Measuring the Head Shape for Infants with “Flat Head” | A Guide for Parents and Therapists

As a parent, and/or therapist, you may find yourself needing to measure the shape of an infant’s head. This is commonly done in infant’s 0-12 months as a way to monitor any changes in the structure of the infant’s soft skill. This process of measuring an infant's head shape is so important in preventing and treating the diagnosis of “flat head” syndrome. 

Infant head shape is often screened and monitored by many practitioners: including the pediatrician, or general practitioner at your baby’s well check, licensed occupational & physical therapists, chiropractors, cranial-sacral therapists, and other infant-based healthcare providers. 

The skull during the first year is very soft and the risk of  the risk of “flat head” syndrome has been on the rise since the Safe to Sleep initative in the late 1990s. This is why measuring and tracking infant head shape is important. 

A little more about “flat head”

“Flat head” is characterized by flattening on the back or side(s) of an infant’s skull due to consistent pressure in one area of the head over time. You may hear the term plagiocephaly, which refers to flattening on one side of the head, as well as scaphocephaly which refers to flattening on both sides of the head. The term brachycephaly is often used to describe the back flattening of an infant's head. Several factors increase the prevalence of infants with “flat head” syndrome and those factors may include: prematurity, multiple births, breeched positioning, gender, 1st born children, and babies with developmental delays or torticollis diagnoses.

Infants with “flat head” syndrome is increasing, now affecting almost 50% of babies around the world. With the increase in “flat head” syndrome, comes an increase in the need to monitor the head shape. Understanding the many methods of measurement is so important, so healthcare practitioners, like myself, can monitor and track the shape changes effectively. Regular monitoring allows parents and healthcare professionals to detect any abnormalities early on, facilitating timely intervention and treatment if necessary. Whether it be the effectiveness of the correction treatment used once flattening has developed, or the monitoring of prevention methods used to ward off any flattening - tracking infant head shape has never been more important.

Let’s dive into the different methods of measurement:

There are SO many ways to measure head shape. And above we discussed why that would need to be completed for your baby! So let's explore these methods more:

The first and most common method you may have heard of is using a photo to track the head shape. No numerical values are taken in this method of "measuring", so tracking is a better way to describe this type. These photos, of your baby's head shape, are subjective based on the person interrupting and are usually done using a technique called the Argenta test. This test includes photo taken of the skull shape from a bird’s eye and profile view. By assessing photos from these views, many observations can be made. We can observe the alignment of the ears from the bird's eye view, in addition to many different other observations. There are typically 5 types of angle assessments made at the bird's eye view and these include: type 1: the differences in the neural head (or back of the skull), type II: the misalignment of the ears, type III and IV: the shift in the forehead and/or facial structures, and type V: the shift in the temporal areas. A profile view is also used in type V to assess any head height increases which may indicate brachycephaly. I have included a photo below to reference based on this type of head shape method of measurement. Source: https://www.researchgate.net/figure/Argenta-classification-system-Type-I-deformation-consists-of-only-occipital-asymmetry_fig3_316975378. 

The second way of measurement we will discuss is plagiocephalometry. That's a big word I know, but this is basically defined as an outlined image of the infant's skull with standardized measurements ran based on this outline. A mold is placed on the skull and the outline is completed. A representation of the infant's head from a bird's eye view is reconstructed and the measurements are taken to determine the severity of the head shape. A cephalic index, the ratio of the width of the head over the length of the head, and a cranial vault asymmetry index (CVAI), the differences in the diagonals of the head (front left to back right, and vice versus) are measured with this method. Many conclusions of the infant's head shape can be made using this method of measurement and this method is more standardized in comparison to the Argenta test. Source for photo: https://www.researchgate.net/figure/llustration-of-plagiocephalometry-31-asymmetry-DP-left-occipital-of-the-skull_fig1_46671935 

A craniometer, or manual measurements, is another method of measurement for infant head shape. This is done using a manual device, called a craniometer, that is placed on the infant's head to determine the shape. This is similar to a goniometer if you are familiar with that measurement tool. A cap is suggested to be placed on the infant's head prior to measuring with a craniometer to ensure that the most standardized measurement is taken. This allows the healthcare provider to measure with more consistency over time. This way of measurement is usually not done by parents because it is more complex and a specific tool is required. This device is used to measure the CVAI and CI much like the other ways of measuring and is an appropriate measurement tool for documenting infant head shape changes for insurance purposes. Three measurement trials should be competed when using this tool and an average of the three should be used to determine the measurement. This method of measurement may be difficult at times if the baby is older and is moving a lot, which can affect the reliability if the measurement. Image source: https://halo-care.com/products/craniometer 

Artificial intelligence (AI) measurement tools are also used to measure infant head shape. There are two softwares that I am familiar with, and one is called Soft Spot. 

Soft Spot is a tool designed for pediatricians and parents, as well as therapist to track an infant's head shape overtime using photos and values generated using an app. This Soft Spot tool is SO EASY to use and very parent friendly. The kit comes with a cap and visual cues that are placed on the infant's head. Inside the app, photos are taken based on the instructions given and results are sent to your email inbox. The results can be interrupted by a healthcare providers, and if you do not have one available, Soft Spot connects you with an expert, like myself. I think this is wonderful and empowering for parents, and makes head shape measurement accessible for people all over the world. How amazing! I am affiliated and use Soft Spot in my own home, and if you are interested in this kit, you can learn more here.  You can watch this video to see how this tool may be used in your home with your baby.

Another AI tool that is used among therapist is called Skully Care. Skully Care is similar to Soft Spot, but aimed more for healthcare provider usage. This is used largely to report and document head shape changes based on treatment and a monthly subscription is required to use this tool if using for multiple infants. You receive the results within 5 minutes during business hours and the app includes places for therapists to input treatment plan recommendations. This is a valuable tool, as parents can access this information if they have the app as well.

The last head shape measurement method I will cover is digital surface imaging (DSI). This is usually done at a Cranial Technology clinic in the US and is a very standardized way of measuring a head shape. This is done by placing a cap on an infant's head and using a machine designed to take very detailed images of the infants head at all angles to produce a 3D image. This machinery is very expensive and a scan like this is completed at a business that specializes in helmeting, like Cranial Technologies in the United States. 

When using any of these tools, some helpful tips may be:

• Be as consistent as possible: Perform measurements regularly using the same technique and equipment to ensure consistency and accuracy.
• Document any changes: Keep a record of measurements and visually document any changes in the infant's head shape over time.
• Seek professional guidance: If you notice significant asymmetry or abnormalities, consult with a specialist for further evaluation and guidance. I am a licensed occupational therapist specializing in head shape, and I would be happy to help! As you can tell, I nerd-out about head shape 🤓 
• Encourage tummy time: Incorporate supervised tummy time sessions into your baby's daily routine to reduce the risk of developing flat spots on the back of the head. You can read this blog post here on tummy time!

At the end of the day, I always tell my clients, your baby is not going to go to school and  asked to measure their head shape. There is no such thing as a perfect head shape, but measuring and monitoring a baby's head shape is important to prevent "flat head" and avoid a cranial helmet if that is a goal for a parent. By utilizing proper measurement techniques and noting any signs of flattening, parents can play an active role in ensuring their baby's head shape is nice and round. Early detection and intervention of "flat head" can make a significant difference in addressing potential concerns and ensuring the best possible outcomes for the baby. If you are interested in rounding your infant's head shape without a cranial helmet, check out my conservative correction course here! 

As always, thanks for reading! 

Brooke, OTR/L

PS - look for a webinar covering this topic and MANY other topics around "flat head" in early Spring! Raising awareness around this topic for parents and therapist is so important, as "flat head" affects so many babies around the world.