PRACTICE CHANGER Do not recommend helmet therapy for positional skull deformity in infants and children. Wearing a helmet causes adverse effects but does not alter the natural course of head growth.1
STRENGTH OF RECOMMENDATION B: Based on a single-blind, randomized controlled trial (RCT).1
ILLUSTRATIVE CASE The parents of a 6-month-old girl with moderate plagiocephaly bring their daughter in for a well-child visit. Previously, you had recommended that the parents increase “tummy time” when the baby is awake, change her position in bed, and monitor the progression of the condition. They do not feel these interventions have made a difference in the shape of their daughter’s skull and ask about using a helmet to help correct the deformity. How would you counsel them?
Approximately 45% of infants ages 7 to 12 weeks are estimated to have positional skull deformity (PSD), although three-quarters of them have mild cases.2 The incidence of PSD began to increase in 1992 after the American Academy of Pediatrics (AAP) introduced its “Back to Sleep” campaign, which encouraged parents to place their infants on their back at bedtime to reduce sudden infant death syndrome.3
There are two common forms of PSD: plagiocephaly and brachycephaly.1 Plagiocephaly is unilateral occipital flattening, which may be accompanied by ipsilateral forehead prominence and asymmetrical ears. Brachycephaly is symmetric flattening of the back of the head, which can lead to prominence of the temporal areas, making the head appear wide. The cranial sutures remain open in both kinds of PSD.
Evaluating infants for PSD is part of the routine physical exam, and when the condition is noted, the exam should also differentiate PSD from other causes of skull deformity (eg, craniosynostosis). Infants and preschool-aged children with PSD may score lower on developmental testing than children without skull deformity.4 However, these differences are small and inconsistent (2-3 points on a 100-point scale).4 Skull deformity persists into adolescence in only 1% to 2% of patients.5
Neither the AAP nor the American Academy of Family Physicians has a guideline or consensus statement on PSD. Helmets are intended to correct PSD by fitting closely to an infant’s head but allowing room for the skull to grow at the flattened area.1 A 2011 clinical report by Laughlin et al6 recommended against use of helmets for infants with mild to moderate deformities but stated that there was little evidence of harm. Earlier studies have suggested that physical therapy might be effective for plagiocephaly identified early (ie, when the child is 7 to 8 weeks of age).7,8 Biggs9 suggested considering helmet therapy for infants whose cranial sutures remain open and who do not respond to four to eight weeks of physical therapy for PSD. van Wijk et al1 conducted an RCT to explore the risks and benefits of helmet therapy for children with PSD.