Babies, Misshapen Heads, and Plagiocephaly Helmets: a Physical Therapist Perspective

A majority of the babies I see in the clinic are those diagnosed with torticollis and plagiocephaly. These babies are often accompanied by bewildered first-time parents with worried looks, scared by those big diagnostic words. The first questions they ask are “could I have prevented this?” and “will he need a corrective helmet?”

What is plagiocephaly and what causes it?

Since the beginning of the “Back to Sleep” program in the 1990s, which kept babies off their tummies to prevent Sudden Infant Death Syndrome, many babies started to develop flat spots on the back of their heads. Plagiocephaly and brachycephaly are two terms used to describe the abnormal head shape, depending on the degree of distortion and location of the flatness. While most parents think they were partially responsible for the flat spot developing in their newborn, an infant’s head is extremely malleable before it reaches cranial maturity. Any prolonged external force leads to some skull shape changes. Plagiocephaly and brachycephaly can be associated with many conditions, from prematurity and twin births, to torticollis (asymmetrically tight neck muscle), to developmental delay. Often times, the asymmetries are resolved with simple repositioning and stretching exercises to encourage the child to look to both sides, physical therapy, as well as nap and play time on the tummy, all with supervision of course.

How do plagiocephaly helmets work and what’s the best time to get one?

Plagiocephaly helmets are cranial orthoses made out of a hard plastic shell with Baby Sleepingfoam lining, custom made to each child, and designed to keep pressure off the flat spots to help the head naturally round itself out. They are meant to be worn for 8-12 weeks for at least 23 hours a day, during sleep and play. Certain hospitals, orthotics companies, and plastic surgeon’s offices design their own version of the helmets, but the concept is still the same.

The earlier a child with torticollis and plagiocephaly starts a repositioning and physical therapy program, the less likely he will need a skull reshaping orthosis. As physical therapists, we usually recommend a helmet evaluation if 1) A baby has been repositioned off his flat spot and participating in physical therapy for 1-2 months without any significant changes noted to his head shape, 2) A baby has spent 1-2 months sitting independently with good head control and playing easily in tummy time, and moderate to severe plagiocephaly is still present, or 3) A baby is over 6 months of age and facial asymmetries are still obvious. Usually, helmets are not expected to be effective for kids over 18 months.  What facial asymmetries do we look for as an indication of moderate to severe cranial change? A smaller chin on the affected side, a smaller ear or an ear that’s shifted forward, and a smaller or droopy eye on one side are examples. Of course, every baby develops differently and other factors may be taken into consideration, such as if his abnormal head shape is keeping him from achieving gross motor milestones (rolling, head control, etc).

Do helmets actually help? Aren’t all of our heads a little bit asymmetrical? What happens if my child doesn’t get one?

In its early years, the infant helmet received a bit of scrutiny. The biggest push-back from some insurance companies and doctors against cranial helmets is that asymmetrical head shape in babies appears to be a cosmetic complaint that hardly justifies a costly and bulky orthosis. Parents and practitioners alike question the association between deformational plagiocephaly and long-term functional delay in kids. There has been research over the last two decades on whether helmets alone prevent long-term asymmetries, if cranial asymmetries lead to other medical issues, or if neurodevelopmental delays occur in school-aged children with plagiocephaly. While the literature is still young and long-term research is still in the works, untreated cranial asymmetries have been linked to visual defects, ear infections, middle ear malfunction, jaw bone changes, developmental delay, learning difficulties, and other psychomotor delays.

In a brand new study out of the Netherlands this month, researchers found that helmet therapy alone yields similar results to natural cranial growth. The study, however, focused only on babies with mild plagiocephaly, not torticollis, prematurity, or other associated conditions. Babies with severe plagiocephaly were also not included in the study, which limited the population to a very specific, underrepresented, group in pediatric clinics. Interestingly enough, the study found that by the time their child was 2 years old, parent satisfaction was much higher and parent anxiety was slightly lower in the group who received helmets. Even in this study suggesting the ineffectiveness of helmets, the authors referenced other studies that discussed the long-term implications of letting deformational plagiocephaly go untreated. These included researchers from different fields, such as neurology, child development, physical therapy, orthotics and prosthetics, and plastic surgery. Overall, developmental experts agree, long term consequences of untreated plagiocephaly are multi-faceted and future research is imperative.

Because physical therapists like us have no association with helmet companies, doctors’ offices, or orthotists, our recommendations are purely based on the child and family’s needs. What I always tell anxious parents trying to make this decision of whether or not to try the cranial orthosis helmet with their child is this:

Helmets are not right for every baby with cranial asymmetry. The results you can get out of a helmet depends on the fit, consistency of wear, and the baby’s growth. The most effective time period to make the most changes to a baby’s head is short. Don’t let a medical professional bully you into making a decision you aren’t comfortable with. At the same time, take on a wider perspective when trying to make this decision. Have we done all the necessary exercises and reposition changes? Have we taken into consideration medical advice from all the different health professionals involved in your baby’s care? Did the helmet evaluation (with measurements done by machines for precision) reveal moderate to severe cranial changes? Are you worried about side effects or costly interventions that might be needed down the road? These are great questions to talk out with your pediatrician or physical therapist.

In my clinical experience, I have never had a parent regret the decision they made, whether it was to seek out a helmet evaluation or to forgo helmet therapy. Though often it was a hard decision to make, we were able to work through the questions together to determine the best course of action for their precious little one’s all-important noggin.

 

Do you still have questions or have experience you want to share? Please let us know!



References:

Kordestani R, Patel S, Bard D. Neurodevelopmental Delays in Children with Deformational Plagiocephaly. Plastic and Reconstructive Surgery 2006;117:1. Available from: www.plasreconsurg.org. [accessed 15 April 2014]

Miller RI, Clarren SK. Long-term developmental outcomes in patients with deformational plagiocephaly. Pediatrics 2000; 105:e26. Available from: http://pediatrics.aapublications.org/content/105/2/e26.full.html. [accessed 15 April 2014]

Stevens, P. Beyond Cosmetic Concerns – Functional Deficits Associated with Deformational Plagiocephaly. April 2012. The O&P EDGE. Available from: http://www.oandp.com/articles/2012-04_02.asp [accessed 15 April 2014]

Van Wikl RM, van Vlimmeren LA, Groothuis-Oudshoorn CGM. Helmet therapy in infants with positional skull deformation: randomized controlled trial. BMJ 2014;348:g2741. Available from: http://www.bmj.com. [accessed 12 May 2014]

 

3 replies
  1. Sarah
    Sarah says:

    We got a helmet for my daughter when she was about 7 months old and she wore it for 12 weeks. I am really thankful to Judy for recommending that we go for an evaluation. I was reluctant to do it because my daughter’s doctor did not think it was necessary. Also, I of course thought my daughter was perfect so her head flatness didn’t really bother me. I am confident now that we made the right decision. Her head shape really improved with the helmet, and she wasn’t bothered at all by wearing it. We decorated it with stickers and she looked really cute in it. I would definitely do it again if I had another baby with torticollis and plagiocephaly.

    Reply
  2. Monica Garcia
    Monica Garcia says:

    Hello, everyone, I would like to share my story with “THE HELMET treatment”. My daughter was about 6 months when we started working with Judy because her neck was tight on the left side and she had difficulty turning her head that way, thanks to this she slept only on that side making it really flat. She had tons of curly long hair and it was really noticeable, I talked to her doctor and said that it would be even with time and lots of tummy time…. time passed and no results, excercises and therapy helped with her neck movement but didn’t make her head shape improve. Soooo after a lot of hesitation we decided to make a free diagnosis appointment, it was then when I realized how bad her head shape was, they took pictures in all degrees possible and looking it from the top angle I coulds see it, so the question was…. to go for it or not. The only thing stopping me was that we would have to cut her beautiful long hair (really, I cried at hair cuttery 🙁 ) , but I decided that health is before beauty. So, we began the process, when we got it seen it on her is a bit shocking, I thought it was hurting her, how was she able to sleep with it.. etc etc, but as days went by I got used to seen her with it, and she seemed completely fine, no trouble sleeping, it was like if she was without it. There’s a really nice place that decorates them for free and when we did, it was sooo cute and that helps with making it look not so medical (sorry for my english). The only thing that I didn’t like was that she sweat a lot, and this was in summer so it just made it worse. When she graduated and had her diploma, they show you before and after pictures and the transformation was AMAZING!! we could’ve had a perfect outcome if we hadn’t waited sooo long, the best time is around 3 months of age and she started around 8 months so there is a big difference in time… time is crucial with this treatment. So, to all the parents out there I would encourage you to go get that free appointment to see and better understand and then make an inform decision. Time flies and it is crucial to make decision before it’s too late…
    Good luck and any questions feel free to contact me!!!
    Monica

    Reply
  3. Monica Garcia
    Monica Garcia says:

    I forgot to thank Judy again.. I know i’ve done so many times but she was amazing with the whole process and I know my daughter was lucky to have her as her therapist!!! xoxo

    Reply

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