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Flat Head Syndrome: A Prevalent Public Health Issue

Positional plagiocephaly/brachycephaly or flat head syndrome (FHS) now affects approximately 20% to 30% of infants based on R01 NIH funded study (a five year study, 2014-2019, $496,000): Article: Long-Term Outcomes in Children with Positional Plagiocephaly/Brachycephaly , Collett Brent Russell, Seattle Children's Hospital, Seattle, WA, United States. Although assumed to be a harmless 'side effect' of supine sleep positioning, recent studies suggest that the development of children with FHS lags behind that of children without FHS. This study will be the first to examine long-term outcomes in children with FHS relative to unaffected controls, testing the hypothesis that FHS is a 'marker' of neuropsychological outcomes that could be used to identify infants who are in need of developmental monitoring and intervention.

Untreated FHS or its underlying causes can lead to long-term health complications [1] including mandibular asymmetry [2, 3], elevated risk of auditory processing disorders [4], and abnormal drainage of the eustachian tube [5]. In severe cases, an anatomical attempt at decompression of growing brain has been clinically confirmed by CT scans [6].

Early FHS detection can be used as a marker for developmental delay. Several studies [7-11] have shown significant correlation between FHS and developmental delays in early childhood, and timely evaluation during infancy was suggested to ensure those children receive appropriate and specific care. Unlike developmental delay, FHS can be detected, early on, in a quantitative and objective manner (enabled by our app); thus helping detect developmental delay at early stages to avoid long term effects.

FHS is often a biomarker for torticollis and repositioning therapy treats both conditions:

“On the basis of observational studies, child health practitioners in primary care settings should consider the diagnosis of congenital muscular torticollis (CMT) in infants with risk factors from birth history for intrauterine malpositioning or constraint (C). On the basis of observational studies, CMT is often associated with other conditions, including positional plagiocephaly—FHS-- and gross motor delays from weakened truncal muscles and/or lack of head control in early infancy (C). On the basis of observational studies, child health practitioners should counsel parents that infants should be on their stomachs frequently whenever they are awake and under direct adult supervision to develop their prone motor skills (C). On the basis of consensus, early identification of CMT(with or without positional plagiocephaly) and prompt referral to a physical therapist experienced in the treatment of CMT should be considered to avoid more costly or invasive treatments, such as cranial orthoses –Helmet-- or surgery (D).” [12]


1. Villani D, Meraviglia MV. Positional Plagiocephaly. Springer; 2014.

2. John DS, Mulliken JB, Kaban LB, Padwa BL. Anthropometric analysis of mandibular asymmetry in infants with deformational posterior plagiocephaly. Journal of oral and maxillofacial surgery. 2002;60(8):873-7.

3. Moon IY, Lim SY, Oh KS. Analysis of Facial Asymmetry in Deformational Plagiocephaly Using Three-Dimensional Computed Tomographic Review. Archives of craniofacial surgery. 2014;15(3):109-16.

4. Balan P, Kushnerenko E, Sahlin P, Huotilainen M, Naatanen R, Hukki J. Auditory ERPs reveal brain dysfunction in infants with plagiocephaly. J Craniofac Surg. 2002;13(4):520-5.

5. Purzycki A, Thompson E, Argenta L, David L. Incidence of otitis media in children with deformational plagiocephaly. J Craniofac Surg. 2009;20(5):1407-11.

6. Argenta L. Clinical classification of positional plagiocephaly. J Craniofac Surg. 2004;15(3):368-72.

7. Collett BR, Starr JR, Kartin D, Heike CL, Berg J, Cunningham ML, et al. Development in toddlers with and without deformational plagiocephaly. Arch Pediatr Adolesc Med. 2011;165(7):653-8.

8. Speltz ML, Collett BR, Stott-Miller M, Starr JR, Heike C, Wolfram-Aduan AM, et al. Case-control study of neurodevelopment in deformational plagiocephaly. Pediatrics. 2010:0052.

9. Collett BR, Gray KE, Starr JR, Heike CL, Cunningham ML, Speltz ML. Development at age 36 months in children with deformational plagiocephaly. Pediatrics. 2013;131(1):e115.

10. Hutchison BL, Stewart AW, de Chalain T, Mitchell EA. Serial developmental assessments in infants with deformational plagiocephaly. J Paediatr Child Health. 2012;48(3):274-8.

11. Kordestani RK, Patel S, Bard DE, Gurwitch R, Panchal J. Neurodevelopmental delays in children with deformational plagiocephaly. Plast Reconstr Surg. 2006;117(1):207-18.

12. Kuo AA, Tritasavit S, Graham JJ. Congenital muscular torticollis and positional plagiocephaly. Pediatrics in review. 2014 Feb;35(2):79-87.

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