Deformational plagiocephaly and orthotic treatment: indications and limitations

Helmet therapy efficacy and its prediction in Japanese infants with positional plagio- and brachycephaly

PURPOSE

To provide additional information on optimal start times and therapeutic effectiveness based on treatment outcome of Japanese infants with positional plagio- and brachycephaly (PPB) receiving cranial molding helmet therapy (CMHT).

METHODS

In this retrospective cohort study, data from a 3D head scanning system was analyzed from 2173 Japanese infants who completed CMHT. Anterior and posterior symmetry ratio (ASR and PSR) and longitudinal to transverse diagonal ratios (LD/TDR) were calculated based on skull shape at helmet design and at completion of therapy. The outcomes were evaluated using the regression analysis and a predictive model using cranial parameters was developed.

RESULTS

The earlier the start of therapy, the greater the therapeutic effect on ASR, PSR, and LD/TDR (ASR, -0.134 percent points (ppt)/day; PSR, -0.086 ppt/day; and LD/TDR, -0.131 ppt/day). In the predictive model, in addition to starting age of the therapy, sex (male), the degree of deformity of the head (DoD) (moderate and severe), quadrant volume, PSR, and head circumference at the start of treatment also had a positive effect on changes in ASR, DoD (moderate and severe), ASR, LD/TDR and transverse diameter for PSR, sex (male), DoD (moderate), quadrant volume, PSR, and head circumference for LD/TDR.

CONCLUSION

The starting age of therapy had a relatively smaller contribution to outcome effects. Applying the cranial parameter obtained at the start of treatment to the predictive model helps to predict the effect of CMHT and whether PPB can be treated with CMHT in infants of older age.

Positional Plagiocephaly and Craniosynostosis

Along with the decrease in sudden infant death syndrome due to the successful "Back to Sleep" Campaign, there was a reciprocal increase in cases of positional plagiocephaly (PP). The prevalence of PP significantly rose from approximately 5% to upward of 46% at age 7 months. Consequently, clinicians have seen a surge in the number of patients presenting with head shape abnormalities. Not only does this increase in patient volume pose a logistical problem to clinics, but it also poses a potential risk to patients with craniosynostosis, whose head shape anomalies are similar to a "needle in a haystack" of patients with more common PP. This review explores the causes, risk factors, and treatment options of PP and craniosynostosis, along with the differential of head shape anomalies based on phenotypic presentation. In doing so, we hope to provide pediatric care clinicians with the tools necessary to effectively evaluate and manage patients with head shape abnormalities. [Pediatr Ann. 2023;52(1):e10-e17.].

Three-Dimensional versus Two-Dimensional Evaluations of Cranial Asymmetry in Deformational Plagiocephaly Using a Three-Dimensional Scanner

This study aimed to assess the measurement precision of a three-dimensional (3D) scanner that detects the geometric shape as surface data and to investigate the differences between two-dimensional (2D) and 3D evaluations in infants with deformational plagiocephaly. Using the 3D scanner that can perform both 2D and 3D evaluations, we calculated cranial asymmetry (CA) for the 2D evaluation, and the anterior symmetry ratio (ASR) and posterior symmetry ratio (PSR) for the 3D evaluation. Intra- and inter-examiner precision analyses revealed that the coefficients of the variation measurements were extremely low (<1%) for all variables, except CA (5%). In 530 infants, the coincidence rate of CA severity by the 2D evaluation and the 3D evaluation was 83.4%. A disagreement on severity was found between 2D and 3D evaluations in 88 infants (16.6%): 68 infants (12.8%) were assessed as severe by 2D evaluation and mild by the 3D evaluation, while 20 infants (3.8%) were evaluated as mild by 2D and severe by 3D evaluation. Overall, the 2D evaluation identified more infants as severe than the 3D evaluation. The 3D evaluation proved more precise than the 2D evaluation. We found that approximately one in six infants differed in severity between 2D and 3D evaluations.

Development and Validation of a Prediction Model for the Treatment Time of Deformational Head Shapes Using a Cranial Remolding Orthosis

The cranial remolding orthosis (CRO) has been shown in previous studies to be an effective method of treatment for deformational head shapes. Many studies have shown younger infants achieve greater correction than older infants and generally have a shorter treatment duration. The goal of this study is to develop and validate a prediction equation for the maximum treatment time for deformational head shapes when utilizing a CRO. This retrospective study included subjects with deformational plagiocephaly (DP), deformational brachycephaly (DB), or deformational asymmetrical brachycephaly (DAB) who began CRO treatment between 3 and 18 months of gestational age. Prediction models were derived from 1250 subjects with DP, DB, and DAB and the validation used data from 210 different subjects. Actual treatment time was less than or equal to predicted treatment time in 85.19% (DP), 56.67% (DB), and 75.40% (DAB) of the cases when rounding the prediction up to the nearest month. The prediction equation has moderate accuracy for predicting the likely maximum amount of CRO treatment time for patients with DP, DB, and DAB and may be used clinically to give caregivers an estimated treatment duration for a patient who is indicated for a CRO, if treatment was initiated immediately.

Side Effects of Cranial Remolding Orthoses: A Multi-Site Review

ABSTRACT

Infants with deformational head shapes may be treated with a Cranial Remolding Orthosis (CRO). Risks of CROs include skin irritations and other minor side effects. It is important to examine the incidence of complications with CRO treatment to determine if the potential benefits outweigh the risks.This study retrospectively examined surveys provided by both practitioners and caregivers regarding orthotic treatment side effects and wear time at four clinics in Canada. Statistical analysis including the Chi-square test and Fisher's exact tests were performed to examine how the side effects varied by treatment site and by reported orthotic wear time.In total, 5,025 surveys about the CRO treatment of 453 patients were reviewed. The most common side effects were pressure spots, redness lasting for more than 1 hour, excessive sweat, and foul odor; however, the vast majority reported no significant issues (87.08%). Only 2.81% of surveys reported multiple side effects, which was about three times more like to happen when the CRO was reported to have fit problems. Wear time is correlated with the report of side effects; infants who wore the CRO 18 to 23.5 hours had statistically fewer side effects than those who wore the CRO for less time. The reported incidence of side effects may be artificially inflated because infants experiencing side effects are more likely to have more frequent follow-up.Overall, the side effects of CRO treatment reported in this cohort were relatively rare and minimal, indicating CRO treatment is a safe way to treat deformational head shapes.

Spherical harmonics to quantify cranial asymmetry in deformational plagiocephaly

Cranial deformation and deformational plagiocephaly (DP) in particular affect an important percentage of infants. The assessment and diagnosis of the deformation are commonly carried by manual measurements that provide low interuser accuracy. Another approach is the use of three-dimensional (3D) models. Nevertheless, in most cases, deformation measurements are carried out manually on the 3D model. It is necessary to develop methodologies for the detection of DP that are automatic, accurate and take profit on the high quantity of information of the 3D models. Spherical harmonics are proposed as a new methodology to identify DP from head 3D models. The ideal fitted ellipsoid for each head is computed and the orthogonal distances between head and ellipsoid are obtained. Finally, the distances are modelled using spherical harmonics. Spherical harmonic coefficients of degree 2 and order − 2 are identified as the correct ones to represent the asymmetry characteristic of DP. The obtained coefficient is compared to other anthropometric deformation indexes, such as Asymmetry Index, Oblique Cranial Length Ratio, Posterior Asymmetry Index and Anterior Asymmetry Index. The coefficient of degree 2 and order − 2 with a maximum degree of 4 is found to provide better results than the commonly computed anthropometric indexes in the detection of DP.

Natural-Course Evaluation of Infants with Positional Severe Plagiocephaly Using a Three-Dimensional Scanner in Japan: Comparison with Those Who Received Cranial Helmet Therapy

This study aimed to clarify the natural course of positional plagiocephaly using a three-dimensional (3D) scanner and investigate the effectiveness of cranial helmet therapy (CHT). One hundred infants with severe plagiocephaly who visited our institutions between April 2020 and March 2021 were included. Cranial shape was measured using an Artec Eva 3D scanner. A cranial asymmetry (CA) >12 mm was diagnosed as severe plagiocephaly. An infant whose CA subsided to <12 mm was considered to have improved naturally or by CHT. The difference in CA between the second and initial scans was defined as the improvement value (median scan interval was two months). In the natural-course group comprising 56 infants with severe plagiocephaly, 37 (66%) with a median CA of 15.6 mm exhibited no improvement after two months. In the scan age- and evaluation interval-matched case-control study, the CA value in the CHT group improved by three times that in the natural-course group (−4.6 mm [n = 33] vs. −1.55 mm [n = 24], p < 0.001). Severe plagiocephaly did not improve naturally in 66% of the cases. Therefore, CHT should be considered if the CA is >12 mm on the initial evaluation.

Two-Dimensional Image-Based Screening Tool for Infants with Positional Cranial Deformities: A Machine Learning Approach

Positional cranial deformities are relatively common conditions, characterized by asymmetry and changes in skull shape. Although three-dimensional (3D) scanning is the gold standard for diagnosing such deformities, it requires expensive laser scanners and skilled maneuvering. We therefore developed an inexpensive, fast, and convenient screening method to classify cranial deformities in infants, based on single two-dimensional vertex cranial images. In total, 174 measurements from 80 subjects were recorded. Our screening software performs image processing and machine learning-based estimation related to the deformity indices of the cranial ratio (CR) and cranial vault asymmetry index (CVAI) to determine the severity levels of brachycephaly and plagiocephaly. For performance evaluations, the estimated CR and CVAI values were compared to the reference data obtained using a 3D cranial scanner. The CR and CVAI correlation coefficients obtained via support vector regression were 0.85 and 0.89, respectively. When the trained model was evaluated using the unseen test data for the three CR and three CVAI classes, an 86.7% classification accuracy of the proposed method was obtained for both brachycephaly and plagiocephaly. The results showed that our method for screening cranial deformities in infants could aid clinical evaluations and parental monitoring of the progression of deformities at home.

Effect of helmet therapy in the treatment of positional head deformity

AIM

Most positional head deformities can be treated conservatively with postural correction training or a head orthosis ('helmet'). We aimed to investigate whether infants with helmet therapy have cosmetic improvement in head deformity.

METHODS

A total of 376 infants at age 2-40 months who were diagnosed with mild-moderate-severe positional head deformity were enrolled. Among these infants, 101 infants were treated with helmet therapy or postural correction training. After matching by infant's age and time of therapy, three retrospective cohort studies of 56 infants were conducted for infants with plagiocephaly, brachycephaly and asymmetrical brachycephaly, respectively. The cephalic ratio (CR), radial symmetry index (RSI), cranial vault asymmetry (CVA) and cranial vault asymmetry index (CVAI) were compared between two groups before and after treatment.

RESULTS

Before treatment, no significant differences in CR, RSI, CVA and CVAI between groups were found. After treatment, compared with the postural correction training group, the helmet therapy group had significant improvements in CR, RSI, CVA or CVAI (Plagiocephaly: P_CVA = 0.017, P_CVAI = 0.028; Brachycephaly: P_CR = 0.002; Asymmetrical brachycephaly: P_RSI = 0.002, P_CVA  < 0.001, P_CVAI  < 0.001). Moreover, there was no significant difference in head circumference growth between the groups.

CONCLUSIONS

Helmet therapy may be more effective in the treatment of mild-moderate-severe positional head deformity than postural correction training in infants. And helmet therapy may not hinder head circumference growth.

Diagnosis and treatment of positional plagiocephaly

Positional plagiocephaly is increasing in infants. Positional plagiocephaly is an asymmetric deformation of skull due to various reasons; first birth, assisted labor, multiple pregnancy, prematurity, congenital muscular torticollis and position of head. Positional plagiocephaly can mostly be diagnosed clinically and by physical examinations. The simplest way to assess the severity of plagiocephaly is to use a diagonal caliper during physical examination, which measures the difference between the diagonal lengths on each side of the head. Plagiocephaly can be treated surgically or conservatively. Positional plagiocephaly, which is not accompanied by craniosynostosis, is treated conservatively. Conservative treatments involve a variety of treatments, such as change of positions, physiotherapy, massage therapy, and helmet therapy. Systematic approaches to clinical examination, diagnosis and treatment of positional plagiocephaly can be necessary and the age-appropriate treatment is recommended for patients with positional plagiocephaly.

Significant Factors in Cranial Remolding Orthotic Treatment of Asymmetrical Brachycephaly

This retrospective chart review focuses on determining the most effective time to begin cranial remolding orthosis (CRO) treatment for infants with asymmetrical brachycephaly. Subjects with asymmetrical brachycephaly started CRO treatment between 3 and 18 months of age. These infants had a cranial vault asymmetry index (CVAI) ≥ 3.5 and a cranial index (CI) ≥ 90. Subjects were excluded if they had any comorbidities affecting growth, dropped out of treatment, were lost to follow-up, or were noncompliant. Factors which were found to statistically influence treatment outcomes were subject initial age, initial CVAI, and initial CI. Overall, younger subjects were more likely to achieve a corrected head shape. The presence of prematurity or torticollis had statistically nonsignificant effects on the success of treatment. Initial CI was found to be a stronger predictor than initial CVAI as to which subjects achieved correction. The less severe the starting CI, the more likely the subject was to achieve full correction. The clinical understanding is that it requires more cranial growth to "round out" a full posterior skull flattening than an asymmetry. Based on the study results, infants with asymmetrical brachycephaly should be treated as early as possible to increase chances of achieving full correction of the deformity.

Positional cranial deformation in children: A plea for the efficacy of the cranial helmet in children

BACKGROUND

Cranial deformations have historically aroused the interest of people worldwide. One of the more debated points about positional plagiocephaly is the choice of the treatment. In this article, the senior author (CM) shares his experience on almost 30 years of use of the helmet molding therapy in children with deformation plagiocephaly.

METHODS AND POPULATION

We retrospectively and systematically reviewed the cases of 2188 patients (75% males and 25% females) presenting positional head deformity and treated between 1991 and 2013 with a cranial helmet. To assess the effectiveness of the helmet, we compared the cranial index in bilateral plagiocephaly and the Cranial Diagonals Difference (CDD) in unilateral plagiocephaly at the beginning and at the end of the treatment.

RESULTS

The cranial indexes ranged between 94.4% and 124.2% before the treatment and decreased significantly between 86.8% and 121.4% after the treatment (P<0.01). The CDD ranged between 0.3 cm and 4.5 cm with an average of 1.50±0.54 cm before the treatment and decreased significantly between 0.1 cm and 2.5 cm with an average of 0.72±0.37 cm after the treatment (P<0.01). For unilateral plagiocephaly, at the beginning of the treatment, 2.5% children presented a mild plagiocephaly, 19.6% a moderate plagiocephaly and 77.9% a severe plagiocephaly. At the end of the treatment, the deformation was classified as mild in 40.2% children, moderate in 44.3% children and severe in 15.5% children with significantly less children in the most severe subgroups (P<0.01) Facial symmetry pre-existed before the treatment in 13.7% of children. This rate was significantly increased at the end of the treatment to 66.7% (P<0.01). In only 8 cases (0.2%), the helmet therapy did not allow to obtain correct clinical results and a surgical posterior cranial remodeling was performed.

CONCLUSIONS

The results observed in this series confirms that cranial helmet is a simple and well tolerated alternative which bring satisfying results. Its success implies a good collaboration with parents and a management both by orthoptist, physiotherapist and doctor. Nevertheless, it remains many controversies in the literature concerning in particular long-term cosmetic and functional outcomes. A long-term multicentric prospective study could enable to remove doubts.

Treatment of Deformational Plagiocephaly With Physiotherapy

Non-synostotic plagiocephaly consists in an asymmetry of the skull due to mechanical forces applied in utero or postnatally: main differential diagnosis is with true synostotic asymmetry, which is caused by the premature closure of a suture. The correction of positional forms is mostly conservative, with 3 main strategies: counterpositioning, physiotherapy and helmet therapy. There is no synthesized evidence on which is the most effective. The Authors evaluate the modification of antropometric measurments before and after a pediatric physical therapy program in a sample of patients with non-synostotic skull asymmetry, in order to evaluate the improvements in the skull shape. The hypothesis being tested was that physical therapy alone could improve the antropometric measurments. The authors enrolled in this study 24 patients diagnosed of non-synostotic asymmetry, clinically and with ultrasound, referred to the Maxillo-facial Unit of Policlinico Umberto I, Rome, within 2013 and 2016. A standardized pediatric physical therapy intervention program was designed: it consisted in a combination of excercises and manipulative procedures to reduce positional preference, musculoskeletal disorders and cranial deformity. Infants received 16 sessions of physical therapy, of 40 minutes each, once a week, for four months. The Authors evaluate the variation of four anthropometric measurments, performed before and after the physical therapy program: Argenta scale, Oblique Diameter Difference Index (ODDI), Cranial Proportional Index (CPI) or Cephalic Ratio (CR), Cranial Vault Asymmetry Index (CVAI). Craniometric evaluations were extrapolated by standardized 2D digital photographs of frontal, sagittal and transverse planes, by the same physician to minimize bias. The management of positional cranial deformities is still controversially discussed and especially the effects of physiotherapy and osteopathy have been only marginally researched. Statistical analysis revealed the effectiveness of the protocol: all anthropometric measurements improved with a high rate, major in youngest children (P < 0.5) and in more severe first presentations (P < 0.05 or P < 0.01). The results suggest manipulative approach may improve the outcome in the long term follow up of cranial asymmetries.

Significant Factors Influencing the Effectiveness of Cranial Remolding Orthoses in Infants With Deformational Plagiocephaly

Infants with deformational plagiocephaly may be indicated for a cranial remolding orthosis (CRO) depending on the severity of deformation. Studies have found torticollis and prematurity to be risk factors for the development of deformational plagiocephaly and indicate younger infants have faster and greater correction. However, clinical decisions about which infants should be recommended for CRO treatment differ among healthcare providers and insurance coverage criteria vary. In order to provide insight into treatment recommendations, this study aims to examine the influence of 4 specific factors on CRO treatment time and the infant's resultant posttreatment head shape. Results indicate that presenting age, presenting severity, and the presence of torticollis significantly influence treatment duration. Presenting age and severity were found to significantly influence final head shape. The presence of prematurity was not found to be significant when infants were categorized by their corrected postpartum ages.

Effects of Initial Age and Severity on Cranial Remolding Orthotic Treatment for Infants with Deformational Plagiocephaly

The aim of this study is to review the effects of an infant's presenting age and severity of deformation on cranial remolding orthotic (CRO) treatment outcomes for patients with deformational plagiocephaly. This study is a retrospective chart review of 499 infants with non-synostotic plagiocephaly who completed CRO treatment. Data collected included age at start of treatment, head shape measurements before and after treatment, total months of CRO treatment, and other factors such as presence/absence of prematurity. The infants were divided into subgroups according to age and severity at initiation of treatment and data for subgroups was analyzed to track the change in head shape over the course of treatment, review overall treatment duration, and discuss the rate of change of cranial deformation. Overall, treatment times tended to statistically increase with increasing initial severity and age. Posttreatment asymmetry measurements statistically trended to greater residual deformation in infants who began treatment in the older or more severe subcategories. This indicates that younger and less severe infants have shorter treatment durations and less residual cranial deformation after CRO treatment. Therefore, clinical consideration may need to be taken to treat infants at younger ages or prior to progression of the cranial deformity.

Molding Helmet Therapy for Deformational Brachycephaly

BACKGROUND

Molding helmet therapy is used for the treatment of infants with deformational brachycephaly (DB). There is a lack of rigorous outcome measures of helmet therapy in patients with DB using 3-dimensional (3D) imaging, with most reports rely on either subjective or 2-dimensional analyses. Furthermore, the longitudinal assessment of head shape improvement over the course of helmet therapy has not been documented. Our goal was to assess the outcome of molding helmet therapy using 3D surface imaging, and to document the pace of improvement during treatment.

METHODS

The head shape of 18 infants with DB who underwent orthotic molding helmet therapy was assessed. The 3D scans were obtained before treatment, during treatment, and at the end of treatment. First, we applied shape analysis techniques based on template deformation to obtain average (composite) heads of the 18 patients at the 3 time points of treatment (pretreatment, during, and posttreatment). In addition, we used 3D curvature analysis to quantify the degree of flatness at the same time points.

RESULTS

Molding helmet therapy started at 6.7 ± 0.9 months of age and lasted for 4.3 ± 0.8 months. The overall difference in the occipital contour between pretreatment and end of treatment was 6.3 ± 1.7 mm. Curvature analysis revealed that 15% of the back of the head had prehelmet marked flatness (mean curvature <5/m), which decreased to 9% at 2.5 months into treatment and 7% at the end of treatment.

CONCLUSION

Over 65% of the head shape improvement occurred during the 2.5 months of molding helmet therapy.

Outcome analysis of molding helmet therapy using a classification for differentiation between plagiocephaly, brachycephaly and combination of both

PURPOSE

The incidence of positional head deformation has increased during the last decades. Helmet therapy has been proved to be a reliable method for the treatment of nonsynostotic skull deformities. Until today, a simple classification to differentiate between different head shapes has not been established.

MATERIALS AND METHODS

We suggest a classification system to group patients with plagiocephaly, brachycephaly, and a combination of both, using two simple values: cranial vault asymmetry (CVA), and cephalic index (CI). We further analyzed a study population of 1050 children treated with molding helmets to identify prognostic variables for better outcome within our proposed classification.

RESULTS

In all, 736 patients were male (70.10%) and 314 patients were female (29.90%). Mean improvement of cranial vault asymmetry index (CVAI) ranged from 2.94% to 7.08% (CVA 0.37 cm-0.86 cm) in subgroups of patients defined by classification and severity of deformation. In patients with brachycephaly, CI improved from 4.17% to 8.22%. Duration of therapy differed from 21 weeks to 24 weeks. Children aged 6 months or less showed greater improvement and shorter duration of therapy compared to older patients. In addition to early onset of therapy, classification and severity of deformation were significantly associated with a reduction of the deformation under therapy. There were distinct differences in outcomes between different head shapes.

CONCLUSION

Helmet therapy should be initiated early. Our analysis suggests that the proposed classification correctly identifies patients whose deformation is reduced under therapy.

LEVEL OF EVIDENCE

III.

Helmet Treatment of Infants With Deformational Brachycephaly

Deformation of the cranium in infancy represents a spectrum of deformity, ranging from severe asymmetric yet proportional distortion of the skull in plagiocephaly, to nearly symmetric yet disproportional distortion in brachycephaly. As such, the condition is best described as deformational plagiocephaly-brachycephaly with isolated plagiocephaly and/or isolated brachycephaly being at either ends of the spectrum. Due to its symmetric appearance, deformational brachycephaly is often incorrectly dismissed as being less concerning, and it has sometimes erroneously been reported that brachycephaly cannot be treated successfully with a cranial orthosis. We prospectively report on 4205 infants with isolated deformational brachycephaly treated with a cranial orthosis from 2013 to 2017. These results demonstrate that the orthosis is successful in the treatment of deformational brachycephaly with an 81.4% improvement toward normal (95.0 to 89.4) in cephalic index. We furthermore demonstrate that entrance age influences treatment results, with younger infants demonstrating both improved outcomes and shorter treatment times.

Parents' Perspectives and Clinical Effectiveness of Cranial-Molding Orthoses in Infants With Plagiocephaly

OBJECTIVE

To investigate the clinical effectiveness of and parents' perspectives on cranial-molding orthotic treatment.

METHODS

Medical charts were reviewed for 82 infants treated for plagiocephaly with cranial-molding orthoses in our clinic from April 2012 to July 2016 retrospectively. Infants who were clinically diagnosed with positional plagiocephaly and had a Cranial Vault Asymmetry Index (CVAI) of more than 3.5% were included. Pre- and post-treatment CVAI was obtained by three-dimensional head-surface laser scan. Parents' perceptions of good outcome (satisfaction) were evaluated with the Goal Attainment Scale (GAS). The GAS score assessed how much the parent felt that his or her initial goal for correcting the skull asymmetry was achieved after the treatment.

RESULTS

The compliance with cranial-molding orthoses was 90.2% (74 of 82 infants). There were 53 infants (65% of the 82 infants) who had adverse events with the cranial-molding orthoses during the study. Heat rash was found in 29 cases (35.4%) and was the most common adverse event. The mean GAS T-score was 51.9±10.2. A GAS T-score of 0 or more was identified for 71.6% of parents. The GAS T-score was significantly related to the age (p<0.001), the initial CVAI, and the difference of CVAI during the treatment (p<0.001).

CONCLUSION

Parents' perception of good outcome was correlated with the anthropometric improvement in cranialmolding orthotic treatment in infants with plagiocephaly. A high percentage of parents felt that the treatment met their initial goals in spite of a high occurrence of adverse events.

Assessing calvarial vault constriction associated with helmet therapy in deformational plagiocephaly

OBJECTIVE Deformational plagiocephaly and/or brachycephaly (DPB) is a cranial flattening frequently treated in pediatric craniofacial centers. The standard of care for DPB involves patient positioning or helmet therapy. Orthotic therapy successfully reduces cranial asymmetry, but there is concern over whether the orthotics have the potential to restrict cranial growth. Previous research addressing helmet safety was limited by lack of volume measurements and serial data. The purpose of this study was to directly compare head growth data in patients with DPB between those who underwent helmet therapy and those who received repositioning therapy. METHODS This retrospective cohort study analyzed pre- and posttherapy 3D photographs of 57 patients with DPB who had helmet therapy and a control group of 57 patients with DPB who underwent repositioning therapy. The authors determined the change in cranial vault volume and cranial circumference between each patient's photographs using 3D photogrammetry. They also computed a cubic volume calculated by multiplying anterior-posterior diameter, biparietal diameter, and height. Linear regressions were used to quantify effects of age and therapy type on these quantities. RESULTS A comparison of the following variables between the two groups yielded nonsignificant results: age at the beginning (p = 0.861) and end (p = 0.539) of therapy, therapy duration (p = 0.161), and the ratio of males to females (p = 0.689). There was no significant difference between patients who underwent helmeting versus positioning therapy with respect to change in either volume calculation or head circumference z-score (p ≥ 0.545). Pretherapy photograph age was a significant predictor of cranial growth (p ≤ 0.001), but therapy type was not predictive of the change in the study measurements (p ≤ 0.210). CONCLUSIONS The authors found no evidence that helmet therapy was associated with cranial constriction in the study population of patients with DPB. These results strengthen previous research supporting helmet safety and should allow health care providers and families to choose the appropriate therapy without concern for potential negative effects on cranial growth.

Relationship between starting age of cranial-remolding-orthosis therapy and effectiveness of treatment in children with deformational plagiocephaly

PURPOSE

The aim of this study was to investigate the optimal age for starting cranial-remolding-orthosis therapy in children with deformational plagiocephaly.

METHODS

Medical records of 310 patients with deformational plagiocephaly were retrospectively reviewed and the initial and final cranial vault asymmetry index (CVAI), age when starting therapy, duration of therapy, mean change of CVAI, improvement rate, and treatment success were analyzed. We compared outcomes according to the groups divided by ages starting therapy.

RESULTS

There were no significant differences in improvement rate and duration of cranial-remolding-orthosis therapy among patients starting therapy at the age of 3, 4, and 5 months. However, when starting therapy after the age of 6 months, the rates of CVAI improvement were significantly lower and the duration of therapy was significantly increased.

CONCLUSION

Considering the spontaneous resolution effect according to the head growth nature, the age 5 month is the optimal period to start cranial-remolding-orthosis therapy for deformational plagiocephaly.

Nonsyndromic Craniosynostosis and Deformational Head Shape Disorders

This article provides an overview of etiology, epidemiology, pathology, diagnosis, and treatment of nonsyndromic craniosynostosis, including sagittal, metopic, coronal, lambdoid, and complex synostosis. Detailed discussion is presented regarding indications for surgical intervention and management options, including frontoorbital advancement, cranial vault reconstruction, endoscopic strip craniectomy, spring-assisted strip craniectomy, and cranial vault distraction osteogenesis. Deformational plagiocephaly is also presented with treatment options including repositioning, physical therapy, and helmet therapy.

Factors influencing outcomes of the treatment of positional plagiocephaly in infants: a 7-year experience

OBJECTIVE Following institution of the Back to Sleep Campaign, the incidence of sudden infant death syndrome decreased while the prevalence of positional skull deformation increased dramatically. The management of positional deformity is controversial, and treatment recommendations and outcomes reporting are variable. The authors reviewed their institutional experience (2008-2014) with the treatment of positional plagiocephaly to explore factors associated with measured improvement. METHODS A retrospective chart review was conducted with risk factors and treatment for positional head shape deformity recorded. Univariate and multivariate analyses were used to assess the impact of these variables on the change in measured oblique diagonal difference (ODD) on head shape surface scanning pre- and posttreatment. RESULTS A total of 991 infants aged less than 1 year were evaluated for cranial positional deformity in a dedicated clinical program. The most common deformity was occipital plagiocephaly (69.5%), followed by occipital brachycephaly (18.4%) or a combination of both deformities (12.1%). Recommended treatment included repositioning (RP), physical therapy (PT) if indicated, or orthotic treatment with a customized cranial orthosis (CO) according to an age- and risk factor-dependent algorithm that the authors developed for this clinic. Of the 991 eligible patients, 884 returned for at least 1 follow-up appointment. A total of 552 patients were followed to completion of their treatment and had a full set of records for analysis: these patients had pre- and posttreatment 2D surface scanner evaluations. The average presenting age was 6.2 months (corrected for prematurity for treatment considerations). Of the 991 patients, 543 (54.8%) had RP or PT as first recommended treatment. Of these 543 patients, 137 (25.2%) transitioned to helmet therapy after the condition did not improve over 4-8 weeks. In the remaining cases, RP/PT had already failed before the patients were seen in this program, and the starting treatment recommendation was CO. At the end of treatment, the measured improvements in ODD were 36.7%, 33.5%, and 15.1% for patients receiving CO, RP/PT/CO, and RP/PT, respectively. Univariate analysis showed that sex, race, insurance, diagnosis, sleep position preference, torticollis history, and multiple gestation were not significantly associated with magnitude of ODD change during treatment. On multivariate analysis, corrected age at presentation and type of treatment received were significantly associated with magnitude of ODD change. Orthotic treatment corresponded with the largest ODD change, while the RP/PT group had the least change in ODD. Earlier age at presentation corresponded with larger ODD change. CONCLUSIONS Earlier age at presentation and type of treatment impact the degree of measured deformational head shape correction in positional plagiocephaly. This retrospective study suggests that treatment with a custom CO can result in more improvement in objective measurements of head shape.

Guidelines: Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline on the Management of Patients With Positional Plagiocephaly: The Role of Repositioning

BACKGROUND

Plagiocephaly, involving positional deformity of the calvarium in infants, is one of the most common reasons for pediatric neurosurgical consultation.

OBJECTIVE

To answer the question: "what is the evidence for the effectiveness of repositioning for positional plagiocephaly?" Treatment recommendations are provided based on the available evidence.

METHODS

The National Library of Medicine MEDLINE database and the Cochrane Library were queried using MeSH headings and key words relevant to repositioning as a means to treat plagiocephaly and brachycephaly. Abstracts were reviewed to identify which studies met the inclusion criteria. An evidentiary table was assembled summarizing the studies and the quality of evidence (Classes I-III). Based on the quality of the literature, a recommendation was rendered (Level I, II, or III).

RESULTS

There were 3 randomized trials (Class I), 1 prospective cohort study (Class II), and 6 retrospective cohort studies (Class III). Repositioning education was found to be equal to a repositioning device and inferior to a physical therapy program. Five of the 7 cohort studies comparing repositioning with a helmet reported helmets to be better and take less time.

CONCLUSION

Within the limits of this systematic review, repositioning education is effective in affording some degree of correction in virtually all infants with positional plagiocephaly or brachycephaly. Most studies suggest that a molding helmet corrects asymmetry more rapidly and to a greater degree than repositioning education. In a Class I study, repositioning education was as effective as repositioning education in conjunction with a repositioning wrap/device. Another Class I study demonstrated that a bedding pillow was superior to physical therapy for some infants. However, in keeping with the American Academy of Pediatrics' warning against the use of soft positioning pillows in the sleeping environment, the Task Force recommends physical therapy over any positioning device. The full guidelines document can be located at https://www.cns.org/guidelines/guidelines-management-patients-positional-plagiocephaly/Chapter_3.

Malocclusion in the primary dentition in children with and without deformational plagiocephaly

OBJECTIVES

Asymmetries of the jaw and orthodontic abnormalities are suspected as long-term consequences of positional cranial deformity. But only few data exist on this issue. As plagiocephaly is a common problem in infancy, potential functional impairments should be investigated to initiate appropriate measures if necessary. The aim of our study was to compare the orthodontic situation in primary dentition of children with positional plagiocephaly and children without cranial deformities.

MATERIAL AND METHODS

Fifty children treated by helmet therapy for plagiocephaly and 50 non-affected children (age 1.98-5.69 years) were examined in a cross-sectional study. Orthodontic parameters of all dimensions were assessed and analyzed.

RESULTS

Children of the plagiocephalic group showed more often orthodontic alterations compared to the others. Especially the frequencies of a class II malocclusion (36 vs. 14 %), an edge-to edge bite (28 vs. 12 %), and deviations of the midline (38 vs. 16 %) were conspicuous. However, none of the differences was significant (p > 0.003). Of all observed mandibular asymmetries, 69 % appeared as a shift to the contralateral side of the former flattened occipital region.

CONCLUSION

Positional head deformity might be associated in some cases with a higher prevalence of occlusal abnormalities in primary dentition.

CLINICAL RELEVANCE

Positional plagiocephaly interfaces medicine and dentistry. As it is a common disorder, this etiology has to be considered in the prevention and therapy of malocclusion.

Preventing deformational plagiocephaly through parent guidance: a randomized, controlled trial

Deformational plagiocephaly (DP) occurs frequently in otherwise healthy infants. Many infants with DP undergo physiotherapy or helmet therapy, and ample treatment-related research is available. However, the possibility of preventing DP has been left with little attention. We sought to evaluate the effectiveness of intervention in the newborn's environment, positioning, and handling on the prevalence of DP at 3 months and to investigate the causal relationship between DP and cervical imbalance. We carried out a randomized controlled trial, with healthy newborns randomized into two groups at birth. All families received standard positioning instructions to prevent SIDS. Additionally, the intervention group received detailed instructions regarding the infant's environment, positioning, and handling, with the goal of creating a nonrestrictive environment that promotes spontaneous physical movement and symmetrical motor development. Two- and three-dimensional photogrammetry served to assess cranial shape and goniometry to measure cervical motion. At 3 months, the prevalence of DP was lower in the intervention group in both 2D (11 vs 31 %) and 3D analyses (15 vs 33 %), and the asymmetry was milder in the intervention group. Infants with DP at follow-up had also developed more torticollis.

CONCLUSION

An early educational intervention reduces the prevalence and severity of DP at 3 months.

WHAT IS KNOWN

•Deformational plagiocephaly, often with associated torticollis, is common in healthy infants. •Parental education is frequently recommended for preventing deformational plagiocephaly, although information regarding the effectiveness of preventive strategies is scarce.

WHAT IS NEW

•Early parent guidance effectively reduces the prevalence and severity of DP and improves the cervical range of motion at three months. •Educating both parents and professionals about proper infant positioning on a national scale could help minimize public healthcare costs.

Positional cranial deformity--the parents' point of view

The parents' point of view regarding positional cranial deformities and helmet therapy has not been the subject of scientific interest yet. However, carer acceptance is a key factor for therapeutic success. We therefore investigated parental perception. The parents of 218 infants were included in a telephone survey; 122 children had undergone helmet therapy and 96 had not. Satisfaction with the outcome, treatment-associated problems, and parental stress were investigated using a structured questionnaire. The great majority (90.8%) of caregivers were satisfied with the outcome, regardless of whether or not helmet therapy was used. Retrospectively, 76% of the parents of infants who had not undergone helmet therapy would decide against helmet therapy again. Therapy was either temporarily stopped (27.0%) or terminated (4.9%) in 31.9% of infants treated with a helmet. Major problems were sweating (51.1%) and skin lacerations (30.9%). The parents indicated minor (54.9%) or even great (25.4%) personal strain. Conflict with others (38.5%), stress for the child (30.3%), and a financial burden (36.9%) were mentioned most frequently. There appear to be more parental problems than expected associated with helmet therapy. Medical experts should take this into consideration. The indication for a helmet should be evaluated critically and the potential parental burdens should be addressed during counselling.

Cranial molding helmet therapy and establishment of practical criteria for management in Asian infant positional head deformity

BACKGROUND

The growing number of infants with deformational plagiocephaly (DP) has raised clinical questions about which children, at what age, and how molding helmet therapy (MHT) should be performed especially in Japan.

METHODS

A total of 1,011 Japanese pediatric head deformity infants had undergone MHT after being diagnosed with non-synostotic DP. Three ratios of left to right comparison (anterior, posterior, and overall) were created and analyzed comparing age of starting treatment, helmet wearing period, and severity of skull deformity before with after MHT.

RESULTS

The averages of head symmetry ratios after treatment in all groups (for the occipital region) showed apparent improvement; t(930) = -60.86, p = 0.000. (t(932) = -57.8, p = 0.000.) In the "severe" deformation group, the earlier the treatment was started, the higher symmetry ratio recovery was obtained. Treatment was especially effective when started in 4-month-old infants. In contrast to the "severe" group, the "mild" deformation group showed that MHT was most effective if treatment started before 6 months of age. Again, the earlier the treatment was started, the higher symmetry ratio was achieved, but compared to the "severe" group, it had a modest effect when treatment was started in infants older than 8 months.

CONCLUSION

This is the first large-scale molding helmet study reporting the method and efficacy in Japanese infants. It demonstrated that despite the structural and physiological differences from infants of other races, molding helmet therapy is effective in Asian-born infants, provided that intervention timing and recognition conditions are met.

Parents' decision for helmet therapy in infants with skull deformation

PURPOSE

Helmet therapy is regularly prescribed in infants with positional skull deformation. Evidence on the effectiveness is lacking, which complicates decision making. This study aims to assess the relation between parents' decision for treatment of skull deformation in their infant and their level of anxiety, decisional conflict, expectations of treatment effect, perceived severity of deformation and perceived side effects.

METHODS

Parents of 5-month-old infants with skull deformation were invited to participate in a survey. Data collection included background characteristics, anthropometric assessment, parent-reported outcomes, decision for treatment (helmet therapy or awaiting natural course), decisional conflict scale and questions about perceived (side) effects of helmet therapy. Factors significantly correlated with treatment decision (p < 0.1) were tested in a multiple logistic regression analysis.

RESULTS

The results of 186 respondents were included in the analysis. Parental satisfaction with their infant's head shape (adjusted odds ratio (aOR) 0.2; 95 % confidence interval (CI) 0.1 to 0.4), expected effect of helmet therapy compared to natural course (aOR 13.4; 95 % CI 5.0 to 36.1) and decision uncertainty (aOR 1.0; 95 % CI 0.9 to 1.0; p = .03) were related to the decision for helmet therapy in infants with skull deformation.

CONCLUSION

With the outcomes of this study, we can better understand parental decision-making for elective 'normalizing' treatments in children, such as helmet therapy in infants with skull deformation. Health care professionals should address the parents' perception of the severity of skull deformation and their expectations of helmet therapy. Furthermore, they can support parents in decision-making by balancing medical information with parents' expectations, values and beliefs.

Orthotic (helmet) therapy in the treatment of plagiocephaly

OBJECT

The goal of this study was to review the current literature on orthotic (helmet) therapy use in the treatment of deformational plagiocephaly.

METHODS

PubMed was used to search English articles using the medical subject headings "deformational plagiocephaly" and "orthosis," and "deformational plagiocephaly" and "helmet."

RESULTS

Forty-two articles were found. There were no Class I studies, 7 Class II studies, 1 Class III study, and 13 Class IV studies. Cranial orthoses have been shown to be effective in treating deformational plagiocephaly. It continues to be debated as to whether the statistical significance of treatment with cranial orthoses compared with conservative therapies is clinically significant. Children older than 12 months of age with deformational plagiocephaly may still benefit from orthotic therapy. The long-term effects of orthotic therapy are controversial.

CONCLUSIONS

There is a lack of Class I literature evidence supporting the use of helmet therapy in deformational plagiocephaly. There are controversies surrounding the use of orthotic therapy such as appropriate use, cost, use in older children, and long-term outcomes. Clinical indications for orthotic therapy need to be better defined with further research studies.

Comparison of helmet therapy and counter positioning for deformational plagiocephaly

OBJECTIVE

To compare effectiveness on correcting cranial and ear asymmetry between helmet therapy and counter positioning for deformational plagiocephaly (DP).

METHODS

Retrospective data of children diagnosed with DP who visited our clinic from November 2010 to October 2012 were reviewed. Subjects ≤10 months of age who showed ≥10 mm of diagonal difference were included for analysis. For DP treatment, information on both helmet therapy and counter positioning was given and either of the two was chosen by each family. Head circumference, cranial asymmetry measurements including diagonal difference, cranial vault asymmetry index, radial symmetry index, and ear shift were obtained by 3-dimensional head-surface laser scan at the time of initiation and termination of therapy.

RESULTS

Twenty-seven subjects were included: 21 had helmet therapy and 6 underwent counter positioning. There was no significant difference of baseline characteristics, head circumferences and cranial asymmetry measurements at the initiation of therapy. The mean duration of therapy was 4.30±1.27 months in the helmet therapy group and 4.08±0.95 months in the counter positioning group (p=0.770). While cranial asymmetry measurements improved in both groups, significantly more improvement was observed with helmet therapy. There was no significant difference of the head circumference growth between the two groups at the end of therapy.

CONCLUSION

Helmet therapy resulted in more favorable outcomes in correcting cranial and ear asymmetry than counter positioning on moderate to severe DP without compromising head growth.

Outcome analysis after helmet therapy using 3D photogrammetry in patients with deformational plagiocephaly: the role of root mean square

Deformational plagiocephaly (DP) is a multifactorial non-synostotic cranial deformity with a reported incidence as high as 1 in 7 infants in North America. Treatment options have focused on non-operative interventions including head repositioning and the use of an orthotic helmet device. Previous studies have used linear and two dimensional outcome measures to assess changes in cranial symmetry after helmet therapy. Our objective was to demonstrate improvement in head shape after treatment with a cranial molding helmet by using Root Mean Square (RMS), a measure unique to 3D photogrammetry, which takes into account both changes in volume and shape over time. Three dimensional photographs were obtained before and after molding helmet treatment in 40 infants (4-10 months old) with deformational plagiocephaly. Anatomical reference planes and measurements were recorded using the 3dMD Vultus(®) analysis software. RMS was used to quantify symmetry by superimposing left and right quadrants and calculating the mean value of aggregate distances between surfaces. Over 95% of the patients demonstrated an improvement in symmetry with helmet therapy. Furthermore, when the sample of infants was divided into two treatment subgroups, a statistically significant correlation was found between the age at the beginning of treatment and the change in the RMS value. When helmet therapy was started before 7 months of age a greater improvement in symmetry was seen. This work represents application of the technique of RMS analysis to demonstrate the efficacy of treatment of deformational plagiocephaly with a cranial molding helmet.

Treatment of positional plagiocephaly--helmet or no helmet?

INTRODUCTION

Positional plagiocephaly has attained widespread attention. There is a lot of data on helmet therapy available, but the natural course of the deformity has not been investigated in depth. The decision for or against helmet therapy can be controversial. This study examined the outcome of both options.

METHODS

128 infants were enrolled in this prospective, non-randomized, longitudinal study. 62 were treated with and 66 without a helmet. The initial cranial vault asymmetry index (modified CVAI) was determined at 6.3 and 6.2 months of age (SD 1.44/2.14). Follow-up took place at the end of helmet therapy (age: 10.2 months, SD 1.77) or after 1 year (age: 18.5 months, SD 2.28) respectively. The outcome and the correlation of the changes to the initial asymmetry were compared.

RESULTS

All infants showed a significant reduction of their plagiocephaly. Although children with helmet had more severe asymmetry initially, they showed significantly better improvement (68% vs. 31%). Only a weak correlation was found between the initial asymmetry and the amount of improvement in both groups.

CONCLUSION

Despite concerns against helmet therapy (comfort, finances), it should be the treatment of choice for moderate to severe cases. Only mild cases (modified CVAI ≤ 6.5%) can be adequately treated by conservative, i.e. non-helmet, management.

Craniosynostosis: imaging review and primer on computed tomography

Craniosynostosis is encountered in the pediatric population in isolated or syndromic forms. The resulting deformity depends on the number and type of sutures involved and, in multi-sutural synostosis, the order of suture fusion. Primary craniosynostosis needs to be differentiated from the secondary variety and positional or deformational mimics. Syndromic craniosynostoses are associated with other craniofacial deformities. Evaluation with 3-D CT plays an important role in accurate diagnosis and management; however, implementation of appropriate CT techniques is essential to limit the radiation burden in these children. In this article, the authors briefly review the classification, embryopathogenesis and epidemiology and describe in detail the radiologic appearance and differential diagnoses of craniosynostosis.