This is a very common question I get from new or expecting parents. Preventing a flat head during the first 3-4 months can be difficult, however it is not impossible! Below I have included my general recommendations for those first few months. If you make it to 4 months without a flat spot, you can take a deep breath! And as always, if you have concerns don't hesitate to reach out to a pediatric physical therapist - the earlier the better!
Alright, buckle up. Here we go!
During the early months, I highly recommend limiting time spent in "baby containers" such as: bouncers, swings, baby loungers, and prolonged time in a car seat. These devices, while often enjoyed by babies, are best when used in moderation, ideally no more than 2 hrs per day. "Baby Containers" restrict a child's movement and can result in less-than-ideal movement patterns and prevent the development of age expected gross motor skills. As a pediatric physical therapist, I am cautious with utilization of as some can increase a child's risk for torticollis and plagiocephaly (flattening of the head) especially if there is already a side preference.
I recommend focusing on floor time. Floor time can be spent on their back, side, tummy, and in supported sitting. It is best to rotate between positions and practice each position daily. And for time spent in a "baby container", because we are all busy Mom's and sometimes we just need a break, try to follow it up with equal amounts of floor time. Some examples of a safe floor environment can be on a blanket, on an activity mat, in a play yard or pack-n-play.
It's important to note, your child's skull is soft and flat spots can be present at birth or developed overtime. Often, they are noticed around 8 weeks and can be exacerbated when a child spends more time in one position, therefore alternate between positions recommended below during wake times.
If a flat spot is detected early, a baby's skull can often be reshaped without a helmet if seen by a pediatric physical therapist before 4 months of age. After 4 months of age, a helmet is the preferred method of treatment for flattening or plagiocephaly. If plagiocephlay occurs, it often occurs in combination with torticollis, or tightening of one side of the neck, this does require individualized treatment from a pediatric physical therapist to address any asymmetries that may be present.
Here are the FOUR KEY positions to include in your daily floor time routine:
Back Play: This can be on a large mat, blanket, or on a play mat reaching overhead and kicking their feet at toys, while you read a book, while you move a toy side to side to encourage tracking, or while you practice bringing feet to their hands and mouth. It is a very important position to help strengthen the front of their body, needed for rolling, sitting, and crawling. If your baby has a side preference, position toys or yourself on the non preferred side
Side Play: This can be done on a large mat, blanket, play mat. Place your leg, a rolled-up blanket, or a large pillow or bolster behind your child while they play in sidelying. Place toys, books, mirrors at eye level and encourage them to reach, bringing their hands to together. Be sure to play on both sides as this helps lengthen any restricted muscles in the trunk and facilitates rolling back to tummy (and we love rolling back to tummy!) thus encouraging time off that noggin.
Tummy Time: Tummy time should be fun and a tear free zone! This can be done on large mats, blankets, on play mats, on wedge mats, a therapy ball, or even in your lap or on your chest. During tummy time it is VERY important to make sure your child is weight bearing through their shoulders. If assistance is needed, cup the shoulders and arms and provide extra support and make sure the elbows are under the shoulders, its much easier to look around this way and your baby will be much happier. By placing your baby on an incline it makes tummy time easier, therefore allowing your child to build strength and endurance with the activity, for this I like to use my chest, a boppy pillow, a firm wedge if you have one, or even a rolled-up blanket. Be sure to place engaging toys, mirrors, water mats, books, or even your faces at eye level - this will increase active participation and improve overall strength. For an added benefit, roll your baby in and out of tummy time and incorporate short intervals throughout the day. The goal is quality over quantity.
Vertical Play: Vertical play is essentially any upright play where your child is upright, either held by you in supported sitting, facing out over your shoulder or facing out on your chest. This position helps your little one develop head control against gravity. Standing in front of a mirror, looking at pictures on the wall, or placing suction cup toys at eye level when held are great ways to incorporate vertical play. Over time this becomes time spent in supported sitting on the floor. This also removes any forces from a child's head to help maintain a rounded skull.
Other General Tips:
Baby Wearing: Baby carriers come in many forms, wraps, slings, adjustment harnesses, etc. Often baby carriers help remove any forces on a child's head and can help prevent flat spots however it will be important to change sides if you utilize a sling and change the direction that your child's head prefers to look when positioned facing inward. Be sure to follow the manufacturer's recommendations on size, positioning, and fit to ensure healthy hips.
Some things to consider throughout the day:
1) Frequently switch sides when carrying your child. Often, we fall into a routine that involves only carrying our child on one side because it is easier for us however it can add to your child's the side preference.
2) Switch the head of the in bassinet with every sleep and nap, alternating each time. Children naturally turn toward stimulus and if the stimulus is constantly on one side it can add to your child's side preference.
3) Switch the direction of diaper changes, alternating each time. Children naturally turn toward stimulus and when we change their diaper from one side it can add to your child's side preference.
4) Frequently switch sides when nursing or feeding your baby. Again, we can often fall into a routine that involves only holding our child on one side.
If you take anything away from this blog post, know variation throughout the day is KEY!
As a mom and a pediatric physical therapist, I am here to help! It is my goal to set kiddos and parents up for gross motor success. Stay tuned as I publish more blog posts with gross motor tips. And if you made it this far, thank you! Please check out and follow, like, comment, etc. our social media accounts. I appreciate it!
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