Brachycephaly

Brachycephaly happens when the back of your baby’s head has a flattened appearance. The back of their skull may look shorter and wider than what’s typical.

Brachycephaly is a type of positional plagiocephaly (flat head syndrome). It’s common and usually doesn’t cause long-lasting health or developmental issues. Most cases improve naturally or with simple management strategies.

Types of brachycephaly

There are two types that vary based on the cause:

• Positional. Positional brachycephaly can happen if your baby spends a lot of time lying on their back (supine position). Parents and caregivers should always put babies to sleep on their backs to prevent sudden infant death syndrome (SIDS). But when infants spend a lot of time on their backs — including while they’re awake — they may develop the positional type.
• Synostotic. Synostotic brachycephaly happens because of craniosynostosis. This makes your baby’s skull bones join together too soon. It’s a congenital condition (your baby is born with it).

Signs and symptoms of brachycephaly

The main sign is flatness in the back of your baby’s head. They may have a wider-than-typical head shape — sometimes, wider than it is long, from front to back.

About 9 out of 10 babies with this condition will also have some level of torticollis. This affects your baby’s neck muscles. It causes their head to twist and tilt to one side.

Brachycephaly causes

Pressure on the back of your baby’s skull causes this condition. It happens because babies’ skulls are soft and somewhat moldable. This allows your baby’s brain room to grow. It also means that too much pressure on a certain area of their skull may change the shape of their head.

Causes of positional brachycephaly

Positional brachycephaly typically happens within the first three months of your baby’s life. Common causes may include:

• Prolonged time on their back. The back of your baby’s head may flatten from always sleeping and/or lying on their back. But it’s essential to put your baby to sleep on their back to reduce their risk of sudden infant death syndrome (SIDS).
• Issues before birth or during delivery. Sometimes, there’s a lack of space in the uterus or a lack of amniotic fluid to cushion the fetus’s head. This can cause positional brachycephaly before birth. Prolonged labor may also lead to it.

Preterm birth is a risk factor for positional brachycephaly. This is because your baby’s skull is softer when they’re born early. It can also take longer for them to develop enough neck muscle strength to move their head into different positions. 

Causes of synostotic brachycephaly

Synostotic brachycephaly develops due to a specific type of craniosynostosis — bicoronal synostosis. Craniosynostosis is when your baby’s skull bones fuse together too soon. Bicoronal synostosis affects the bones on the sides of your baby’s skull.

In most babies, experts can't identify one known cause of craniosynostosis. Sometimes, it happens because of a sporadic (random) gene variation, or it may run in biological families.

In other cases, some factors during pregnancy increase your baby’s risk for developing craniosynostosis. These include:

• Fertility medications, like clomiphene (Clomid®)
• Developing thyroid disease during pregnancy
• Being born preterm

Complications of brachycephaly

The main complication of untreated positional brachycephaly is differences in how your baby’s head looks (aesthetic concerns). This type rarely affects your baby’s brain development.

If it’s not treated, synostotic brachycephaly or the resulting increased intracranial pressure can lead to:

• Developmental delays
• Seizures
• Persistent head or facial deformities

How doctors diagnose brachycephaly

Your child’s healthcare provider (pediatrician) will start with a physical exam to diagnose brachycephaly. They’ll want to find out if it’s positional or synostotic. They’ll gently feel your baby’s head for hard edges along the areas where skull sections fuse. They’ll also look for unusual soft spots. 

Hard edges typically point to the synostotic type. If there aren’t any hard edges but a flattened head, your baby likely has the positional type.

A physical exam is usually enough to diagnose positional brachycephaly. But if your baby’s provider is unsure, they may recommend imaging tests.

If your baby has signs of synostotic brachycephaly, they’ll need imaging tests to confirm the diagnosis. This may include one or more of the following:

• Skull X-ray
• CT scan of their head
• Ultrasound or MRI (if they suspect hydrocephalus)

How is brachycephaly treated?

Brachycephaly treatment depends on the type. It could range from changing your baby’s position to surgery.

Positional brachycephaly treatment

Most cases of positional brachycephaly improve naturally over time as your baby’s skull develops and they start moving around more.

In the meantime, your child’s pediatrician will offer strategies for repositioning your baby’s head. These will help during sleep and throughout the day to take pressure off the back of their head. For example, they may recommend:

• Giving your baby time on their belly (tummy time) while they’re awake
• Switching your baby between a sloping chair, a sling and a flat surface
• Alternating the side on which you hold your baby when feeding and carrying them
• Reducing the time your baby spends lying on a firm flat surface, like in car seats and strollers (try using a sling or front carrier when possible)

It’s important to remember that it’s safest for your baby to sleep on their back during naps and at night.

Other treatments may include:

• Massage therapy. Your child’s pediatrician may show you techniques to gently massage your baby’s head.
• Physical therapy for torticollis. If your baby has difficulty turning their head, stretching exercises may help loosen and strengthen their neck muscles.
• Helmet therapy. Your baby can wear a custom-fitted helmet for several weeks. The helmet helps reshape their skull. Pediatricians only recommend helmet therapy for severe cases.

Synostotic brachycephaly treatment

Surgery is a necessary treatment for synostotic brachycephaly. It won’t go away without it. Surgery usually happens before your child’s first birthday.

Skull surgery will:

• Reshape your baby’s skull
• Relieve increased intracranial pressure (pressure inside their skull)
• Give your baby’s brain room to grow and develop properly

There are different types of skull surgery. A surgeon will decide which one is best for your baby’s unique case. They’ll explain the pros and cons of it. Don’t hesitate to ask questions.

After surgery, your baby will likely need helmet therapy. They may need to wear a specially fitted helmet for up to a year after the surgery.

When should I see my baby’s healthcare provider?

Talk to a pediatrician if you're concerned about the shape of your baby’s head or think they may have problems turning their head. Visit the emergency room if your child has a seizure for the first time.

Also, take your baby to their well-baby care appointments so their pediatrician can regularly check their head shape and overall development.

Can adults have brachycephaly?

Yes, adults can have brachycephaly. This is possible if the condition didn’t go away naturally or with treatment when you were a baby. It can cause self-esteem issues in adults. You may be self-conscious if the back of your head is flat.

Reach out to your healthcare provider and/or a mental health professional if this condition is causing you distress as an adult. There are some treatment options available.