Helmet treatment of deformational plagiocephaly: the relationship between age at initiation and rate of correction

Discrepancies Between Objective and Subjective Outcomes of and Quality of Life During Molding Helmet Therapy for Cranial Deformities

Positional skull deformities have been on the rise for decades and can be treated with molding helmets in early childhood. Parents often fear later cosmetic stigmatization, but also a reduced quality of life (QoL) during treatment. The aim of this study was to examine therapy results in our patient collection from a new perspective. Cranial vault asymmetry (CVA), cranial vault asymmetry index (CVAI), and cranial index (CI) were compared before and after molding helmet therapy. Correction was defined by a decrease in CVA <3.5 mm and CI <90%. Subjective therapy outcome, side effects and QoL from the parents' perspective were determined using a questionnaire. There were 25 patients included. Differences between pretherapeutic and posttherapeutic CVA, CVAI, and CI were significant (P<0.01). An objective correction according to the defined values was observed in only 12% of cases. However, 76% of parents stated that their child's skull shape was normal after therapy. There were 60 side effects reported in 23 cases. The QoL of 21 children was assessed as unimpaired during helmet therapy. Even though complete normalization was rarely observed, the parameters were significantly different after therapy, and subjective reduction in skull deformity was common.

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.

Predictive Value of Sonographic Parameters on the Effects of Cranial Molding Helmet Therapy in Infants with Positional Plagiocephaly

Positional plagiocephaly is a deformational cranial flattening frequently treated in pediatric neurosurgical practice. Positional maneuvers and orthotic helmet therapy are preferred therapeutic options for moderate-to-severe forms. Treatment response seems to be age-dependent. Nevertheless, predictive data are vague, and cost-efficiency might be a limiting factor for treatment. The purpose of this study was to investigate the early predictive value of sonographic parameters on the efficacy of orthotic helmet therapy through the assessment of changes in skull shape and correlation of the parameters with caliper cephalometry values and with age. A consecutive cohort of 49 patients < 10 months of age, undergoing orthotic helmet therapy for positional plagiocephaly, was recruited prospectively. The authors routinely assessed the patency of the lambdoid sutures by ultrasound and the following additional skull parameters were measured: suture width, adjacent full bone thickness, adjacent cortical bone thickness and occipital angle. Caliper cephalometric values, as well as demographic and clinical data were collected. Retrospective data analysis showed an inverse relation between both cortical and full skull bone thickness and early treatment efficacy, defined by a reduction in the occipital angle. The improvement of sonographic parameters correlated with the development of cranial caliper cephalometry values. In conclusion, the sonographic assessment of skull bone thickness is a safe and cost-effective tool to predict the early efficacy of orthotic helmet therapy in positional plagiocephaly and might, therefore, help the clinician to foresee the potential evolution of the deformity.

A computational modelling tool for prediction of head reshaping following endoscopic strip craniectomy and helmet therapy for the treatment of scaphocephaly

BACKGROUND

Endoscopic strip craniectomy followed by helmet therapy (ESCH) is a minimally invasive approach for correcting sagittal craniosynostosis. The treatment involves a patient-specific helmet designed to facilitate lateral growth while constraining sagittal expansion. In this study, finite element modelling was used to predict post-treatment head reshaping, improving our comprehension of the necessary helmet therapy duration.

METHOD

Six patients (aged 11 weeks to 9 months) who underwent ESCH at Connecticut Children's Hospital were enrolled in this study. Day-1 post-operative 3D scans were used to create skin, skull, and intracranial volume models. Patient-specific helmet models, incorporating areas for growth, were designed based on post-operative imaging. Brain growth was simulated through thermal expansion, and treatments were modelled according to post-operative Imaging available. Mechanical testing and finite element modelling were combined to determine patient-specific mechanical properties from bone samples collected from surgery. Validation compared simulated end-of-treatment skin surfaces with optical scans in terms of shape matching and cranial index estimation.

RESULTS

Comparison between the simulated post-treatment head shape and optical scans showed that on average 97.3 ± 2.1 % of surface data points were within a distance range of -3 to 3 mm. The cranial index was also accurately predicted (r = 0.91).

CONCLUSIONS

In conclusion, finite element models effectively predicted the ESCH cranial remodeling outcomes up to 8 months postoperatively. This computational tool offers valuable insights to guide and refine helmet treatment duration. This study also incorporated patient-specific material properties, enhancing the accuracy of the modeling approach.

Orthotic Helmet Therapy for Deformational Plagiocephaly: Stratifying Outcomes by Insurance

OBJECTIVE

Deformational Plagiocephaly (DP) is commonly treated with cranial orthosis, or helmet therapy. A large, national study on the impact of insurance status on helmet outcomes is lacking. We assessed treatment outcomes for helmet therapy based on insurance status.

DESIGN

This was a retrospective data analysis of patients referred to Cranial Technologies, Inc for helmet therapy between 2014-2020 across 21 states.

PATIENTS, PARTICIPANTS

There were a total of 211,417 patients referred for helmeting, of whom 141,513 received helmet therapy.

MAIN OUTCOMES MEASURES

Multivariate regression was used to assess the relationship of insurance status with post-treatment residual flattening, measured by cephalic index (CI) and cranial vault asymmetry index (CVAI), and treating provider rating of success.

RESULTS

Patients with Medicaid were more likely to complete treatment with residual flattening measured by CI and CVAI when compared to patients with private insurance (OR: 1.58, CI: 1.51-1.65, p < 0.001 and OR: 1.21, CI: 1.15-1.28, p < 0.001, respectively). Providers of patients with Medicaid were more likely to give a low rating of success following treatment (OR: 3.25, CI: 2.70-3.92, p < 0.001).

CONCLUSIONS

Our study investigating the impact of insurance status on helmet therapy across 21 states found that patients with Medicaid were more likely to experience residual flattening and have lower provider-rated outcomes compared to those with commercial insurance. Given significant caregiver burden posed by helmet therapy, which requires frequent visits and consistent helmet use, caregivers of patients with Medicaid may require greater support to reduce outcome disparities observed here.

Effects of adherence to treatment for repositioning therapy, physical therapy, and cranial remolding orthoses in infants with cranial deformation

Deformational head shapes are most often treated through repositioning therapy (RT) and/or cranial remolding orthotic (CRO) treatment. However, there is conflicting evidence about the effectiveness of each method, and treatment compliance is suspected to affect treatment effectiveness. This study examines participant adherence with these treatment methods and explores if cranial correction is related to compliance. This study also reviews effects of developmental milestones and explores other potential impacts on compliance. A total of 45 infants with cranial deformation were consented and those with congenital muscular torticollis (CMT) concurrently received physical therapy. Infants were followed from 2 to 12 months of age and initially assigned to RT. Caregivers continued RT until the head shape corrected, caregivers chose to switch to a CRO, or infants turned 12 months of age. All participants were scheduled for a final visit at 12 months of age. Throughout treatment, caregiver surveys were used to examine compliance and developmental milestones. Results show promise for future investigation into the relationship between treatment modalities and adherence with treatment for deformational head shapes. Our findings provide preliminary support that treatment adherence may be linked with treatment success and concurrent enrollment in physical therapy increases patient compliance.

Effectiveness of Conservative Treatments in Positional Plagiocephaly in Infants: A Systematic Review

OBJECTIVE

The objective of this study is to analyze conservative treatments implemented to manage positional plagiocephaly in infants.

METHODS

This is a systematic review conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, performed in the Medline (PubMed), Scopus, Web of Science, and Cochrane databases. Articles were selected according to the eligibility criteria, regarding the effectiveness of conservative treatments in positional plagiocephaly in infants, published in the last 10 years with a score ≥3 in the PEDro Scale.

RESULTS

A total of 318 articles were identified and 9 of them were finally selected.

CONCLUSIONS

Physical therapy treatment is considered as the first line of intervention in plagiocephaly with non-synostotic asymmetries and manual therapy is the method that obtains the best results within this intervention. In cases of moderate or severe plagiocephaly, helmet therapy can be an effective second-line intervention; however, the best way to prevent this condition is through counseling of parents or caregivers, and early treatment is essential for optimal therapeutic outcomes. The review was registered in PROSPERO (CDR42022306466).

Disparities in Access to Cranial Remodeling Orthosis for Deformational Plagiocephaly

OBJECTIVE

Moderate to severe cases of deformational plagiocephaly (DP) may be treated with cranial remolding orthoses (CRO). This study investigated the socioeconomic disparities in access to care for CRO for DP correction.

DESIGN

This was a retrospective review of medical records from a single CRO company in Connecticut from 2014 to 2020.

METHODS

Demographic variables were collected from all patients. Univariable logistic regressions were used to identify differences for presenting age at consultation, whether CRO was pursued, and length of CRO treatment by insurance payor and household income quartile.

RESULTS

Of the 5620 patients identified, 4100 (73.0%) received CRO, with 674 (12.0%) receiving a second helmet. Of those receiving CRO, 1536 (37.5%) had Medicaid insurance while 2558 (62.4%) were commercially insured. Patients on Medicaid were 1.30 times more likely to have delayed presentation (P  =  .017), while patients from the lowest income quartile were 1.26 1.50 (P < .001) and 1.58 (P < .001) times more likely to have a delayed presentation relative to those in the highest and second-highest income quartiles, respectively. Patients in the highest and second-highest income quartiles were also 1.55 (P < .001) and 1.45 (P < .001) more likely, respectively, to receive CRO after consultation than those from the lowest income quartile.

CONCLUSIONS

Lower income and Medicaid-insured patients had delayed presentation for CRO consultation. Those from the lowest income quartile were more likely to never receive CRO than those from wealthier backgrounds. Low socioeconomic status and Medicaid insurance, which can have more restrictive coverage policies for CRO, may result in the delayed treatment of DP.

Predictive Factors of Outcomes in Helmet Therapy for Deformational Plagiocephaly and Brachycephaly

Deformational plagiocephaly and brachycephaly, or abnormal flattening of the infant skull due to external forces, are often managed with orthotic helmet therapy. Although helmet therapy is widely used, the factors that predict poor outcomes are not well characterized. In this study of over 140,000 patients who received helmet therapy, older age and greater severity at presentation, and noncompliance with treatment were each independently associated with worse craniometric and provider-reported outcomes. Each additional point of cranial vault asymmetry index or cephalic index at a presentation is associated with an increased likelihood of residual brachycephaly at completion [odds ratio (OR): 1.067; 95% Cl: 1.058-1.075; P <0.0001 and OR: 2.043; 95% CI: 2.021-2.065; P <0.0001, respectively], whereas each additional point of cranial vault asymmetry index at a presentation associated with increased likelihood of residual asymmetry at completion (OR: 2.148; 95% Cl: 2.118-2.179; P <0.0001). Patients were more likely to have residual brachycephaly or asymmetry with increasing age at treatment initiation (OR: 1.562; 95% CI: 1.524-1.600; P <0.0001 and OR: 1.673; 95% Cl: 1.634-1.713; P <0.0001, respectively, for each additional month of age at initiation). These results highlight a need for prompt referral for helmeting, especially in cases with severe features or when patients present late to care. Potentially modifiable factors are age at helmeting and compliance with treatment protocols, and consideration of these factors may be important for achieving success in some cases.

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.

Three-Dimensional Quantification of Facial Asymmetry in Children with Positional Cranial Deformity

BACKGROUND

The extent of facial involvement in positional plagiocephaly is only little investigated so far. Investigation methods that take into account the challenging anatomical conditions and growth of infants' faces are desirable. In this study, the authors established a new three-dimensional photogrammetry quantification method evaluating pretherapeutic and posttherapeutic facial asymmetry in positional plagiocephaly. Furthermore, a facial asymmetry index was established and evaluated.

METHODS

Three-dimensional photographs of 100 children undergoing treatment with head orthoses were analyzed by constructing a standardized interindividual coordinate system. Defining landmarks, section planes, and point coordinates with a computer-aided design software, both sides of the faces were compared. Facial asymmetry was quantified by measuring differences between left and right sides and pretherapeutic and posttherapeutic changes in each patient. The facial asymmetry index was calculated by putting the absolute differences in relation with the coordinates of the nonaffected side.

RESULTS

Present results indicate that positional plagiocephaly results in a distinct facial asymmetry (range, -3.8 to 9.6 mm) in nearly all spatial directions and facial regions. Helmet therapy led to a significant reduction (p < 0.05) of intraindividual facial asymmetry (median change in facial asymmetry index, -1.9 to 3.1 percent). However, no correlation of the Cranial Vault Asymmetry Index and facial asymmetry (Spearman rank correlation coefficient, ρ = -0.09 to 0.47) has been seen. According to these results, severe occipital deformation does not necessarily provoke distinct facial asymmetry.

CONCLUSIONS

Present three-dimensional photogrammetry method allows the longitudinal quantification of facial involvement in positional plagiocephaly. Asymmetry has been determined in all facial regions. The facial asymmetry decreased through helmet therapy but was not eliminated completely.

Long-Term Results After Head Orthosis Therapy for Early Childhood Position-Related Cranial Deformities: Stability of Treatment Outcome and Parental Satisfaction

The purpose of this study was to determine whether different types of position-related cranial deformities show changes after completion of head orthosis therapy. We investigated how children's age at the begin of molding helmet therapy affects the duration and long-term stability of treatment. In addition, parental satisfaction with helmet therapy has been investigated. Between 2012 and 2019, 47 patients have been analyzed after undergoing helmet therapy. At the beginning of treatment different disease pattern were classified. Posterior deformational Plagiocephalus defined by a cranial vault index (CVA) > 1 cm and a cranial index (CI) <= 90%. Posterior deformational Brachycephalus defined by CVA <= 1 cm and CI > 90%. Posterior deformational combined Plagio- and Brachycephalus defined by CVA > 1 cm and CI > 90%. At the beginning of therapy, the end of therapy and within 5-year-follow-up CI and CVA was measured by three-dimensional photogrammetry for 2 age groups (4-6 and 7-12 months). Additionally, parents completed a standardized questionnaire to evaluate the personal assessment of treatment outcome. During treatment CI and CVA of all children decreased significantly (P < 0.001). Furthermore, CI significantly decreased after ending helmet therapy (P < 0.001). Cranial vault index decreased not significantly in the same period (P = 0.361). For the 4 to 6 months old group treatment time was significantly shorter than for the older group. Before starting helmet therapy nearly half of the parents graded the scull as moderate and one-third as severe deformed. After ending treatment, the majority of parents report satisfaction and compliance. However, one-third of parents noted a slight scull deformation and personal load during therapy. After completion of therapy an improvement of head shape can be expected for the majority of children. This is particularly evident for improvement of the CI and a shorter treatment time until the age of 6 months at the beginning of therapy. Parents reported satisfaction and child compliance. Almost all parents were convinced that treatment was useful and would repeat it again.

Subjective perception of craniofacial growth asymmetries in patients with deformational plagiocephaly

OBJECTIVES

The present investigation aimed to evaluate the subjective perception of deformational cranial asymmetries by different observer groups and to compare these subjective perceptions with objective parameters.

MATERIALS AND METHODS

The 3D datasets of ten infants with different severities of deformational plagiocephaly (DP) were presented to 203 observers, who had been subdivided into five different groups (specialists, pediatricians, medical doctors (not pediatricians), parents of infants with DP, and laypersons). The observers rated their subjective perception of the infants' cranial asymmetries using a 4-point Likert-type scale. The ratings from the observer groups were compared with one another using a multilevel modelling linear regression analysis and were correlated with four commonly used parameters to objectively quantify the cranial asymmetries.

RESULTS

No significant differences were found between the ratings of the specialists and those of the parents of infants with DP, but both groups provided significantly more asymmetric ratings than did pediatricians, medical doctors, or laypersons. Moreover, the subjective perception of cranial asymmetries correlated significantly with commonly used parameters for objectively quantifying cranial asymmetries.

CONCLUSIONS

Our results demonstrate that different observer groups perceive the severity of cranial asymmetries differently. Pediatricians' more moderate perception of cranial asymmetries may reduce the likelihood of parents to seek therapeutic interventions for their infants. Moreover, we identified some objective symmetry-related parameters that correlated strongly with the observers' subjective perceptions.

CLINICAL RELEVANCE

Knowledge about these findings is important for clinicians when educating parents of infants with DP about the deformity.

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.

Applicative Factors of Helmet Molding Therapy in Late-diagnosed Positional Plagiocephaly

BACKGROUND

Although the benefits of helmet therapy for positional plagiocephaly are strongly correlated with age, the effective period remains controversial. However, most physicians agree that effective results can be obtained in patients within the age of 6 months. Owing to the characteristics of positional plagiocephaly in Koreans, many Korean patients have delayed diagnosis, and because this results in delayed onset of the helmet therapy, the outcomes remain largely underevaluated. In the management of late-diagnosed positional plagiocephaly, we aimed to determine the factors affecting the effective application of helmet therapy.

METHODS

We recruited 39 consecutive patients with positional plagiocephaly who received helmet therapy and completed the treatment between December 2008 and June 2016. The ages at initiation and completion of treatment, duration of daily use, initial and final absolute diagonal differences, cephalic index, and cranial vault asymmetry index (CVAI) were analysed using data retrospectively collected from the patients' medical records.

RESULTS

We identified 12 patients with late-diagnosed positional plagiocephaly, of whom 83.33% were effectively treated. The effective change in CVAI (%) was affected by age at treatment initiation (P = 0.001), initial absolute diagonal distance differences (P < 0.001), and initial CVAI (P < 0.001). Up to 9 months, a gradual change of at least 1% CVAI was attained. Treatment initiation at ages < 5.5 months was beneficial. Even at a later age, patients with an initial absolute diagonal distance difference of > 13.50 mm and initial CVAI of > 11.03% could receive effective helmet therapy.

CONCLUSION

The efficacy of helmet therapy in late-diagnosed patients can be predicted on the basis of not only age at treatment initiation, but also initial absolute diagonal distance differences and initial CVAI. We anticipate that even patients with late-diagnosed positional plagiocephaly can expect better helmet therapy outcomes.

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.

The role of age on helmet therapy in deformational plagiocephaly and asymmetric brachycephaly

PURPOSE

This study aimed to investigate the effect of age at helmet therapy onset on treatment efficacy in moderate-to-severe deformational plagiocephaly (DP) and combined DP and asymmetrical brachycephaly (AB) in infants.

METHODS

Ninety-eight infants who were referred to our institution and who underwent helmet therapy between 2014 and 2018 were retrospectively reviewed. Patients with DP [cranial vault asymmetry index (CVAI) > 7% and DD > 10 mm] and AB [CVAI > 7% and cephalic ratio (CR) ≥ 94] were included. Pre- and post-treatment calvarial asymmetries (difference among DD, CVAI, and CR) were measured using 3D screening systems (SmartSoc and Omega Scanner 3D). Infants were classified according to age at treatment onset: group 1 (age, < 6 months) and group 2 (age, ≥ 6 months).

RESULTS

CVAI was statistically different between treatment onset and end in subgroups. Moreover, the regression of CVAI between groups DP1 (- 7.5% ± 1.2%) versus DP2 (- 5.4% ± 1.5%; p = 0.001) and groups AB1 (- 6.6% ± 1.4%) versus AB2 (- 4.4 ± 2.5; p = 0.0013) was statistically significant. CVAI was < 3.5% and CR was ≤ 89 (assumed as normal cranial shape) after treatment in 48%, 40%, 32%, and 6% of infants in groups DP1, DP2, AB1, and AB2, respectively.

CONCLUSION

These findings emphasize the efficacy of helmet therapy for DP and AB. Helmet is an appropriate treatment option particularly for infants with severe DP and AB, and early onset of helmet therapy before the age of 6 months is advised.

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.

Cranial Suture Measurement by 2-point Method in Ultrasound Screening of Craniosynostosis

Background:

Diagnostic imaging for craniosynostosis currently relies entirely on radiation images, but it has been estimated that a risk of cancer from diagnostic x-rays may exist. Use of ultrasound imaging has been reported, but very little has been written on normal findings of the cranial suture. Also, ultrasound diagnostic methods have not been established. To obtain images for the diagnosis of abnormal sutures in craniosynostosis, we investigated the normal ultrasonographic appearance of the suture. To establish screening methods for craniosynostosis, we prepared a 2-point method for simple evaluation and confirmed its usefulness.

Methods:

Ultrasonography was performed in infants with normal head, deformational plagiocephaly, and craniosynostosis. We focused on the measurement indices and decided on the order for making our observations. Furthermore, we developed an evaluation method (2-point method) and recorded our finding in a useful table.

Results:

We could clearly judge whether the cranial suture was patent or closed and were able to measure the suture width. Even for 2-year-old children, the width of the sutures at the points measured exceeded the echocardiographic resolution. By using the 2-point evaluation method, all the sutures could be inspected in about 2 minutes. Sensitivity was 100% and specificity was 95.1%.

Conclusions:

Our present studies showed that normal or abnormal suture can be clearly distinguished by ultrasound. By evaluating the fixed points instead of the whole line, it was possible to shorten the inspection time. Ultrasound screening by applying the 2-point method is very useful.

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.

Head orthosis therapy in positional plagiocephaly: longitudinal 3D-investigation of long-term outcomes, compared with untreated infants and with a control group

Background

As there are very few long-term studies on the effects of head orthosis on deformational plagiocephaly (DP), we investigated the outcomes of patients, including facial symmetry and dental occlusion.

Methods

Forty-five infants with DP [cranial vault asymmetry index (CVAI) > 3.5 per cent] were divided into two groups: one treated with head orthosis (32 infants) and another without (13 infants). Another group without head asymmetry (CVAI ≤ 3.5 per cent) served as control. Using 3D-stereophotogrammetry, cranial asymmetry was analysed using symmetry-related variables [CVAI, posterior cranial asymmetry index (PCAI), and ear offset]. Data acquisition was performed before (T1) and at the end of treatment (T2), and at the age of 4 years (T3) for the treated group and at T1 and T3 for the remaining groups. Parameters of facial symmetry and dental occlusion were assessed at T3 for infants with DP.

Results

Symmetry-related variables (∆T1-T3) improved significantly more in the treated than the control group, whereas these parameters did not differ significantly between the untreated and control group. Comparing the treated and untreated groups between T1 and T3, the reduction in the asymmetry at the treated group was significantly higher for the CVAI and PCAI. In follow-up, the untreated group showed higher incidences of facial asymmetries than the treated group. Seventy-five per cent of all lateral crossbites found in patients with DP were contralateral to the posterior flattening.

Limitations

Due to ethical reasons, the investigation is a non-randomized study. Parameters of facial symmetry were only assed for the treated and untreated groups.

Conclusion

Head orthosis therapy in patients with DP leads to significantly better long-term outcomes. Facial asymmetries are more frequent in patients with DP who do not receive this treatment.

Periocular Asymmetry in Infants with Deformational Posterior Plagiocephaly

PURPOSE

To analyze the clinical significance of the periorbital features associated with the facial asymmetry that is common in deformational posterior plagiocephaly (DPP).

PATIENTS AND METHODS

We identified 32 patients with DPP, photographed their faces and tops of their head, and performed a complete eye examination. Four examiners analyzed the patient's periorbital features on the photographs.

RESULTS

Median age was 6.5 months (range 3-12 months). Pseudoptosis was identified in 30 patients and pseudo-brow ptosis in 19. Pseudoptosis was marked in 17 patients. Five patients were misdiagnosed with congenital blepharoptosis and received regular follow-ups for amblyopia checks until the diagnosis of pseudoptosis was established. All patients had normal levator function and symmetric eyelid crease. One patient with pseudoptosis and physiologic anisocoria was diagnosed with pseudo-Horner syndrome after a negative 10% cocaine test. None of the patients developed meridional or occlusion amblyopia.

CONCLUSION

DPP is the most frequent form of skull deformation in infants. Its main features are occipital flatness and facial asymmetry. Infants with DPP may present with pseudoptosis and pseudo-brow ptosis on the contralateral side of the occipital flatness. The pseudoptosis in DPP is non-amblyogenic, therefore, ophthalmologic intervention and regular follow-ups are not necessary unless other abnormalities co-exist.

Cranial orthosis after cochlear implantation in an infant: Helmet modifications

We present an infant with bilateral sensorineural hearing loss caused by bacterial meningitis, and moderate/severe plagiocephaly requiring simultaneous treatment of cochlear implantation for hearing loss and cranial orthosis for plagiocephaly. A helmet modification was created, so that the infant was able to be treated for his plagiocephaly while bilateral cochlear implants were in place, bringing attention to serve needs of those patients requiring cochlear implant and cranial orthosis concurrently. While this case was the first time such a modification was required, which was due to the young age at implantation, the occurrence of the concurrent need may increase as we continue to push the boundaries of early implantation.

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.

A Clinical Photographic Method to Evaluate the Need for Helmet Therapy in Deformational Plagiocephaly

PURPOSE

With an increase in positional plagiocephaly patients, various therapy methods have been researched and helmet therapy is the most widely used and effective treatment method. To devise a method that would allow medical professionals and patients' parents to more easily identify the shape and outcomes before and after the therapy.

METHODS

This study included 399 patients who had helmet therapy from November 2014 to February 2016. Patients wore a cast helmet for more than 20 hours per day. A cranial caliper was used to measure their head before they wore the helmet (prehelmet), once a month during outpatient visits, and 6 months after they stopped wearing the helmet (posthelmet). Clinical photographs were taken on a transparent acrylic sheet with a grid of 5-mm intervals to measure cranial vault asymmetry (CVA), cranial vault asymmetry index (CVAI), and symmetry ration (SR). The patients' photographs were then measured twice: first against the background without the grid and then against the background with the grid.

RESULTS

Average age at prehelmet was 20 weeks while their average therapy period was 12 weeks. Patients' prehelmet CVA was 13.3 mm, and their posthelmet CVA was 3.1 mm. Their prehelmet CVAI was 10.1%, and their posthelmet CVAI was 2.1% (P < 0.001). Their overall prehelmet and posthelmet SRs were 0.820 and 0.969, respectively (P < 0.001). In addition, the measurements based on clinical photographs with and without the grid were compared using Fleiss kappa. The results showed κ = 0.847 and 0.956 when the patient was mild, κ = 0.744 and 0.919 when it was moderate, and κ = 0.767 and 0.924 when it was severe (P < 0.001). In all 3 patients, the consistency was higher with the grid.

CONCLUSION

Since cast helmet manufacturing for positional plagiocephaly therapy does not require computed tomography scanning, there is no need to administer a sedative, nor does it pose any radiation exposure risk. Since the cast helmet is easier to manufacture and operate and is more cost effective, it could be used to treat more people. In addition, it would be useful for both medical professionals and patients' guardians to use clinical photographs with the acrylic sheet with the grid as a method to analyze shapes and outcomes before and after therapy, along with traditional CVA and CVAI.

Head Orthosis Therapy in Positional Plagiocephaly: Influence of Age and Severity of Asymmetry on Effect and Duration of Therapy

BACKGROUND

Only a few studies investigating the optimal time point at which to start orthotic treatment for deformational plagiocephaly take into account the severity of skull asymmetry. The present study performs a three-dimensional analysis of the effects of age and severity of asymmetry on the final outcome.

METHODS

A total of 144 patients with deformational plagiocephaly treated by molding orthosis were examined and divided into three age groups (group I, <24 weeks; group II, ≥24 to <32 weeks; and group III, ≥32 weeks) and two severity levels (mild to moderate, 30-degree cranial vault asymmetry ≥3 mm to ≤12 mm; and moderate to severe, 30-degree cranial vault asymmetry >12 mm). The extent of the reduction of asymmetry was analyzed using three-dimensional stereophotogrammetry.

RESULTS

Therapy with molding orthosis led to a significant reduction in asymmetry in all defined age groups. Efficacy of reduction decreased with increasing age. Successful treatment (cranial vault asymmetry index <3.5 percent) was achieved in 83, 69, and 40 percent of patients with mild to moderate asymmetry in groups I, II, and III, respectively; and in 50, 30, and 7 percent of patients with moderate to severe asymmetry in groups I, II, and III, respectively. The average duration of treatment increased from 18.6 weeks to 25.3 weeks (age groups I and III).

CONCLUSION

Age at the beginning of treatment and severity of asymmetry have a definite impact on the duration and effectiveness of molding orthosis therapy.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

The course of skull deformation from birth to 5 years of age: a prospective cohort study

In a continuation of a prospective longitudinal cohort study in a healthy population on the course of skull shape from birth to 24 months, at 5 years of age, 248 children participated in a follow-up assessment using plagiocephalometry (ODDI-oblique diameter difference index, CPI-cranio proportional index). Data from the original study sampled at birth, 7 weeks, 6, 12, and 24 months were used in two linear mixed models.

MAIN FINDINGS

(1) if deformational plagiocephaly (ODDI <104%) and/or positional preference at 7 weeks of age are absent, normal skull shape can be predicted at 5 years of age; (2) if positional preference occurs, ODDI is the highest at 7 weeks and decreases to a stable lowest value at 2 and 5 years of age; and (3) regarding brachycephaly, all children showed the highest CPI at 6 months of age with a gradual decrease over time.

CONCLUSION

The course of skull deformation is favourable in most of the children in The Netherlands; at 5 years of age, brachycephaly is within the normal range for all children, whereas the severity of plagiocephaly is within the normal range in 80%, within the mild range in 19%, and within the moderate/severe range in 1%. Medical consumption may be reduced by providing early tailored counselling. What is Known: • Skull deformation prevalence increased after recommendations against Sudden Infant Death Syndrome, little is known about the longitudinal course. • Paediatric physical therapy intervention between 2 and 6 months of age reduces deformational plagiocephaly at 6 and 12 months of age. What is New: • The course of skull deformation is favourable in most of the children in The Netherlands; at 5 years of age, deformational brachycephaly is within the normal range for all children, whereas the severity of deformational plagiocephaly is within the normal range in 80%, within the mild range in 19%, and within the moderate to severe range in only 1%. • Paediatric physical therapy intervention does not influence the long-term outcome; it only influences the earlier decrease of the severity of deformational plagiocephaly.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline on the Role of Cranial Molding Orthosis (Helmet) Therapy for Patients With Positional Plagiocephaly

BACKGROUND

No evidence-based guidelines exist on the role of cranial-molding orthosis (helmet) therapy for patients with positional plagiocephaly.

OBJECTIVE

To address the clinical question: "Does helmet therapy provide effective treatment for positional plagiocephaly?" and to make treatment recommendations based on the available evidence.

METHODS

The US National Library of Medicine Medline database and the Cochrane Library were queried by using MeSH headings and key words relevant to the objective of this systematic review. Abstracts were reviewed, after which studies meeting the inclusion criteria were selected and graded according to their quality of evidence (Classes I-III). Evidentiary tables were constructed that summarized pertinent study results, and, based on the quality of the literature, recommendations were made (Levels I-III).

RESULTS

Fifteen articles met criteria for inclusion into the evidence tables. There was 1 prospective randomized controlled trial (Class II), 5 prospective comparative studies (Class II), and 9 retrospective comparative studies (Class II).

CONCLUSION

There is a fairly substantive body of nonrandomized evidence that demonstrates more significant and faster improvement of cranial shape in infants with positional plagiocephaly treated with a helmet in comparison with conservative therapy, especially if the deformity is severe, provided that helmet therapy is applied during the appropriate period of infancy. Specific criteria regarding the measurement and quantification of deformity and the most appropriate time window in infancy for treatment of positional plagiocephaly with a helmet remains elusive. In general, infants with a more severe presenting deformity and infants who are helmeted early in infancy tend to have more significant correction (and even normalization) of head shape. The full guidelines document can be located at https://www.cns.org/guidelines/guidelines-management-patients-positional-plagiocephaly/Chapter_5.

Long-term outcomes in treatment of deformational plagiocephaly and brachycephaly using helmet therapy and repositioning: a longitudinal cohort study

OBJECTIVES

Deformational plagiocephaly and/or brachycephaly (DPB) is a misshapen head presenting at birth or shortly thereafter, caused by extrinsic forces on an infant's malleable cranium. There are two treatment methods available for DPB: helmeting and repositioning. Little is known about the long-term outcomes of these two treatment options. The purpose of this study was to examine children who received helmeting or repositioning therapy for DPB as infants and compare the long-term head shape outcomes of the two groups.

METHODS

A longitudinal cohort study design was used to evaluate change in head shape of the two groups. One hundred children (50 helmeted, 50 repositioned) were initially evaluated at 6 months or younger for DPB. Anthropometric skull measurements taken as infants before treatment were compared with measurements taken for this study. Inclusion criteria included initial clinic visit at age 6 months or younger, evaluation by the same practitioner, and current age 2-10 years. Cephalic index and cranial vault asymmetry were calculated based on caliper measurements.

RESULTS

Data from 100 children were evaluated for this study. Significant differences between the treatment groups in the mean change in cephalic index (p = 0.003) and cranial vault asymmetry (p < 0.001) were found; the children that used helmet therapy demonstrated greater improvement.

CONCLUSIONS

This is one of the larger published long-term outcome studies comparing children that used helmets and repositioning to treat their DPB as infants. The data suggest that infants will have more improvement in head shape with a helmet than with repositioning.

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.

Effectiveness of conservative therapy and helmet therapy for positional cranial deformation

BACKGROUND

The authors investigated the effectiveness of conservative (repositioning therapy with or without physical therapy) and helmet therapy, and identified factors associated with treatment failure.

METHODS

A total of 4378 patients evaluated for deformational plagiocephaly and/or deformational brachycephaly were assigned to conservative (repositioning therapy, n = 383; repositioning therapy plus physical therapy, n = 2998) or helmet therapy (n = 997). Patients were followed until complete correction (diagonal difference <5 mm and/or cranial ratio <0.85) or 18 months. Rates of correction were calculated, and independent risk factors for failure were identified by multivariate analysis.

RESULTS

Complete correction was achieved in 77.1 percent of conservative treatment patients; 15.8 percent required transition to helmet therapy (n = 534), and 7.1 percent ultimately had incomplete correction. Risk factors for failure included poor compliance (relative risk, 2.40; p = 0.009), advanced age (relative risk, 1.20 to 2.08; p = 0.008), prolonged torticollis (relative risk, 1.12 to 1.74; p = 0.002), developmental delay (relative risk, 1.44; p = 0.042), and severity of the initial cranial ratio (relative risk, 1.41 to 1.64; p = 0.044) and diagonal difference (relative risk, 1.31 to 1.48; p = 0.027). Complete correction was achieved in 94.4 percent of patients treated with helmet therapy as first-line therapy and in 96.1 percent of infants who received helmets after failed conservative therapy (p = 0.375). Risk factors for helmet failure included poor compliance (relative risk, 2.42; p = 0.025) and advanced age (relative risk, 1.13 to 3.08; p = 0.011).

CONCLUSIONS

Conservative therapy and helmet therapy are effective for positional cranial deformation. Treatment may be guided by patient-specific risk factors. In most infants, delaying helmet therapy for a trial of conservative treatment does not preclude complete correction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

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.

Positional plagiocephaly: an analysis of the literature on the effectiveness of current guidelines

OBJECT

Positional plagiocephaly (PP) has been on the rise in recent years. In this review, the authors' aim was to assess the effectiveness of current recommendations to parents on this exceedingly common problem through a comprehensive literature search. Additionally, the current treatment options and the most recent studies on PP are reviewed.

METHODS

A search of the existing literature was conducted to obtain all relevant studies on guidelines, recommendations, parental and clinician practices, and epidemiological aspects.

RESULTS

Although the incidence and risk factors for PP have been well delineated, there continues to be debates on its management and association with developmental delays. Current guidelines and recommendations on prevention set by the American Association of Pediatrics may not be easily followed by both parents and clinicians. There is also evidence that certain populations, including those with lower education, socioeconomic status, and in particular geographic regions may be more affected by the condition. Additionally, the marketing and financial aspects of PP treatments exist and should be addressed.

CONCLUSIONS

Better awareness and education are necessary to inform the population as a whole, although certain populations should be given special attention. Additionally, current guidelines and recommendations can be modified to foster a better grasp of the condition by both parents and clinicians. Adjusting current recommendations, introducing initiatives, and offering elaborate educational campaigns would help deliver these aims. Educating parents on PP as early as possible through clearer guidelines and close monitoring is central to preventing and managing this common condition.

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.