“Should I be concerned about my baby’s head shape?” – a frequent question from parents
Babies are beautiful and so are their fuzzy (mostly) bald heads.
Their bones in their head (“cranial bones”) are like an amazing 3D jigsaw puzzle of the world, with 22 bones (8 cranial, 14 facial) interlocked yet subtly movable and expandable – their brain grows staggering amounts in the first 2 years. By the age of 2, the baby’s brain and skull is about 80% of their future adult brain and skull size. These first two years are critical for cranial growth and shaping. I have previously written about the amazing changes a baby’s skull goes through and how parents can (literally) help shape it – read more here.
“Should I be concerned about my baby’s head shape?”
With the rise of plagiocephaly in babies since the “Back to Sleep” campaign in the early 1990s, more parents are aware and concerned about their baby’s growth and development, and in our clinic (and amongst our friends, family and colleagues), pediatric physical therapists are asked almost daily to peek at various baby heads to screen for plagiocephaly and other related cranial issues. “Plagiocephaly” literally means “slanted head.” When deformational or positional forces such as gravity, tight muscles (torticollis), trauma from birth, in utero positioning, sleeping in one position, and overuse of baby equipment occur, the malleable infant head can become misshaped. As pediatric physical therapists, we love to hold babies and to check visually from multiple viewpoints, and can take anthropometric measures with calipers if concerns arise.
A parent or a primary care provider (PCP) can visually screen a baby to assess their head shape. Generally, any asymmetries or unusual shaping from the birth event will have resolved fully by 2 months of age.
Here are 3 easy views you can do at home to get a sense of your baby’s head shape…
..to see if they might have plagiocephaly, also know as “flat head syndrome,” or other unique head shapes. But please note: most of our heads, and especially our new babies, may have minor imperfections and asymmetries. Having one or two of these signs may not indicate a concern, but noting these differences from several viewpoints may be an indicator of concern.
Start with your baby on your lap or, best, have someone hold your baby on their lap while you stand and check out these viewpoints. If your baby has lots of hair, you might do this assessment in the bathtub, when the water slicks their hair down onto their skull for a clearer view.
- first, peer down from above: Sometimes it is helpful to place your open hands alongside the top of their head, like you are framing the top of their head with your hands, to clearly see the shape.
- what general shape do you see?
- typically, baby’s heads are round with the length of the head (nose to back of the baby’s head) about 1/3 longer proportionally than the width (ear to ear)
- if your baby’s head appears flat (not rounded) in the back and is as wide as it is long or wider than it is long, they may have or be at risk for brachycephaly – a short, wide head shape
- if your baby’s head appears flat (not rounded) on one side, typically towards the back of the head, and the whole head from above resembles a parallelogram (with the forehead shifted forward on the same side), the baby may have or be at risk for plagiocephaly – an asymmetric head shape
- while viewing from above, place one finger in each ear (yes!) from the side. A line drawn between your fingers/baby’s ears should intersect with your baby’s cute nose at about a right 90-degree angle. “Ear stagger” occurs when one ear is more forward of the other ear, generally indicating a risk for plagiocephaly.
- if your baby’s head appears more than ~ 1/3 longer (nose to back of the baby’s head) than it is wide (ear to ear), your baby may have or be at risk for scaphocephaly – long, thin shape
- next, check out your baby’s side or profile while he/she is still seated. Typically, the back of the baby’s head when viewed from the side is rounded and there is only a mild elevation of the back of the head (crown) compared with the front of the head above the forehead. When you compare each side, the shape should appear similar, without much asymmetry or flattening.
- if one side of the head appears higher than the other, your baby may have or be at risk for plagiocephaly
- if the back of the head is flat (like a book) and/or the crown of the head is elevated significantly or appears”tall,” and/or the forehead is sloped backwards significantly, your baby may have or be at risk for brachycephaly. You may also observe from this view that the head has more width than length.
- if the overall length from front to back is significantly longer than the width, your baby may have or be at risk for scaphocephaly
- finally, view your baby’s facial structures. This is the hardest viewpoint as the baby smiles, coos, and it’s difficult to concentrate! Some parents note that they see the differences best when looking at their baby’s face in a mirror. Besides their beauty, what do you see?
- typically, eye openings and cheek bones heights should be symmetrical and level, the top of the head should only have a gentle slope or rounding, both sides by the ears (temples) should be gently rounded/not flat and symmetrical, and the jaw/mandible should be centered under the nose
- if you observe one eye that appears bigger than the other, or a more prominent cheek bone, and/or a flattening on one side, and/or a jaw which appears to be drawn to one side and/or a forward side of forehead or top of head, your baby may have or be at risk for plagiocephaly
- if you observe that the face appears small in comparison to the width of the head and/or a prominent or high forehead, and/or that the main width of the head is above the ear level (bulges) and/or the tips of the ears protrude outwards while the lobe is close to the neck, your baby may have or be at risk for brachycephaly
- if you observe that the head appears tall and narrow from this viewpoint, without much width, your baby may have or be at risk for scaphocephaly
Remember – one unique feature does not make a cranial issue! It’s the trend of several features from several viewpoints that may raise a red flag and warrant further evaluation. Do other people see the asymmetries or prominences? Ask relatives and friends to check as well.
Unusual head shaping past that initial two month period warrants a closer inspection by your baby’s PCP, a referral to a pediatric physical therapist for further assessment including anthropometric measures with calipers, and a carefully designed positioning program. An additional referral to an orthotist for a non-invasive cranial scan to get the most accurate head measurements may be helpful – those babies do wiggle and calipers can give basic info, but not as extensive or as accurate as a non-invasive cranial scan. A rare skull issue, craniosynostosis, occurs when one or more of the sutures or seams between the cranial bones fuses prematurely, before full skull growth. Your pediatric physical therapist and PCP can screen for this rare but more serious malformation.
Thankfully, when plagiocephaly, brachycephaly, and scaphocephaly and even craniosynostosis are identified early and treated early, most babies have good-to-excellent outcomes with no long-term impact.
So, snuggle those precious babies, give their head bones a visual assessment from these three viewpoints, and be sure to mention any concerns you have to your baby’s PCP at your next appointment.