Torticollis in babies

How does this happen?

The sternocleidomastoid runs diagonally from behind the ear down to the collarbone. Contract the one on the right and the head tilts right and turns left.

In most babies with torticollis, that muscle is shortened or has a firm area within it. Explanations include position in the uterus late in pregnancy, a tight fit, a difficult delivery, or a small injury to the muscle with subsequent scarring. Sometimes a firm lump can be felt in the muscle in the first weeks, which softens and disappears over months. ¹

Two things follow from a fixed head position.

Head shape. A baby who always rests on the same part of the skull flattens that part. That is called positional plagiocephaly, and it is a consequence of the torticollis rather than a separate problem. Treating the neck usually resolves the head shape in young babies.

Development. A baby who cannot turn one way looks less in that direction, reaches less on that side, and may be slower to roll toward it. This is usually a positional effect and it resolves with treatment.

Torticollis can also be a sign of something else. A head tilt that appears after the newborn period, that is painful, that comes with eye problems, or that does not respond to stretching needs investigating rather than continued therapy. ²

What causes it?

Two different questions get mixed together here. The first is what leads to this injury in the body. The second is whether anyone could have prevented it. They are not the same question, and the answer to the first does not settle the second.

Happens even with perfect care

• Position in the uterus, particularly in the last weeks, in a tight space or with a large baby. ⁴
• breech position. ⁵
• Twin or multiple pregnancy.
• A first pregnancy, where the uterus is less stretched.
• A difficult or assisted delivery. ⁶
• No identified cause, which is common.

Associated with gaps in care

These are situations where published standards say what the care team should watch for and do. A gap here does not prove anyone caused your child's injury. It points to where the medical records will have an answer.

Torticollis is rarely caused by a gap in care. The gaps that matter are about recognition and about what else was missed.

• Not recognized at the newborn or well-child examination, so treatment started late when it works less well. Newborn and well-child examinations are standard practice. ⁷
• Hips not examined. Hip problems occur more often in babies with torticollis, and hip examination is part of routine newborn care. ¹
• A head tilt attributed to torticollis without considering other causes, particularly when it appears later, is painful, or comes with neurological or eye signs. ²
• Referral to therapy delayed while waiting to see whether it settles, when early stretching is what works. ³
• clavicle fracture or a brachial plexus injury not identified, both of which can produce a head position preference. ⁸

Whether any of this amounts to a departure from the standard of care takes a physician expert reading the whole record.

What are the signs, by age?

Signs change as a child grows. A newborn cannot show you a walking problem. Some children look fine at first and show differences months later.

At birth and the first hours

• The head resting tilted to one side and turned to the other.
• A firm lump felt in the neck muscle in some babies, appearing in the first weeks.
• Difficulty turning the head to one side during handling.

The first week

• A clear preference for looking one way.
• Feeding easier on one side than the other.
• Resistance when the head is gently turned the other way.

Around 3 months

• Persistent head tilt and turn preference.
• Flattening starting on one side of the back of the head.
• Facial asymmetry in some babies, with one eye or ear sitting slightly differently.
• Reduced reaching on one side.

Around 6 months

• Head shape asymmetry more obvious.
• Delay in rolling toward the restricted side. ⁹
• Sitting with a persistent head tilt.

Around 12 months

• A residual tilt if untreated.
• Preference for using one hand, which should always be assessed rather than assumed to be positional. An early hand preference is a separate and important finding. ¹⁰

Toddler years

• Persistent tilt in children whose torticollis did not resolve.
• Compensating posture through the shoulders and trunk.
• Difficulty with activities requiring head turning.

School age

• In treated children, no expected effects.
• In untreated persistent torticollis, tightness, asymmetry and occasionally the need for surgery.

How is it diagnosed?

Diagnosis is by examination: a head tilt with limited turning to one side and a tight or lumpy sternocleidomastoid muscle. ¹

What should be checked alongside

• The hips, because hip problems occur more often in babies with torticollis. ¹
• The head shape, documented so change can be tracked.
• The eyes, because an eye muscle problem can cause a compensatory head tilt. This is one of the important alternatives.
• The neck bones, where the picture is unusual.
• The clavicle, since a fracture can produce a position preference. ¹¹
• The arm nerves, since a brachial plexus injury can too. ⁸

Imaging is not routinely needed. Ultrasound of the muscle is used in some centers. X-ray or MRI is used where the presentation is atypical, painful, late in onset, or not responding.

The rule that matters

Torticollis present from the newborn period that improves with stretching is the ordinary kind. Torticollis that appears later, hurts, comes with neurological or eye signs, or does not respond needs a different workup, not more stretching. ²

What is the treatment?

Stretching and positioning, taught by a physical therapist and done several times a day at home. This is the treatment, and the great majority of babies resolve with it. ¹

Positioning through the day.

• Put toys and interesting things on the restricted side so the baby turns that way to look.
• Alternate the direction the baby faces in the crib.
• Alternate the side you carry them on and the side you feed from.
• Tummy time, which builds the neck and shoulder strength that supports the correction.

Referral to early intervention for a child under 3, which is free to evaluate. ³

Helmet therapy is used for head shape in some babies whose flattening does not correct once the neck is treated. It addresses the skull, not the neck, and the neck comes first.

Botulinum toxin or surgery is reserved for the small number of children who do not respond to consistent stretching over months.

Treat what else is there. If the hips are affected, that is treated on its own terms. If an eye problem is causing a compensatory tilt, stretching will not help.

What is the long-term outlook?

Very good. Most babies with torticollis resolve completely with stretching and positioning, particularly when treatment starts early. ¹

Head shape usually improves as the neck frees up and the baby stops resting on the same spot, and most flattening corrects on its own in young babies.

Residual tightness and asymmetry are more likely where treatment started late or was not done consistently.

Facial asymmetry from prolonged positioning usually improves but can persist to a mild degree.

What does daily life look like?

Stretches several times a day for weeks to months. This is the whole treatment and consistency is what decides how it goes.

Rearranging the room, the crib direction, the feeding side and where the toys go, so that turning the harder way is what the baby wants to do rather than something being done to them.

Tummy time, which most babies dislike at first and which matters here more than usual.

The main practical challenge families describe is remembering. Attaching stretches to something that already happens, such as every diaper change, works better than setting aside a session.

What does care cost over a lifetime?

Treated torticollis generates the cost of therapy visits over a few months. Helmet therapy, where used, has a substantial cost and coverage varies by insurer and state.

No agency publishes a lifetime cost estimate for torticollis and this site does not invent one.

Early intervention evaluation is free, and services are provided at no cost or on a sliding scale depending on the state. ³ See paying for care.

What can you do this week?

1. Ask for a physical therapy referral now. Early is better.
2. Ask to be shown the stretches and to do them while the therapist watches.
3. Ask whether the hips have been examined.
4. Ask whether the eyes have been checked as a cause of the tilt.
5. Turn the crib around so the interesting side of the room is on the restricted side.
6. Start tummy time and build it up.
7. Take a photo of the head from above every two weeks so you can see change.

What should you ask each specialist?

Take these with you. Write the answers down in the moment, because you will not remember them later.

For the pediatrician

• Which side is tight, and how far can the head turn each way?
• Have the hips been examined?
• Have the eyes been checked as a cause?
• Is the head shape being measured or photographed?
• When should we see improvement, and what if we do not?

For the physical therapist

• Show me the stretches and watch me do them.
• How many times a day, and how long should each hold be?
• How should I position my baby for sleep, feeding and play?
• When would you consider a helmet, and why?

You can also build a printable list with the question generator.