What are the treatment options for a patient diagnosed with Brachycephaly?

Treatment Options for Brachycephaly

Physical therapy and repositioning education should be the first-line treatment for mild to moderate brachycephaly, with cranial molding helmets reserved for moderate to severe cases or when repositioning fails to show improvement. 1

Diagnosis and Assessment

Before initiating treatment, proper diagnosis is essential:

• Clinical examination is typically sufficient for diagnosis of brachycephaly 1
• Imaging is rarely necessary except when clinical diagnosis is equivocal 1
• When needed, 3D cranial topographical imaging, skull x-rays, or ultrasound are preferred over CT scanning 1
• Brachycephaly is defined as flattening of the entire occipital region, resulting in a foreshortened head in the anterior-posterior dimension 1
• Quantitatively measured as a cranial index (CI = width divided by length × 100%) greater than 81% 2

Treatment Algorithm

First-Line Treatment: Repositioning and Physical Therapy

1. Repositioning education:

   • Vary head position when putting infants to sleep 2
   • Avoid prolonged time in one position in strollers, car seats, swings, etc. 3
   • Implement supervised tummy time when awake
   • Alternate sides when feeding and holding infant

2. Physical therapy:

   • Structured physical therapy program is superior to repositioning education alone 1
   • Includes neck stretching exercises for any associated torticollis
   • May include exercises to strengthen neck muscles

Second-Line Treatment: Cranial Orthotic Therapy (Helmet)

Consider when:

• Moderate to severe brachycephaly (CI ≥ 90%) 2
• Failed improvement with repositioning and physical therapy
• Infant is between 4-6 months of age (optimal starting time) 4

Effectiveness of Treatment Options

Repositioning and Physical Therapy

• Provides some degree of correction in virtually all infants with brachycephaly 1
• Less effective for severe brachycephaly (CI ≥ 90%) 2
• More effective when started early (before 4 months of age)

Cranial Orthotic Therapy (Helmet)

• More effective than repositioning for correcting severe brachycephaly 2
• Corrects asymmetry more rapidly and to a greater degree 1
• For severe cases (CI ≥ 90%), can reduce mean CI from 96.1% to 91.9% 2
• Long-term studies show greater improvement in head shape with helmet therapy compared to repositioning 5
• Earlier treatment initiation correlates with greater therapeutic effect 4

Important Considerations and Caveats

• Timing is critical: Earlier intervention (before 6 months) yields better outcomes for both methods 4
• Duration of therapy: Helmet therapy typically continues until 12 months of age or until correction plateaus
• Distinguish from craniosynostosis: True craniosynostosis (fusion of skull sutures) requires surgical intervention rather than conservative management 6
• Monitor for complications: Intracranial hypertension can occur in some cases of severe brachycephaly, particularly if associated with craniosynostosis 6
• Avoid positioning devices: The American Academy of Pediatrics warns against using soft positioning pillows in the sleeping environment due to SIDS risk 1
• Regular follow-up: Necessary to monitor progress and adjust treatment as needed

Predictors of Treatment Success

For helmet therapy, factors associated with better outcomes include 4:

• Male sex
• Moderate to severe degree of deformity at treatment initiation
• Larger head circumference at start of treatment
• Earlier treatment initiation

Remember that while brachycephaly is primarily a cosmetic concern in most cases, severe untreated cases can potentially affect facial symmetry and appearance, which may have psychosocial implications as the child grows.