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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]

 

When is Stiffness Problematic in Infants?

If your child seems stiff or rigid, he/she may have what is described as “high muscle tone” (hypertonia). This means that the muscles baby in towelare chronically contracted. Stiffness can become problematic in an infant when it limits the movements and acquisition of a child’s gross motor skills.

Signs of Stiffness in Infants:

  • Your child might hold his/her hands in tight fists or may seem unable to relax certain muscles.
  • He/She may have difficulty letting go of an object or difficulty moving from one position to another.
  • The legs or trunk of the child might cross or stiffen when you pick the child up as well.

How Can A Physical Therapist Help?

While limb stiffness is a sign of abnormal signals that are being sent from the brain to the body that over-activate certain muscle groups, some of these movement/coordination disorders are mild and can be treated with physical therapy. The physical therapist will help the child break out of her stiff positions, stretch out the tight muscles, strengthen the weak muscles and develop efficient movement patterns.

At times, limb stiffness is a symptom of spastic cerebral palsy; however, parents should not focus on a medical diagnosis within babies. Regardless of the medical diagnosis, the focus of therapy will be to stretch the tight, overactive muscles and guide the child to acquire motor skills and perform functional tasks in a more efficient manner.

How Can A Parent Help?

Parents should set up the environment to be motivating and organize activities so that the child can practice in a variety of ways. Both massage and Yoga can help to improve muscle length and flexibility. While Botulinum Toxin (commonly known by the brand name “Botox”) can help, it is not used in children that are younger than 18 months. This toxin is injected directly into a child’s muscles and temporarily paralyzes the muscle’s activity, giving the child the opportunity to stretch the tight muscle and strengthen the opposing muscle. Muscle relaxants may be prescribed for adults that have cerebral palsy, but they’re rarely used for toddlers as they cause drowsiness.

If you are concerned about the stiffness in your baby or if your child’s rigidity is keeping him/her from interacting with toys, contact your doctor and schedule an evaluation with a physical therapist.