What is the treatment for a 5-month-old infant with a flat occiput (back of the head) due to sleeping on their back?

Management of Positional Plagiocephaly in a 5-Month-Old Infant

For a 5-month-old infant with a flat occiput from sleeping on their back, supervised tummy time while awake is the primary recommended treatment, along with repositioning strategies, while continuing to place the infant on their back for sleep to reduce SIDS risk. 1

First-Line Treatment Approaches

Supervised Tummy Time

• Implement daily supervised tummy time when the infant is awake 1, 2
  • Start with short periods (3-5 minutes) and gradually increase duration as tolerated
  • This helps strengthen neck and shoulder muscles while reducing pressure on the occiput
  • Promotes motor development and minimizes further progression of plagiocephaly

Repositioning Strategies

• Continue placing infant on their back to sleep (this is critical for SIDS prevention) 2
• Implement the following repositioning techniques:
  • Alternate head position during sleep (turn head to different sides) 1
  • Change crib orientation periodically to encourage infant to look in different directions 1
  • Limit time in car seats, swings, and other positioning devices to necessary use only 1, 2
  • Hold infant in upright position when awake 1
  • Alternate sides when feeding 1

Assessment and Monitoring

Evaluate for Associated Conditions

• Check for torticollis (neck muscle tightness), which often accompanies plagiocephaly 1
• If torticollis is present, consider referral for physical therapy which may include stretching exercises

Follow-up Timeline

• Reassess the infant's progress in 4-6 weeks 1
• If no improvement after 2-3 months of repositioning therapy, consider referral to a specialist for evaluation for helmet therapy 1, 2

Important Considerations

Safety Precautions

• Never use positioning pillows or soft bedding to prevent rolling, as these increase SIDS risk 2
• The American Academy of Pediatrics explicitly warns against using soft positioning pillows in the sleeping environment 2

Prognosis

• Mild to moderate plagiocephaly typically improves with conservative management 1
• The incidence of positional plagiocephaly decreases spontaneously from 20% at 8 months to 3% at 24 months in healthy children 2, 1
• No evidence suggests that plagiocephaly impacts brain development or neurological function 1

When to Consider Additional Interventions

Physical Therapy

• Consider if plagiocephaly is associated with torticollis or limited neck mobility 1
• A Class I study demonstrated that physical therapy intervention was superior to repositioning education alone 2

Helmet Therapy

• Consider only if no improvement after 2-3 months of repositioning therapy 1
• Research shows higher correction rates with helmet therapy compared to repositioning alone for more severe cases 1
• Typically more effective when started earlier (before 6 months of age) 1

Remember that while treating the plagiocephaly is important, maintaining safe sleep practices to prevent SIDS remains the priority. The flat occiput is a cosmetic issue that generally improves over time with appropriate management and has no known impact on brain development.