Beyond tummy time:  8 tips and strategies for successful repositioning for infants with plagiocephaly

Beyond tummy time: 8 tips and strategies for successful repositioning for infants with plagiocephaly


The rise in cranial deformities since the important initiation of the Back to Sleep campaign (now the Safe to Sleep) to prevent Sudden Infant Death (SIDS) in babies in the 1990s has changed babies development and head shaping, parenting rituals, and my role as a pediatric physical therapist. There has been an associated rise in the incidence of “Flat Head Syndrome,” also known as plagiocephaly, which impacts baby’s head shaping as they rapidly grow from infant to ~ age 2 years. I’ve already written an article with the details. Early prevention and intervention is key.

I am passionate about preventing cranial deformities and providing early treatment to maximize outcomes for babies diagnosed with plagiocephaly or brachycephaly. Baby’s heads grow rapidly, and our parenting can impact their head shaping from an early age. There has been significant research about the usage of cranial helmets, repositioning, and windows of opportunity to remodel baby’s skills. And I’ve written previously about the critical need for babies to develop motor skills in “prone” or tummy positions from an early age, including the importance of learning to crawl.

Almost daily in my clinical practice I make recommendations to parents who are concerned about their baby having plagiocephaly (“How do we prevent it? How do we resolve it?”) and we are diligently treating it (“How can we maximize cranial remolding?”) through early and intensive conservative treatments.

But daily, frequent tummy time can be a struggle for parents and a challenge for babies. Consistency,  a variety of positions, frequent opportunities , and FUN are key elements to success – it’s a rare baby in my practice that doesn’t come to enjoy the benefits of tummy time (better motor skills and development) while shaping their precious heads as they rapidly grow. It’s a short window of opportunity that we shouldn’t miss.

These are the tips, tools, and products  for success I commonly recommend to parents of newborns and to parents whose babies I am already treating for plagiocephaly. Not all of these are appropriate at the same age and stage, as each baby and situation need to be addressed individually for best outcomes.

Here are some therapist and parent tips for  tried & true success:

  1. Minimize the deforming forces on soft baby heads: A positioning pillow for when the baby is awake &  supervised yet needs to be, despite our best recommendations to avoid, in a position where their head is in contact with a flat surface such as a car seat, stroller, swing, or changing table. These pillows are designed to disperse the weight bearing head contact and promote a more symmetrical and rounded head. The Noggin Nest is inexpensive (so you can have one at home, daycare, and at grandma’s), washable, and some versions are approved for usage in a car seat (check carefully). It’s my favorite baby shower present!  There are different versions and designs by other manufacturers, including expensive yet breathable (non-suffocating) memory foam pillows – please  check with your baby’s PCP, read manufacturer’s usage directions and safety warnings carefully before using with your infant. Safety first!
    Noggin Nest for plagiocephaly - easy to use!

    Noggin Nest for plagiocephaly – easy to use!

  2. Discourage asymmetryTortle:  Designed by a pediatrician/neonatologist, these cute caps are to be worn when the baby is awake & supervised. They have a soft roll sewn into the cap to gently encourage the baby to keep their head off of the already-flat spot when the baby has a preference for turning their head one way. The concept is good, but I find parents are challenged with positioning the cap adequately especially with newborns or as the baby starts to develop head movements and wiggle the cap into non-helpful positions. Their newer designs, with the adjustable elastic strap seems to be more stable. As far as I know, there are no studies on the effectiveness of the Tortle.
    Cute and effective Tortle for plagiocephaly and torticollis

    Cute and effective for plagiocephaly and torticollis

  3. Gentle movement is comfortingA comfortable, colorful therapy ball:  many families already have one in their home from their own workouts or from prenatal classes. Babies seem to enjoy tummy time more on these gentle balls with soft support underneath their tummies and the ability to slowly and gently rock them in a variety of directions. Important motor skills are encouraged!  Note that a large ball  (65 cm+) is better than a smaller ball – more surface underneath the baby which gives them more comfort and security. Otherwise, they can feel like they are being rolled over a cliff!  The ball can also be used with the adult sitting on the ball, securely holding the baby in sitting or tummy down while the adult slowly and gently  rocks or bounces. Be safe!
  4. Repurpose: A positioning pillow, like this Boppy Nursing and Positioning Pillow, which many families also already have for good alignment and support during nursing activities. This same pillow can be used with the baby for tummy positions or in supported sitting (when the baby has sufficient head and body control and is supervised and awake) to again help with important motor skill development and to promote time in prone activities for cranial remolding. Great alternatives to backlying or supine, which tend to increase cranial deformities.
  5.  Avoid/minimize Baby Carriers:  It is critical that babies with risk for or presence of plagiocephaly avoid further “container syndrome” by limiting the time in baby equipment such as car seats and swings which have a flattening deformational force that adds to the “flat head” shape. Babies should be, of course, transported in a car seat when in a vehicle, but as much as possible, remove them upon arrival at your destination. An alternative to carrying around those large, bulky, and detrimental carriers are baby carriers or slings  that are worn by an adult. These soft-sided ways to carry a baby gently cradle their heads and babies tend to love the movement (versus the bump-bump-bump in a car seat carrier!) and the closeness to their parents.
  6. Stimulate development while working outA high contrast, interactive yet soft padded mat for supervised awake play in side lying or prone/tummy time. More fun and visually interesting “play”  at these early developmental stages helps with the work-to-fun ratio for babies. Baby’s heads make up about one-third of their body weight, so tummy time is WORK at the beginning – like an adult doing a plank position with a 30# weight on their shoulders!  Short, fun, and frequent opportunities to practice will gradually bring more enjoyment to the position, less work. Make it worth their efforts with crinkly textures, attached toys, and soft fabrics to explore.
    Worth the effort to lift my head!

    Worth the effort to lift my head!

  7. Mirror, mirror on the floor: babies love to watch themselves in mirrors, and a soft, safe, high contrast mirror can provide great motivation for play and practice in tummy/prone and sitting positions, especially if you join them!
    Mirror, mirror on the floor, who is the cutest workout baby of all?

    Mirror, mirror on the floor, who is the hardest working baby of all?

  8. Explore: babies want to explore, mouth, and play!  A variety of easy to manipulate, textured, high contrast, and (gently) noisy toys can engage a baby during their side lying, tummy, or sitting work outs!  No need for toys with excessive lights and artificial sounds at this stage – simple toys are often easier to engage with and explore. Some of my favorites are the old-but-still-loved-by-babies rainbow ring stacks, the easy-to-grasp and soft-while-the-baby-learns “O-Ball” and “Winkle.” These toys are always packed in my clinical bag!

Sound off:  What do you, your baby, or your baby patients find challenging about repositioning for remolding?  What activities, products, or strategies have you found helpful?  Please share! We all benefit from each other’s experiences.

(Please note that affiliate links for Scatter Joy are included in this list. Please use to offset the costs of this site if you find this website helpful. Thanks!)

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