Do you want an opinion on the relevance of using a helmet for your baby’s plagiocephaly or brachycephaly?
Are you interested in knowing the before and after results?
You’ve come to the right place!In recent decades, an increasing number of parents, and sometimes healthcare professionals, have noticed and expressed concern about babies developing a flat head or cranial deformations known as plagiocephaly.
In recent years, helmets have been introduced as a treatment for plagiocephaly. This article covers plagiocephaly, its different forms, how to treat or prevent it, and whether it is appropriate to use a helmet for babies with a flat head, with before and after photos with and without a helmet.
I provide answers to the most frequently asked questions by parents, based on:
- my experience as a physical therapist (including in pediatric physical therapy) since 2009;
- my extensive research in international scientific literature.
This article is updated at least once a year, incorporating the latest findings from international research published in scientific journals.
Enjoy your reading 🙂!
Last update: August 2023
What is plagiocephaly or baby’s flat head?
Infants can be affected by malformations in different parts of their bodies, and one of these parts is the skull. There are various degrees of cranial deformities, and in the vast majority of cases, the deformation occurs after birth. The most common presentation is flattening of the back of the head.
- The flattening can be symmetrical, where both sides of the head are flattened equally, and this is referred to as brachycephaly.
- When the flattening is asymmetrical, it is known as plagiocephaly, where one side of the back of the skull is flatter than the other.
Generally, the deformity is noticed for the first time starting from 6 weeks of age. Sometimes, it may only be noticed around 4 months. This is why it is called positional plagiocephaly (or brachycephaly) as it does not appear in utero.
There are other cranial deformities, rarer ones, that are not discussed in this article. They usually appear in utero and are related to premature fusion of different parts of the newborn’s skull. This condition is called craniosynostosis with plagiocephaly.
Diagnosis of plagiocephaly & brachycephaly
The diagnosis is made by simply observing the child’s skull in different positions. In case of doubt about possible craniosynostosis, babies may be referred for a specialized consultation with a pediatric orthopedic surgeon. However, this remains very rare:
- only 1.4% of babies seen by a first healthcare professional are referred to another more specialized professional for suspected craniosynostosis;
- only 25% of babies referred to the specialist actually had craniosynostosis.
In such cases, further examinations (imaging) are required to confirm this diagnosis. (Khormi 2020)
The opinion provided by healthcare professionals on the existence and severity of plagiocephaly without measuring the skull is similar to that given by individuals who perform measurements. This means that there is no need to use special devices to measure a child’s skull: the eye is sufficient.(Kunz 2021)
The diagnosis of plagiocephaly or brachycephaly can be made by simply observing the baby, by the physician, physiotherapist, or pediatrician who usually follows the baby. The opinion of a specialized surgeon is not necessary in the vast majority of cases.
Frequency and Causes of Skull Deformations
When observing and measuring the skulls of babies at 6 weeks old, 16% of them show positional plagiocephaly or brachycephaly. Therefore, this is an extremely common evolution of the newborn’s skull, at least in countries where these studies are conducted.
By the time these same children reach 2 years old, only 3.3% of them still have a considered flattened skull. Most of these children have not undergone any specific treatment.The risk factors for “flat head” are still poorly understood. The literature on this topic indicates factors such as:
- Being a boy
- Being the first child in the family
- Use of forceps or vacuum during childbirth
- Sleeping on the back
- Presence of congenital torticollis or restricted head movements
Children with spastic or non-spastic cerebral palsy also have a higher risk of developing plagiocephaly or brachycephaly.
Natural evolution of plagiocephaly: before and after with or without a helmet
Families may be concerned about the aesthetic impact. However, as mentioned earlier, even without any treatment, the flat head gradually disappears over the months or even years.
- As the child spends more time in a sitting and standing position, the skull becomes more symmetrical and regains its curvature as the sutures gradually close over the months.
- Additionally, as the child grows, the hair masks the precise shape of the back of the skull.
Plagiocephalies and brachycephalies may be impressive for parents, but they have no consequences on the child’s brain development, even without treatment.
Before and after photos taken at the age of 4 months can help understand the evolution of plagiocephaly without the use of a helmet.
The evolution without wearing a helmet for positional plagiocephaly or brachycephaly is favorable: the child at a few years old, as well as the adult, has a completely aesthetic skull.
Treatment and Prevention of Plagiocephaly
Concerned parents wanting to actively address their baby’s flat head can implement several strategies.
- During their baby’s awake time, they can position them on their tummy (tummy time). This way, the back of the head won’t be in contact with the surface, and flattening won’t be exacerbated.
- If the baby does not tolerate or enjoy tummy time, other positions can be offered, such as varying between back, side, in a baby seat, in a specially designed chair, carried in a baby carrier or sling, on the lap, etc., as well as on different surfaces (on a mattress on the floor, in a playpen, crib, etc.).
- If the baby seems to turn their head more often to one side than the other during awake or rest time, adjust their environment to encourage looking to the other side. For example, if they often look to the left, talk to them from their right side, place toys at a higher level on their right side, position the source of light on their right side, feed them while being on their right side, etc.
- Avoid leaving the baby in the same transport seat for an extended period. If you use an infant car seat, make sure to carry your baby in a baby carrier or sling when you take them out of the car, or use a bassinet or reclining stroller based on their age. This will vary the pressure points on their head.
In all cases, it is strongly recommended to place the baby on their back to sleep.
The frequency of sudden infant death syndrome has significantly decreased since parents were encouraged to put their babies to sleep on their backs. Studies have shown a clear causal link between placing babies on their backs and the reduction in the frequency of sudden infant death syndrome.
The most natural and straightforward treatment is time!
Seeking occasional advice from healthcare professionals (general practitioners, pediatricians, physiotherapists) can reassure parents, provide personalized advice, and monitor the development of the flat head.
Do not use pillows
What about positioning pillows for preventing or reducing plagiocephaly (see example on Amazon) ? No studies have been conducted to evaluate their effectiveness. National and international recommendations advise parents to place their baby on a firm mattress (no memory foam mattress for infants) without any cushion to prevent the risk of sudden infant death syndrome.
Therefore, anti-plagiocephaly pillows should not be recommended. It is better to simply vary the baby’s positions, including in the crib.
Regarding the prevention of infant cranial deformations, the same positional advice applies.
I have written a more detailed article on the treatment of flat head in babies (coming soon in English!).
Simple positional advice can reassure parents and allow plagiocephaly or brachycephaly to evolve favorably.
Are there physiotherapists specialized in plagiocephaly?
Some physiotherapists specialize in pediatric physiotherapy. These physiotherapists undergo training in the management of plagiocephaly. Moreover, they see more babies and children in their practice, which allows them to develop more diagnostic, preventive, and therapeutic experience in the treatment of flat head.
Here are some tips to find a physiotherapist with more experience in plagiocephaly:
- Search “physiotherapist specialized in plagiocephaly” on Google Maps (perhaps you came across this article that way!). Some physiotherapists in your area may indicate on their website that they have received training in plagiocephaly or even create content on the subject.
- Simply ask physiotherapists in your area if they are accustomed to treating babies with suspected or confirmed plagiocephaly.
- Ask your pediatrician or the general practitioner who takes care of your child if they know any physiotherapists who are used to treating plagiocephaly.
One caveat, however: I have noticed around me that some physiotherapists specialized in pediatrics tend to easily fall into overtreatment of plagiocephaly. For example, they may propose weekly physiotherapy sessions for several months for babies with good motor skills and attentive parents, or recommend going to an osteopath.
This is not necessarily a problem if the frequency suits you. If you feel overwhelmed, discuss it directly with your physiotherapist. Keep in mind that positional plagiocephaly and brachycephaly naturally improves over time, regardless of what you do.
If you are seeking information about it, you are probably a parent who is already very involved in your baby’s development – everything will be fine!
Some physiotherapists specialize in pediatrics and see babies with positional plagiocephaly more frequently.
Why is the helmet for plagiocephaly often unnecessary?
For the past two decades, an orthopedic treatment has been proposed to parents of some babies aged a few months who have plagiocephaly or brachycephaly. It involves wearing a helmet (cranial orthosis or helmet therapy) for several months.
The helmet is typically fitted after the age of 4 months (the age of peak observation for positional plagiocephaly and brachycephaly). Orthotists recommend wearing the helmet for at least 18 hours a day, and up to 23 hours.
Multiple appointments are required, both to custom design the helmet and to monitor its fit regularly, usually every month.
The cost of the cranial helmet and all the appointments often ranges:
- from 1,000 to 2,000 euros and is not covered by health insurance in France or by supplementary health insurance;
- from $1500 to $3000 in United-States (Watt 2022).
Some children wearing the helmet and their parents experience side effects, such as skin irritations, sweating, resistance to wearing the helmet, discomfort, and unpleasant odor.
Wearing a helmet for flat head does not correct deformations compared to other children who have not worn a helmet, but it exposes the babies who wear them to side effects. However, these side effects do not impair the quality of life at 2 years old.
Picture of helmets for flat head
Here is a photo preview of 3 helmets for plagiocephaly or brachycephaly:
The helmet for babies with flat head is no more effective than encouraging position changes
Does wearing a helmet for plagiocephaly lead to less deformation at 12 months, 2 years, or later in childhood and adulthood?
Only one study directly compared babies aged 5 to 6 months with and without helmets, dividing them into two groups. Some babies wore a helmet, while others received physical therapy or their parents were given advice on better positioning. All babies had a form of moderate or severe flat head. None of them had congenital torticollis or craniosynostosis (conditions often leading to more severe forms of plagiocephaly and brachycephaly). The babies were then followed for 2 years.
What about 2 years later? The children in both groups had completely comparable average measurements, whether they wore a helmet or not. In other words, the helmet is no more effective than simply letting things happen while reassuring and informing parents about the small changes they can make in their daily routines.
However, it is possible that children who wore helmets regained a more aesthetically pleasing cranial shape faster than others; in any case, by 2 years old, the difference between those who wore helmets and those who did not is no longer present.
There are other studies on the subject, but none of them properly compare the evolution of similar babies with or without helmets.
Studies conducted by or with helmet manufacturers and retailers more often compare the evolution of a group of babies who wore helmets. Of course, the deformation decreases, but there is no evidence that it would not have decreased just as much without the helmet.
One study (Ryall 2021) even shows that the quality of life of children who wore helmets did not improve after wearing them.
Why do some professionals still recommend the helmet for plagiocephaly?
Several healthcare professionals, including physiotherapists, pharmacists, and doctors, sometimes suggest to concerned parents to use a helmet for their child. This is also the case for some healthcare practitioners like osteopaths.
The market is flooded with books that present plagiocephaly as a problem that needs treatment. They advocate for systematic screening, the implementation of public health policies focused on plagiocephaly, or even mandatory visits to osteopaths. However, none of them rely on solid scientific data or coherent biomechanical reasoning.
The parents’ reaction is often as follows:
“Since a professional recommends it, it must be effective.”
“Even if we are not sure if it’s really necessary, I prefer not to take the risk and give my child every chance to correct it as quickly as possible.”
This reaction is understandable. Ideally, all parents questioning the use of a helmet should have access to the most reliable information available to date on the subject, such as the study presented earlier.
Based on this information, they can make a decision: do the current data (no superior effectiveness of the helmet compared to positional advice), the financial and time cost, the side effects, and the fear of missing out justify my decision to have my child wear this helmet?
Often, parents do not have access to this information but rather to images showing before/after photos of children who have used the helmet, as shown below.
Photos before/after wearing the plagiocephaly helmet
Parents sometimes also see images representing measurements taken by an orthotist showing the evolution of the skull before/after wearing the helmet. Again, it would be interesting to compare these evolutions to those of children who did not wear a helmet, and at the age of 2 years: we would most likely realize that the evolution is identical.
Why do some healthcare professionals still recommend wearing a helmet?
Several explanations can be given:
- Some professionals may not be aware of the existing scientific literature on helmets for plagiocephaly and brachycephaly. They may have been exposed only to patient testimonials or documentation provided by orthotic manufacturers.
- Others may want to offer treatment alternatives to very demanding parents, without necessarily being convinced of the effectiveness of the helmet.
- Some may also believe that the helmet “can’t hurt” and prefer to propose a concrete treatment for fear that parents will be dissatisfied if the deformation does not evolve as well as they would like.
Sometimes, it is difficult to accept that there is not much else to do other than wait and reassure. We are more inclined to believe that we can do something more active for our patients, especially when it comes to babies.
Wearing a helmet for flat head: a controversial topic
I had the opportunity to work for several years with a company that manufactures and sells helmets for plagiocephaly. I collaborated with this company effectively for the management of my patients with lower limb amputations. Therefore, I wanted to provide feedback to this company on their website promoting helmets for plagiocephaly, pointing out some inaccurate information they were disclosing.
My message was forwarded to a professor at a French university hospital, who responded with a lengthy message. Here is an excerpt from our exchange:
Hello Sir,I am surprised by your feedback; did you receive the right article? You wrote:
“There are many confusions in your statements that lead to debatable conclusions. Indeed, you talk about cranial malformations that must be treated with surgery (craniosynostosis), and you omit to develop the positional newborn syndrome, which is essential.”
However, my article clearly distinguishes between cases of craniosynostosis and positional syndrome, as shown in the following passages: “In general, the deformation is noticed for the first time from 6 weeks of life. Sometimes, it is not noticed until around 4 months. This is why we refer to positional plagiocephaly (or brachycephaly): it does not appear in utero.”
“There are other, rarer cranial deformities that are not treated in this article. They generally appear in utero and are related to premature fusion of different parts of the newborn’s skull. This is known as plagiocephaly due to craniosynostosis.”
I also mention congenital torticollis as one of the risk factors identified in the literature.
Regarding this statement:
“Finally, plagiocephaly does not correct itself during growth, as you claim (2 publications attached).”
The first publication you attach actually supports the opposite: “Point prevalence tends to decrease with age and may be as low as 3.3% at 2 years.”
I appreciate your willingness to discuss this topic; for now, I am more interested in the scientific literature on the subject, to which I have access myself. However, if you know of any RCTs on the effectiveness of helmet use that I might have missed, I am certainly interested. I would also be interested to know the results of your study, which I hope will demonstrate the effectiveness of the helmet in a comparative manner, as data supporting this are currently absent.
Furthermore, in March 2020, the French National Authority for Health (HAS) and the National Professional Council of Pediatrics (CNPP) issued a statement on plagiocephaly, following an alert from an association expressing concerns about the consequences of these positional deformations. The HAS and CNPP state, among other things, that:
“Plagiocephalies – positional cranial deformations – are benign and naturally disappear around the age of two years.”HAS 2020
The HAS also emphasizes that only reference or competence centers for craniofacial deformities are qualified to recommend the use of a cranial orthosis (or plagiocephaly helmet), which should remain exceptional due to its limited benefits.
Here’s what I wanted to tell you about this! Do you have any comments or questions? Your comments are welcome 🙂 !
You may also like:
- My blog posts on physical therapy for babies and children
Linz et al. Positional Skull Deformities. Etiology, Prevention, Diagnosis, and Treatment. 2017. Dtsch Arztebl Int.
Graham et al. Effects of Initial Age and Severity on Cranial Remolding Orthotic Treatment for Infants with Deformational Plagiocephaly. 2019. J Clin Med
Van Wijk et al. Helmet therapy in infants with positional skull deformation: randomised controlled trial. 2014. BMJ
Rowland et al. PURLs: Helmets for positional skull deformities: A good idea, or not? 2015. J Fam Pract
Kluba et al. What is the optimal time to start helmet therapy in positional plagiocephaly? 2011. Plast Reconstr Surg.
HAS (2020). Prévenir la plagiocéphalie sans augmenter le risque de mort inattendue du nourrisson
Ellwood J, Draper-Rodi J, Carnes D. The effectiveness and safety of conservative interventions for positional plagiocephaly and congenital muscular torticollis: a synthesis of systematic reviews and guidance. Chiropr Man Therap. 2020 Jun 11;28(1):31. doi: 10.1186/s12998-020-00321-w. PMID: 32522230; PMCID: PMC7288527.
Khormi Y, Chiu M, Goodluck Tyndall R, Mortenson P, Smith D, Steinbok P. Safety and efficacy of independent allied healthcare professionals in the assessment and management of plagiocephaly patients. Childs Nerv Syst. 2020 Feb;36(2):373-377. doi: 10.1007/s00381-019-04400-z. Epub 2019 Nov 14. PMID: 31728704.
Kunz F, Hirth M, Schweitzer T, Linz C, Goetz B, Stellzig-Eisenhauer A, Borchert K, Böhm H. Subjective perception of craniofacial growth asymmetries in patients with deformational plagiocephaly. Clin Oral Investig. 2021 Feb;25(2):525-537. doi: 10.1007/s00784-020-03417-y. Epub 2020 Jul 1. PMID: 32607831; PMCID: PMC7819928.
Pastor-Pons I, Lucha-López MO, Barrau-Lalmolda M, Rodes-Pastor I, Rodríguez-Fernández ÁL, Hidalgo-García C, Tricás-Moreno JM. Interrater and Intrarater Reliability of Cranial Anthropometric Measurements in Infants with Positional Plagiocephaly. Children (Basel). 2020 Dec 17;7(12):306. doi: 10.3390/children7120306. PMID: 33348822; PMCID: PMC7766735.
Ryall JJ, Xue Y, Turner KD, Nguyen PD, Greives MR. Assessing the quality of life in infants with deformational plagiocephaly. J Craniomaxillofac Surg. 2021 Jan;49(1):29-33. doi: 10.1016/j.jcms.2020.11.005. Epub 2020 Nov 17. PMID: 33239212.
Cranial Helmet Cost: Watt A, Alabdulkarim A, Lee J, Gilardino M. Practical Review of the Cost of Diagnosis and Management of Positional Plagiocephaly. Plast Reconstr Surg Glob Open. 2022 May 16;10(5):e4328. doi: 10.1097/GOX.0000000000004328. PMID: 35702535; PMCID: PMC9187200.
By Nelly Darbois
I love to write articles that are based on my experience as a physiotherapist and extensive research in the international scientific literature.
I live in the French Alps 🌞❄️ where I work as a physiotherapist and scientific editor for my own website, where you are.