Torticollis and Plagiocephaly
by Emily Jackson, BSc (Hons) Ost, MSc Paediatric Ost.
May 2023
As an osteopath and a cranial osteopath, I often come across infant torticollis (a condition in which a baby’s head becomes persistently turned to one side due to shortening of the sternocleidomastoid muscle in the baby’s neck) and plagiocephaly (a condition where a baby’s head has a flat spot or is misshapen). I would like to share my thoughts and experience in order to help parents understand how best to prevent these conditions from developing or worsening.
In the late 1980s, the guidance on sleep positioning changed to advise that parents should put their babies to sleep on their backs rather than on their fronts. Researchers in the Netherlands and New Zealand found that babies who slept on their stomachs had a much higher risk of SIDS (Sudden Infant Death Syndrome). This research was confirmed in the U.K. in 1990 by Professor Peter Fleming of the University of Bristol, who pioneered the Back to Sleep campaign. Since then, SIDS rates in the U.K. have dropped 81%. It is therefore clear that the advice has been very effective in preventing SIDS and I would strongly recommend following it, but unfortunately there seems to have been a significant rise in torticollis and plagiocephaly now that babies are regularly placed on their backs to sleep, especially since the Back to Sleep guidance also advises that babies sleep on a firm surface. Babies’ skulls are soft and can mould to the surface that they are lying on. The younger the baby, the softer their skull bones are. Plagiocephaly can be directly on the back of the baby’s head, or more to one side, and can be associated with tension in the neck muscles.
The preference some babies have to turn their head in one direction can start in utero, be due to labour or delivery, or can be influenced by the way they are held or laid down. It’s useful for parents and caregivers of a baby to take note if the baby favours lying with their head on one side and if they do, to encourage the baby from early on to turn their head to the other side as well by guiding their head when placing them down so that the baby regularly alternates which side they’re facing. Ideally they should spend about half the time with their head on each side to allow the head to round out equally. If you notice your baby’s head has already started to flatten on the back, either to one side or straight at the back, then the more time they spend off that flat part of their head, the better. I recommend encouraging them to lie with their head facing the other side, or placing the baby on their side when they’re awake.
Give your baby more time in all positions: side lying, tummy time, or on your chest, so they are not putting as much pressure on the back of their head. Slings and carriers are also a great way for carrying babies and for them to have naps without pressure being placed on the back of their heads.
If you are bottle feeding, make sure to regularly swap the side you hold your baby on, just like one switches sides when breastfeeding, otherwise the baby can develop a tendency to prefer one side. Switching sides allows your baby to experience different positions and stimulates eye development. You can also change their nappy from different sides. Tell other people who care for your baby to be aware of this too.
Flattening of the head is most likely to occur before 3 months. If your baby is turning their head freely to both sides, lying on both sides, and spending time in different positions, plagiocephaly is less likely to occur after this. When babies are sleeping for longer periods at night, it’s a good idea to check whether they are favouring one side and to encourage them to face both sides. Once the flatness has occurred it can be more difficult to encourage them to turn the other way, as it is easier to lie on the flatter area. Also, because of the imbalance of tensions in the neck, they tend to spring back to face the favoured side.
When you hold your baby in an upright/seated position, check if their head tilts to one side. If so, you can try to correct this by gently guiding your baby’s head to the midline.
I have noticed that it is often babies who are the most ‘placid’ who develop flat heads as they are more willing to lie on their backs for longer periods. Whereas babies who insist on being held or carried all the time are less likely to develop a flat head, as they tend to spend more time in different positions or being held, and therefore don’t experience as much pressure on the back of their head. I have also noticed more twins with plagiocephaly perhaps because they tend to spend more time on their backs, especially the more placid twin. Sometimes the space they have had in utero may have been compromised and therefore they develop a preference for turning their heads one way. This can be the same for babies in the breech position. Premature babies’ heads will be softer and they will possibly have less control of their head movements early on.
Does your baby tend to soothe themselves by putting one hand in their mouth more than the other? If this is the side the flatness is on, encourage them to soothe themselves with their other hand, as this will help them to turn their head in the other direction.
Tummy time is important, especially for these babies, as it not only pulls the back of the head into a more rounded shape, it also strengthens the neck and allows more time off the back of the head. Make sure your baby can turn their head both ways in tummy time and in a seated position. If they don’t like tummy time, put your hand underneath their chest for extra support, or lie them over a pillow on your knee, inclined so their head is higher than their body to make it easier for them. You can use a mirror so they can see you or themselves. Make it fun! You can build it up gradually, starting by placing your baby on your chest.
It’s helpful to sometimes place your baby on their side to play. This is good for their development and also means time spent off the back of their head. You can also put your baby to sleep on their side if you are with them and can keep an eye on them, to make sure they don’t roll on to their tummy while asleep. If you do this, make sure you regularly alternate which side you put them on. Once they are able to roll over by themselves, they will be sleeping in different positions and this will help their head to round out.
The take-home message is to look out for and recognise a preference early on, to try to equalise and rectify it yourself, and if you don’t see an improvement, then to see an osteopath or other practitioner who works with children, as some preferences and tensions in the muscles can be stubborn, especially if due to strain patterns from birth or some positions in utero. The earlier a baby is seen, the easier it is to treat them. If in doubt, see a professional who can show you what to look out for and what you can do to help.
Contact details:
Emily Jackson BSc (Hons) Ost, MSc Paediatric Osteopathy, and IBCLC Lactation Consultant, works at 41 Leinster Square, London W2 4PU, (tel 020 7229 8144) and also does home visits. Her mobile number is 07971 675 612 and her email is emilyjackson228@hotmail.com
Links:
https://www.nhs.uk/conditions/plagiocephaly-brachycephaly/
https://www.cc4c.imperial.nhs.uk/our-experience/blog/gp-faq-torticollis
