Pregnancy and child

Sudden infant death advice 'being ignored' due to flat head worries

"Parents are risking their babies' lives by putting expensive pillows in their cots to stop the back of their heads being flattened," the Daily Mail reports.

A review of parental attitudes found some were ignoring advice about sudden infant death syndrome (SIDS) by letting them sleep with pillows.

Since the 1990s, parents have been advised to put babies to sleep on their backs, in a cot with a flat mattress and no pillows, to avoid SIDS. And this had led, over time, to the lowest number of SIDS deaths (128 in 2014) in England and Wales since records began.

However, about one in five children now develop a flat area on the back of their head (called plagiocephaly) because babies' skulls are soft and still growing. Researchers in Canada and Australia talked to parents, grandparents and healthcare professionals to find out more about attitudes to these issues.

Their interviews showed that the parents were often very worried about plagiocephaly and some said they were "willing to do anything" to prevent it, even if that meant using products that contradict SIDS safe sleeping guidelines.

For most children, flat head syndrome is mild and not particularly noticeable. If you do have pressing concerns then speak to your GP.

While SIDS cases may be at a record low, just one death is one too many. So it is important to stick to safe sleeping advice.  

Where did the story come from?

The study was carried out by researchers from the University of Sydney and the University of Toronto. It's not clear how it was funded. The study was published in the peer-reviewed journal Child: Care, Health and Development.

The Mail reported the study reasonably accurately, although there were a couple of errors. It said that flat head disappears over time "in the vast majority of cases," but the study cites previous research saying that only about a quarter of children had their skull shape return to normal. This study followed babies from age five or six months to 18 months and found that the use of helmets did not significantly improve this rate.

The Mail also cites SIDS advice from Australia, which says babies should not sleep with a blanket. UK advice says blankets tucked under the babies' arms, no higher than the shoulders, are fine.

What kind of research was this?

This was a qualitative study, which used focus groups and interviews to identify themes of concern among parents, grandparents and health professionals.

The researchers wanted to explore people's beliefs and worries, rather than to find out (for example) how many parents followed SIDS advice or how many were concerned about flat head. Qualitative studies look at how people experience and feel about subjects, rather than trying to find out factual data.

What did the research involve?

The researchers recruited 121 people through leaflets and social media advertisements. The majority (91) were parents, mostly women. They conducted several focus groups and individual interviews, either in person, by phone, Skype or email. They identified themes from the discussions and interviews. They carried out interviews until they stopped identifying new themes or concerns.

The researchers communicated with 91 parents, six grandparents and 24 clinicians, including:

  • four paediatricians
  • two child-care nurses
  • two midwives
  • nine GPs
  • two chiropractors
  • five paediatric physiotherapists.

Focus groups of parents or grandparents were interviewed. Focus groups and interviews used semi-structured questions to find out about people's experiences, with questions based on the existing research into flat head, SIDS and people's experiences of healthcare. They looked at four main themes:

  • the importance of flat head
  • SIDS guidelines and flat head
  • health services for flat head
  • costs to families with a child affected by flat head

What were the basic results?

Researchers found that most of the parents knew about flat head, and some of them were very concerned about it. The main concerns were about the effect on the child's looks, with a "round head" being seen as normal and parents worried that children would be teased for having a flat head.

Parents of children with severe flat head, where the condition can affect facial features (such as the positioning of the ears) were most concerned. Some parents were also worried it could affect childhood development or brain growth. (There's not enough evidence at present to know whether that's true).

Some parents expressed frustration or even anger that the SIDS campaign "leads to flat head," and that parents were being "scared" into believing their children would die if they didn't sleep on their backs.

Many of the parents had tried modified pillows sold with the intention of preventing or treating flat head, or had modified the cot by rolling up a towel to tilt the mattress, although these things are against SIDS advice. Others said that the advice to give children "tummy time" where they spent part of the day, supervised by an adult, lying on their stomachs, was too simplistic.

Some of the parents with more severely affected children had taken them for "helmet therapy" where the child is fitted with a helmet that is intended to reshape the child's head. They said the babies found the helmets uncomfortable and hot, and the parents felt self-conscious, guilty and embarrassed about taking them out in public. Research in 2014  showed that helmets don't seem to work any better than waiting to see if the condition improved.

The GPs interviewed said they had little knowledge of the condition and tended to refer patients on to specialists. Specialist paediatric departments and physiotherapy services said they were being "swamped" with referrals, which took them away from seeing children with other "more serious" conditions. 

How did the researchers interpret the results?

The researchers said their research showed a "strong caregiver desire to prevent" flat head, and that healthcare professionals who saw children with this condition should remind parents of the SIDS guidelines for safe sleeping, because parents of children with flat heads may be ignoring them.

They added that, given the prevalence of the condition, GPs and others in primary care should be better educated about it, so they didn't have to refer immediately to specialist services. They suggest that group physiotherapy might be a good way to treat the condition efficiently, although there was nothing in their research to back this up.


The success of the campaign to reduce the devastating experience of SIDS is not in doubt. Since the Back To Sleep campaign began, numbers of these "cot deaths" have reduced by 65%  in the UK. And, at time of writing, recorded deaths from SIDS are at a record low in England and Wales.

Still, there is no room for complacency. Safe sleeping advice remains important and parents should take it very seriously.

There's no research to show whether cushions or pillows marketed as suitable for preventing flat head are either safe or effective. They are best avoided.

There are some things to bear in mind about the research. It was carried out in Canada and Australia, which have different healthcare systems and may have differing attitudes to health. A survey of UK parents and doctors might have had different results. Also, because the study relied on people volunteering to take part, it's likely that more of the parents who took part were worried about flat head than parents who did not volunteer. This means the level of worry about flat head may be over-stated.

However, as this study shows, many parents are very concerned about flat head. If you are worried about your baby, talk to your GP or health visitor. There are some simple things you can try at home to reduce the amount of time a baby spends with the back of their head on a flat surface:

  • Ensure your baby spends some time lying on its tummy while they are awake, while you watch them, but put them to sleep on their back.
  • Switch the baby between different positions during the day, using a sling or a sloping chair as well as their cot.
  • Move the position of mobiles above the baby's cot, so they move their head to different positions to watch them.
  • Swap over the sides you carry or feed the baby.

NHS Attribution