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

Cranial remolding orthosis for children with deformational skull deformities: A systematic review on the factors affecting success and duration of treatment

Deformational plagiocephaly, deformational brachycephaly, and deformational scaphocephaly are the most common types of skull deformities during the first year of life. Using a cranial remolding orthosis (CRO) can have an important role in achieving a satisfactory level of improvement in symmetry and proportion of the deformed skulls. However, there is no consensus on the most important parameters for the success or length of treatment with a CRO. In this study, we did a systematic literature review in PubMed, Scopus, Web of Science, and EMBASE on January 2023. Titles/abstracts of the found studies were screened by two independent reviewers. The Newcastle-Ottawa Scale was used to evaluate the quality of the included articles. The best evidence synthesis was considered to determine the strength of the reported factors. A total of 25 articles with an accumulated sample of 7594 participants were included. Nine predictive factors, including age at initiation of CRO treatment, CRO compliance, deformity severity, deformity type, torticollis, gestational age, gestational type, delivery method, and developmental delay, were considered for CRO treatment length or success. Moderate evidence suggests that CRO treatment length is linked to a patient's age at the start of treatment and the deformity severity. Moreover, treatment success is correlated with a patient's age at the start of treatment, CRO compliance, and deformity severity. Moderate evidence indicates that there is no relationship between the presence of torticollis and gestational age with CRO treatment success.

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.

Prevalence and Severity of Positional Posterior Plagiocephaly and Positional Posterior Brachycephaly in Children and Adolescents in Japan

This study aimed to assess the prevalence, severity, and natural history of positional posterior plagiocephaly (PPP) and positional posterior brachycephaly in Japan. We conducted a cross-sectional study of pediatric patients, ranging from 0 to 15 years old, evaluated for head trauma with negative computed tomography (CT) findings. The cranial vault asymmetry index (CVAI) was calculated using CT images at the superior orbital rim. Asymmetry according to CVAI values was subcategorized as follows: mild (3.5%-7%), moderate (7%-12%), and severe (>12%). The results were analyzed according to different age groups: group 1, 2-23 months (54 patients); group 2, 2-6 years (123 patients); and group 3, 7-15 years (123 patients). Overall, 300 patients were included (109 [36.3%] girls and 191 [63.7%] boys). The overall prevalence of PPP in the 300 patients was 46.7% (140 patients). PPP prevalence decreased consistently with age group: group 1, 57.4%; group 2, 47.2%; and group 3, 41.5%. Severe asymmetry was seen in all age groups. The overall mean cephalic index (CI) was 85.2. Cephalic index scores decreased consistently with age: group 1, 87.4; group 2, 85.1; and group 3, 84.3. The prevalence of PPP in Japan was higher than that reported in other countries. Although there was an overall decrease in the prevalence and severity of PPP with increasing patient age, PPP does not necessarily resolve spontaneously in all children. Furthermore, severe asymmetry was seen across all age groups.

Efficacy of Cranial Orthosis for Plagiocephaly Based on 2D and 3D Evaluation

Background  With the advent of cranial orthoses as therapeutic medical devices for the treatment of severe positional head deformities in Japan, an increasing number of patients are being treated with them. However, assessing the effectiveness of a treatment is often difficult due to the use of different metrics. This study aimed to evaluate the effectiveness of cranial orthoses for deformational plagiocephaly using two- (2D) and three-dimensional (3D) evaluation metrics. Methods  We conducted a retrospective study of infant patients with deformational plagiocephaly who underwent cranial orthosis treatment. We evaluated the severity of deformational plagiocephaly using cranial asymmetry (CA) and the cranial vault asymmetry index (CVAI) as 2D metrics, and anterior and posterior symmetry ratios as 3D metrics. The patients were divided into 24 subgroups based on the initial severity of each outcome and their age at the start of treatment. We analyzed the changes in outcomes and correlations within improvements across the age and severity categories. Results  Overall, 1,038 infants were included in this study. The mean CA, CVAI, and anterior and posterior symmetry ratios improved significantly after cranial orthosis treatment. The improvement in each score was greater in patients with more severe initial deformities and in those who underwent treatment at a younger age. Conclusion  Cranial orthosis treatment was effective in correcting deformational plagiocephaly in infants, as demonstrated by improvements in both 2D and 3D metrics. Patients with more severe initial deformities and those who underwent treatment at a younger age showed greater improvement.

Changes in Cranial Shape and Developmental Quotient at 6 Months of Age in Preterm Infants

The purpose of this study was to investigate changes in cranial shape among preterm neonates aged 1-6 months and the relationship between developmental quotient (DQ) and cranial shape at 6 months of age. Preterm infants who were hospitalized in our hospital were prospectively followed for 6 months. The cephalic index (CI) and cranial vault asymmetry index (CVAI) were evaluated at 1 (T1), 3 (T2), and 6 months (T3) of age and compared with those of the full-term infants. The relationship between CI or CVAI and DQ at T3 was analyzed using the Enjoji Scale of Infant Analytical Development. A total of 26 participants born at 34.7 ± 1.9 weeks of gestation were included. The CI increased with age (T1: 77.2%, T2: 82.9%, T3: 85.4%, p < 0.01). The prevalence of dolichocephaly at T3 did not significantly differ from that in full-term infants (15.4% vs. 4.5%, p = 0.08). CVAI did not significantly differ between preterm and full-term infants. The DQ showed no significant correlation with either the CI or CVAI (correlation coefficients: 0.23 for CI, -0.01; CVAI). Dolichocephaly improved over time in preterm infants and no relationship between cranial shape and development was observed in preterm infants at 6 months of age.

[Follow-up and prognostic study of infants with positional plagiocephaly]

OBJECTIVES

To study the effects of infantile positional plagiocephaly on the growth and neural development.

METHODS

A retrospective study was conducted on the medical data of 467 children who underwent craniographic examination and were followed up to 3 years of age in Peking University Third Hospital from June 2018 to May 2022. They were divided into four groups: mild positional plagiocephaly (n=108), moderate positional plagiocephaly (n=49), severe positional plagiocephaly (n=12), and normal cranial shape (n=298). The general information of the four groups and the weight, length, head circumference, visual acuity screening results, hearing test results, and the scores of Pediatric Neuropsychological Developmental Scales/Gesell Developmental Schedules of the four groups from 6 to 36 months old were compared.

RESULTS

The rates of adverse perinatal factors, congenital muscular torticollis, and supine fixed sleeping posture in the mild, moderate, and severe positional plagiocephaly groups were higher than the normal cranial group (P<0.05). There was no significant difference in weight, length, and head circumference among the four groups at 6, 12, 24 and 36 months of age (P>0.05). The incidence rate of abnormal vision in the severe positional plagiocephaly group was higher than that in the mild positional plagiocephaly, moderate positional plagiocephaly and normal cranial shape groups at 24 and 36 months of age (P<0.05). The scores of the Pediatric Neuropsychological Developmental Scales at 12 and 24 months of age and the scores of the Gesell Developmental Schedules at 36 months of age in the severe positional plagiocephaly group were lower than those in the mild positional plagiocephaly, moderate positional plagiocephaly and normal cranial shape groups, but the difference was not statistically significant (P>0.05).

CONCLUSIONS

Adverse perinatal factors, congenital muscular torticollis, and supine fixed sleeping position may be associated with infantile positional plagiocephaly. Mild or moderate positional plagiocephaly has no significant impact on the growth and neural development of children. Severe positional plagiocephaly have adverse effects on the visual acuity. However, it is not considered that severe positional plagiocephaly can affect the neurological development.

Cranial Shape Measurements Obtained Using a Caliper and Elastic Bands Are Useful for Brachycephaly and Deformational Plagiocephaly Screening

We assessed a method for screening the cranial shape of 1-month-old infants using a simple measuring instrument instead of a three-dimensional scanner. The Mimos craniometer was used to measure cranial length, cranial width, and two diagonal lengths to calculate the cranial index (CI) and cranial asymmetry (CA). We defined a CI > 90% as brachycephaly and CA > 5 mm as deformational plagiocephaly (DP). Intra- and inter-examiner accuracy analyses were performed on a dummy doll and 1-month-old infants. The measurements of healthy 1-month-old infants were compared with previously reported three-dimensional scanner measurements. Intra- and inter-rater measurements showed good accuracy; diagnostic accuracy comparisons of brachycephaly and DP using a three-dimensional scanner showed kappa values of 1.0 and 0.8, respectively. Comparisons were made among 113 infants matched for day-age at the date of measurement; there were no significant differences in the CI (85.0% vs. 85.2%, p = 0.98) and CA (5.9 mm vs. 6.0 mm, p = 0.48) between the scanner and caliper measurements, nor in the prevalence of brachycephaly (12.4% vs. 17.7%, p = 0.35) or DP (58.4% vs. 56.6%, p = 0.89). This simple measurement method using calipers and bands was useful in screening for brachycephaly and DP in 1-month-old infants.

Cranial shapes of Japanese preterm infants at one month of age using a three-dimensional scanner

BACKGROUND

Recently, cranial shape measurements of preterm infants have been performed using handheld three-dimensional (3D) scanners and can now be objectively quantified.

AIMS

To measure the cranial shapes of Japanese preterm infants at one month of age using a 3D scanner, compare these values with those of healthy term infants, and examine the risk factors for dolichocephaly.

STUDY DESIGN

A multicenter, retrospective cohort study.

SUBJECTS

Preterm infants born at <37 weeks of gestation and staying in the neonatal intensive care unit or visiting an outpatient clinic for a one-month checkup between April 2020 and March 2022.

OUTCOME MEASURES

A 3D scanner was used to quantify cranial shape. Comparison was made with full-term, one-month-old infants.

RESULTS

Ninety-four preterm infants (42 boys) and 165 full-term infants were enrolled. Preterm infants had a significantly lower cephalic index (77.9% and 85.0%, p < 0.01) and a higher incidence of dolichocephaly (54.3% and 13.3%, p < 0.01) compared to term infants. No significant difference in incidence of deformational plagiocephaly was found between the groups (41.5% vs. 47.3%, p = 0.44). The risk of dolichocephaly was significantly higher for female sex (odds ratio [OR], 3.32; 95% confidence interval, 1.30-8.50), cesarean section (OR, 4.07; 95% confidence interval, 1.23-13.5), and use of mechanical ventilation (OR, 4.66; 95% confidence interval, 1.09-20.0).

CONCLUSIONS

Japanese preterm infants at the first month of life had longer heads than full-term infants; the risk factors identified were female sex, cesarean section, and use of mechanical ventilation.

Evaluating Cranial Growth in Japanese Infants Using a Three-dimensional Scanner: Relationship between Growth-related Parameters and Deformational Plagiocephaly

In this study, we aimed to evaluate the longitudinal changes in the cranial shape of healthy Japanese infants using a three-dimensional scanner and construct a normal values database for the growth process. Preterm infants (gestational age < 37 weeks), infants with neonatal asphyxia (5-minute Apgar score of <7), and patients who started helmet therapy for deformational plagiocephaly were excluded from this study. The first scan was performed at approximately 1 month of age, followed by two scans conducted at 3 and 6 months of age. The parameters considered were as follows: cranial length, width, height, circumference, volume, cranial vault asymmetry index, and cephalic index. A cranial vault asymmetry index >5% was defined as deformational plagiocephaly. Changes in each parameter were examined using repeated-measures analysis of variance classified by sex and deformational plagiocephaly status. The rate of increase in each parameter was also examined. In total, 88 infants (45 boys and 43 girls) were included in this study. All growth-related parameters were noted to increase linearly with time. Sex differences were observed in all parameters except cranial length. Deformational plagiocephaly was found to have no effect on growth-related parameters. Cranial volume increased by 60% from 1 to 6 months of age. The growth almost uniformly influenced the rate of increase in volume in each coordinate axis direction. Overall, the mean trends in three-dimensional parameters in infants up to 6 months of age were obtained using a three-dimensional scanner. These trends could be used as a guide by medical professionals involved in cranioplasty.

Modified endoscopic strip craniectomy technique for sagittal craniosynostosis: provides comparable results and avoids bony defects

PURPOSE

This study describes a modified technique addressing bony defects and incomplete ossification after endoscopic strip craniectomy (ESC) for SC followed by postoperative helmet therapy (PHT). The study aims to delineate quantitative and qualitative outcomes of this modified ESC technique followed by PHT and discern the optimal duration of PHT following ESC. A secondary aim is to address the effects of the technique on bony defects.

METHODS

Patients undergoing ESC followed by PHT between 2017 and 2021 were included. Patient sex, age at surgery, duration of surgery, red blood cell transfusion, length of hospital stay, PHT duration, cephalic index (CI) at multiple time points, and bony defect information were collected. Descriptive and correlative analysis was done.

RESULTS

Thirty-one patients (25 male, 6 female) were operated in study period. Mean age at surgery was 12.81 weeks, mean duration of surgery was 57.50 min, average transfused RBC volume was 32 cc, mean length of hospital stay was 1.84 days, mean PHT duration was 33.16 weeks, and mean follow-up time was 63.42 weeks. Mean preoperative CI was 70.6, and mean CI at the end of PHT was significantly higher, being 77.1. Maximum improvement in CI (CI_max) took place at week 22.97. PHT duration did not have a correlation with CI at last follow up. There were no bony defects.

CONCLUSION

Modified ESC technique is effective in successful correction of sagittal craniosynostosis. CI_max already takes place, while PHT is continuing, but there is no certain time point for dishelmeting. The technique avoided bony defects and incomplete ossification.

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.

Cranial Shape in Infants Aged One Month Can Predict the Severity of Deformational Plagiocephaly at the Age of Six Months

In this study, we aimed to monitor changes in cranial shape using three-dimensional (3D) scanning to determine whether the severity of deformational plagiocephaly (DP) at the age of 6 months could be predicted at the age of 1 month. The cranial shape was measured at the ages of 1, 3, and 6 months (T1, T2, and T3, respectively) in 92 infants. We excluded those who received helmet treatment before T3. The cranial vault asymmetry index (CVAI) using 3D scanning was evaluated in all infants. DP was defined as a CVAI > 5.0% with mild (CVAI ≤ 6.25%) or moderate/severe severity (CVAI > 6.25%). The CVAI cut-off value at T1 for severe DP at T3 was determined using receiver operating characteristic (ROC) curves. At T1, T2, and T3, the respective CVAI median values were 5.0%, 5.8%, and 4.7% and the DP incidence was 50.0%, 56.8%, and 43.2%, respectively. The DP severity temporarily worsened from T1 to T2 but then improved at T3. Among the infants, 73.9% had a similar DP severity at T1 and T3 (p = 1.0). A ROC curve analysis revealed a CVAI cut-off value of 7.8% at T1 predicted severe DP. It was concluded that later DP severity could be predicted using 3D scanning at T1 with properly defined cut-off values.

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.

Reference Values for Cranial Morphology Based on Three-dimensional Scan Analysis in 1-month-old Healthy Infants in Japan

Currently, molded helmet therapy is used to treat infants with deformational plagiocephaly. However, the indices of normal cranial shape remain unclear, and thus, the prevalence of deformational plagiocephaly is unknown, particularly in Japan. We investigated the reference values for cranial morphological characteristics in 1-month-old Japanese infants using a three-dimensional scanner, to determine the prevalence of deformational plagiocephaly. One hundred fifty-three healthy infants who visited three hospitals (from April 2020 to March 2021) were enrolled. Cranial shape was measured using a three-dimensional scanner and was analyzed using image analysis software. Outcome measures were cranial volume, length, width, length-width ratio, circumference, asymmetry, and vault asymmetry index; cephalic index; and anterior, posterior, and overall symmetry ratios. The cranial vault asymmetry index >3.5% or ≥10% were diagnosed as deformational or severe deformational plagiocephaly, respectively. The mean age at measurement was 35.7 days. The mean cranial volume was 559 mL; cranial length, 129 mm; cranial width, 110 mm; length-width ratio, 118%; cephalic index, 85.2%; cranial circumference, 377 mm, cranial asymmetry, 6.4 mm; cranial vault asymmetry index, 5.0%; and anterior, posterior, and overall asymmetry ratios, 93.1%, 91.3%, and 96.4%, respectively. The prevalence of deformational and severe deformational plagiocephaly was 64.7% and 6.6%, respectively. Sex-based differences were observed for cranial volume and width. The results obtained in this study can be considered standard values that can facilitate the differentiation of abnormal infant cranial morphological characteristics for Japanese medical practitioners.

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.

Evaluation of the Molding Helmet Therapy for Japanese Infants with Deformational Plagiocephaly

INTRODUCTION

Deformational plagiocephaly (DP) is cranial flattening on one side of the back of the skull produced by an extrinsic force on the intrinsically normal skull. When the flattening is symmetrical, the deformity is called deformational brachycephaly (DB). In the US, its prevalence has increased since the "Back to Sleep" campaign by the American Association of Pediatrics. Helmet therapy is reported to be effective in improving head deformity by multiple studies, but there are few evidences from Japan. The purpose of this study is to investigate the safety and efficacy of helmet therapy for DP, and the feasibility of introducing this treatment to the clinical setting in Japan.

METHODS

This was a single-arm, retrospective, nonrandomized study. Data were collected on infants who visited the "Clinic for Baby's Head Shape" in the National Center for Child Health and Development, Tokyo, Japan, between 2011 and 2014. Improvements in Argenta classification, cranial asymmetry (CA), and cranial vault asymmetry index (CVAI) were evaluated. The relationships between CA and influencing factors were evaluated using a linear mixed-effects model.

RESULTS

Three hundred eighty-seven infants (273 boys and 114 girls; average age, 4.7 months) visited the clinic during the period, and 159 patients who completed the helmet therapy were analyzed. There were statistically significant improvements in Argenta classification, CA, and CVAI. Almost all of the parents reported increased sweating and mild skin irritation, but no adverse events necessitated the cessation of helmet therapy, except for one patient with increased sweating.

CONCLUSIONS

Helmet therapy is safe and effective in treating DP and is feasible to introduce to the clinical setting in Japan. Through the distribution of knowledge regarding the etiology and treatment of head deformity, earlier detection and an evidence-based approach to head deformity are expected in the future.

Analysis of cranial type characteristics in term infants: a multi-center study

Background

Positional head deformity (PHD) is defined as a change in the shape of an infant’s skull due to an external force. In certain cases, it can lead to cosmetic deformities or even neurological issues due to its impact on the developing nervous system. Therefore, we conducted this study to investigate the incidence and characteristics of PHD in term infants in China and preliminarily establish a localized diagnostic reference standard.

Methods

Overall, 4456 term infants from three medical institutions in Chongqing were and divided and analyzed according to their age. Cranial vault asymmetry (CVA) and cephalic index (CI) were calculated in all infants. The current international diagnostic criteria were used to understand PHD incidence and analyze the CVA and CI distribution.

Results

According to the current international standards, the total detection rate of PHD in Chongqing’s term infants was 81.5%, with brachycephaly alone being the most frequent (39.4%), followed by brachycephaly with plagiocephaly (34.8%) and plagiocephaly alone (6.2%). The detection rates of dolichocephaly were low: alone, 0.9% and combined with plagiocephaly, 0.2%. According to age, plagiocephaly (44.5%) and brachycephaly (82.0%) were the most frequent in the 2-3-month group. The 75th/90th/97th and 3rd/10th/25th/75th/90th/97th percentiles of CVA and CIs were 0.4/0.7/1.0 and 76.4/78.8/82.3/91.1/94.6/99.2%, respectively.

Conclusions

According to the current international standards, the PHD detection rate among term infants in Chongqing was high. Therefore, a new diagnostic standard for Chinese infants was proposed where CVA ≥ 0.4 cm indicates plagiocephaly, CI ≥ 91% indicates brachycephaly, and CI ≤ 82% indicates dolichocephaly.

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.

The Effects of Helmet Therapy Relative to the Size of the Anterior Fontanelle in Nonsynostotic Plagiocephaly: A Retrospective Study

Helmet therapy is an important nonsurgical approach for patients with nonsynostotic plagiocephaly, but its effectiveness may depend on certain anatomical features. We retrospectively examined the effects of helmet therapy according to the size of the anterior fontanelle. Two hundred patients with nonsynostotic plagiocephaly who underwent helmet therapy between 2016 and 2018 were included. Data regarding age at treatment onset and treatment duration were collected. Patients were divided into two groups depending on the age at treatment initiation: the 12-23 weeks group and the >23 weeks group. Patients were also divided based on the anterior fontanelle size to analyze the effects of helmet therapy according to the severity of plagiocephaly in each group as the change in the cranial vault asymmetry index (CVAI). Therapeutic effects were evaluated using the cranial vault asymmetry (CVA), CVAI, anterior symmetry ratio, posterior symmetry ratio (PSR), and overall symmetry ratio at baseline and treatment completion. Treatment initiation at age 12-23 weeks resulted in better effects than that after age 24 weeks. There were no sex-dependent differences in therapeutic effects. Greater changes in the CVA, CVAI, and PSR were associated with larger anterior fontanelles. Therefore, the anterior fontanelle size could be a prognostic factor for estimating helmet therapy outcomes.

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.

Facial asymmetry correction with moulded helmet therapy in infants with deformational skull base plagiocephaly

PURPOSE

The recommendation issued by the American Academy of Pediatrics in the early 1990s to position infants on their back during sleep to prevent sudden infant death syndrome (SIDS) has dramatically reduced the number of deaths due to SIDS but has also markedly increased the prevalence of positional skull deformation in infants. Deformation of the base of the skull occurs predominantly in very severe deformational plagiocephaly and is accompanied by facial asymmetry, as well as an altered ear position, called ear shift. Moulded helmet therapy has become an accepted treatment strategy for infants with deformational plagiocephaly. The aim of this study was to determine whether facial asymmetry could be corrected by moulded helmet therapy.

MATERIALS AND METHODS

In this retrospective, single-centre study, we analysed facial asymmetry of 71 infants with severe deformational plagiocephaly with or without deformational brachycephaly who were undergoing moulded helmet therapy between 2009 and 2013. Computer-assisted, three-dimensional, soft-tissue photographic scanning was used to record the head shape before and after moulded helmet therapy. The distance between two landmarks in the midline of the face (i.e., root of the nose and nasal septum) and the right and left tragus were measured on computer-generated indirect and objective 3D photogrammetry images. A quotient was calculated between the two right- and left-sided distances to the midline. Quotients were compared before and after moulded helmet therapy. Infants without any therapy served as a control group.

RESULTS

The median age of the infants before onset of moulded helmet therapy was 5 months (range 3-16 months). The median duration of moulded helmet therapy was 5 months (range 1-16 months). Comparison of the pre- and post-treatment quotients of the left vs. right distances measured between the tragus and root of the nose (n = 71) and nasal septum (n = 71) revealed a significant reduction of the asymmetry (Tragus-Nasion-Line Quotient: 0.045-0.022; p < 0.0001; Tragus-Subnasale-Line Quotient: 0.045-0.021; p < 0.0001). The control group without treatment showed no significant change in the quotient (Tragus-Nasion-Line Quotient no helmet: 0.049-0.055/Tragus-Subnasale-Line Quotient no helmet: 0.039-0.055).

CONCLUSION

Moulded helmet therapy can correct facial symmetry in infants with deformational plagiocephaly and associated facial and basal skull asymmetry.

[A clinical analysis of 101 infants with plagiocephaly]

OBJECTIVE

To investigate the possible causes of plagiocephaly in infants and the therapeutic effect of postural correction training on plagiocephaly.

METHODS

A total of 101 infants who were diagnosed with plagiocephaly were enrolled. According to the age at diagnosis, these infants were divided into 1-4 month group (31 infants), 5-8 month group (40 infants), and 9-12 month group (30 infants). The possible causes of plagiocephaly were analyzed in three groups. The cranial vault asymmetry index (CVAI) before and after postural correction training was compared in three groups.

RESULTS

Of the 101 infants, 89 (88.1%) had a sleeping posture in the supine position, and there was no significant difference in the percentage of infants with such posture between the three groups. Compared with the 5-8 month group and the 9-12 month group, the 1-4 month group had significantly higher rate of preterm birth, incidence rate of adverse perinatal factors, and incidence rate of congenital muscular torticollis. The three groups showed a significant decrease in CVAI 3 months after postural correction training (P<0.001). Compared with the 5-8 month group and the 9-12 month group, the 1-4 month group had a significantly greater change in CVAI after postural correction training (P<0.001).

CONCLUSIONS

The sleeping posture in the supine position may be associated with the development of plagiocephaly. Adverse perinatal factors, preterm birth, and congenital muscular torticollis as possible causes of plagiocephaly are commonly seen in early infancy. Postural correction training has a significant effect in improving plagiocephaly, especially in early infancy.

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.

The course of positional cranial deformation from 3 to 12 months of age and associated risk factors: a follow-up with 3D imaging

Deformational plagiocephaly is reported in up to 46.6 % of healthy infants, with the highest point prevalence at around 3 months of age. Few prospective studies on the natural course of skull deformation have been conducted, and we know of no studies using 3D imaging starting from the highest point prevalence period. In this prospective, population-based cohort study, we describe the course of cranial asymmetry and shape in an unselected population using 3D stereophotogrammetry and investigate factors associated with late cranial deformation and failure to recover from previous deformation. We evaluated 99 infants at 3, 6, and 12 months of age. We acquired 3D craniofacial images and performed structured clinical examinations and parental interviews at each visit. Eight outcome variables, representing different aspects of cranial shape, were calculated from a total of 288 3D images. Scores of asymmetry-related variables improved throughout the observation period. However, the rate of correction for cranial asymmetry decreased as the infants grew older, also in relation to the rate of head growth, and a significant amount of asymmetry was still present at 12 months. Positional preference at 3 months predicted an unfavorable course of cranial asymmetry after 3 months, increasing the risk for DP persisting. What is known: • The prevalence of deformational plagiocephaly spontaneously decreases after the first months of life. • Limited neck range of motion and infant positional preference increase the risk of deformational plagiocephaly during the first months of life. What is new: • Positional preference at 3 months predicts an unfavorable spontaneous course of deformation also from three to 12 months of age, presenting a potential target for screening and treatment. • The spontaneous rate of correction for cranial asymmetry decreases after 6 months of age, also in relation to the rate of head growth.

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.

Three-dimensional analysis of cranial and facial asymmetry after helmet therapy for positional plagiocephaly

PURPOSE

Helmet therapy is a non-surgical option for treating positional plagiocephaly, and its effectiveness has been validated by various researches. In addition to cranial flattening and asymmetry, ipsilateral prominence of the mid-face and relative anterior transposition of the ipsilateral ear is also common. Hence, we investigated the impact of helmet therapy on mid-facial asymmetry.

METHODS

Ninety-nine patients diagnosed with positional plagiocephaly and treated by helmet therapy between September 2005 and July 2012 were enrolled. Therapy was initiated at various ages: group I, <6 months (n = 35); group II, 6 months to 1 year (n = 43); group III, >1 year (n = 21). A cranial vault asymmetry index was measured at the levels of the inferior orbital rim (CVAIIOR-MF) and superior orbital rim (CVAISOR-LC) and midway from the superior orbital rim to the vertex (CVAIMID-UC). Anterior transposition of the ipsilateral ear was verified by measuring the distance (D EAR) between the actual position of the ear and its expected position relative to the contralateral ear. All variables were compared before and after helmet therapy and were categorized by age at treatment initiation.

RESULTS

CVAIIOR-MF and CVAISOR-LC were lower in all three age groups after helmet therapy, confirming therapeutic efficacy. CVAIMID-UC (upper level cranial asymmetry) and D EAR (mid-facial soft tissue asymmetry) also improved significantly in groups I and II which were younger than 1 year old.

CONCLUSION

In positional plagiocephaly, helmet therapy is effective in correcting both cranial and mid-facial asymmetries. Outcomes were optimal in patients <1 year of age, but older patients also showed some improvement.