Plagiocephaly in babies: how physiotherapy can help

Daniel Smit | APA Titled Paediatric Physiotherapist

A parent guide to positional head flattening, safe sleep, play and when to seek advice

A flat area on a baby’s head can be worrying to notice. Positional plagiocephaly is common and usually improves as babies grow and move more. A paediatric physiotherapist can check your baby’s head and neck movement, look for a preferred position or neck tightness, and show you practical ways to encourage comfortable movement while your baby is awake. Safe sleep always comes first.

What is positional plagiocephaly?

Positional plagiocephaly is flattening on one side at the back of a baby’s head. Brachycephaly is flattening across the back of the head, which can make it look wider. These shapes can occur when pressure rests on the same part of a young, soft skull for repeated periods. Some babies have head-shape changes from their position before or during birth; others develop them after birth. Birth moulding often settles over time. [1, 2]

Does it affect my baby’s brain or development?

Positional plagiocephaly changes the outside shape of the head and does not affect brain growth. It is not known to cause developmental delay. If you have concerns about your baby’s movement or development, discuss them with your maternal and child health nurse, GP or paediatrician. Head shape alone cannot tell you how a baby is developing. [1, 2]

Why might a flat spot develop?

A baby may spend more time looking or resting in one direction. Neck tightness, called torticollis, can make it harder to turn the head both ways. Limited movement for other health reasons can also mean the head rests in one position for longer. This is not caused by a parent doing something wrong. Back sleeping remains the safest sleep position; the aim is to offer varied movement and positions during awake time. [1, 2]

How can paediatric physiotherapy help?

A paediatric physiotherapist will ask about your baby’s birth, health, daily positions and movement. They may check head shape, head-turning preference, neck movement, head tilt, posture, head control and early motor skills. They can also look for signs that another medical assessment is needed.

Your physiotherapist can then make a plan that fits your baby and family. This may include:

• ways to arrange play and the room so your baby has reasons to look both ways;
• comfortable carrying, holding and feeding positions that vary the direction your baby looks;
• short, frequent periods of supervised tummy time and other awake movement;
• specific neck movement or stretching activities if your baby has restricted movement or torticollis; and
• follow-up to check movement and head shape and discuss whether a medical or specialist referral is appropriate.

What physiotherapy can and cannot do

Only use activities shown by your physiotherapist; never force your baby’s head or neck. Physiotherapy supports movement and reduces repeated pressure while your baby is awake; it does not directly reshape the skull. The 2024 APTA guideline supports an individualised physiotherapy plan for torticollis specifically, rather than head shape alone. [3]

What can I do at home?

Keep sleep safe

• Always place your baby on their back to sleep, on a firm, flat mattress in a clear cot.
• Do not use pillows, wedges, head-shaping pillows, positioners or rolled towels in the cot.
• You can alternate which end of the cot your baby’s head is placed at when putting them down, so they have different things to look towards. You do not need to keep turning a sleeping baby. [1, 2]

Vary positions while your baby is awake

• Offer short, frequent tummy-time sessions while your baby is awake and supervised. Start with what your baby can manage and build gradually.
• Use your face, voice or a toy on both sides to encourage your baby to turn their head.
• Vary holding and feeding sides where practical. Give your baby opportunities for floor play and movement in different comfortable positions.

What does current research say?

A 2025 systematic review found that early, clinician-supported guidance for parents may help prevent infant asymmetry. The studies differed too much to combine, and the authors rated the overall evidence very low. This supports offering practical advice early while being honest that the best programme and its effects are not yet certain. [4]

Most babies do not need a helmet. A specialist may discuss helmet therapy when flattening is severe and persists despite appropriate advice and physiotherapy. If you are concerned about your baby’s head shape, ask early so that assessment and referral can be considered in good time. The decision depends on the degree of flattening, your baby’s age and progress, neck movement and family circumstances. [1, 2]

Research findings are mixed. A 2025 meta-analysis of 13 studies involving 1,189 infants found greater short-term improvement in head-shape measures in the helmet groups. However, results varied greatly between studies, and the authors called for better randomised trials and longer-term evidence. A 2026 systematic review also suggested helmets may speed early correction in some moderate-to-severe cases, but highlighted that much of the evidence is observational and does not establish clear long-term superiority. [5, 6]

In one randomised trial, 84 selected infants with moderate-to-severe skull deformation were assigned to helmet treatment or natural improvement. The researchers found no significant difference in head shape at two years. This trial does not answer every clinical question, including what is best for very severe cases or babies with torticollis. Taken together, the evidence supports an individual discussion with a clinician rather than routine helmet use for every baby with a flat spot. [7]

When should I ask for medical advice?

Talk with your maternal and child health nurse, GP, paediatrician or paediatric physiotherapist if your baby usually looks one way, has a head tilt, has difficulty turning their head both ways, or you notice flattening or facial or ear asymmetry. Seek prompt medical review if the head shape was unusual from birth, is progressively worsening, or you notice a firm ridge along a skull suture. These signs can have causes other than positional flattening, including craniosynostosis, and need clinical assessment. Imaging is not usually needed to diagnose positional plagiocephaly; a clinician will decide if further tests or specialist review are indicated. [1, 2]

Frequently asked questions

Should I use a pillow to protect the flat spot?

No. Do not use pillows or positioning devices in the cot. Always place your baby on their back to sleep. Use awake time for supervised tummy time, play and varied comfortable positions. [1, 2]

Will the flat spot go away on its own?

Many babies improve as they grow, gain head control and move more. The amount of change varies. A clinician can monitor progress and help identify neck tightness or other factors that may need attention. [1, 2]

Does every baby with a flat spot need physiotherapy?

Not always. Many babies need reassurance and practical positioning advice only. Physiotherapy can be especially useful when a baby has a strong head-turning preference, neck tightness, torticollis or difficulty moving symmetrically. Your health professional can help decide what is appropriate.

Download the plagiocephaly in babies: how physiotherapy can help handout (PDF)

References and further reading

Related resources and physiotherapy support

Explore Little Strides physiotherapy in Narre Warren. Selected appointments are available in Nunawading. View appointment and booking information or ask us about your needs.

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