduate Diploma Paediatric Neurological Rehabilitation - University of Western Australia

Tim additionally holds the following positions and memberships:

Chairperson of the Queensland Paediatric Physiotherapy Clinical Network 2013 - 2016

Child Development Service Team Leader - 2016/2017. 

Australian Physiotherapy Association Member


Please note that the clinical information included in this article is of a general nature and might not apply to every family. Please see your local health professional for individualised developmental advice.

Short Reference List:

1. Van Wijk, R.M., et al., Helmet therapy in infants with positional skull deformation: randomised controlled trial. Vol. 348. 2014.

2. Robinson, S. and M. Proctor, Diagnosis and management of deformational plagiocephaly. J Neurosurg Pediatr, 2009. 3(4): p. 284-95.

3. Bialocerkowski, A., Physiotherapy reduces the risk of deformational plagiocephaly in infants who have a preferred head position when lying supine. Australian Journal of Physiotherapy, 2008. 54(4): p. 283.

4. Flannery, A.B., W.S. Looman, and K. Kemper, Evidence-based care of the child with deformational plagiocephaly, part II: management. J Pediatr Health Care, 2012. 26(5): p. 320-31.

5. Ehert, F.W., et al. Differential Diagnosis of the Trapezoid-Shaped Head. The Cleft Palate-Craniofacial Journal, 2004. 41: p13-19.