What is the approach to managing congenital brachycephaly?

Management of Congenital Brachycephaly

Physical therapy is recommended as the first-line treatment for congenital brachycephaly, with cranial orthotic devices (helmets) being more effective for moderate to severe cases or when physical therapy fails to provide adequate correction. 1

Diagnosis and Assessment

• Clinical examination is the primary method for diagnosing brachycephaly, with imaging rarely necessary except in equivocal cases 1
• Brachycephaly is characterized by flattening of the entire occipital region, resulting in a foreshortened head in the anterior-posterior dimension 1
• In cases where clinical examination is unclear, three-dimensional surface imaging or stereophotogrammetry is recommended for assessment 1
• CT scans should only be used when x-rays or ultrasound are non-diagnostic, to definitively rule out craniosynostosis 1

Treatment Algorithm

First-Line Interventions

1. Repositioning Therapy

   • Effective for mild cases of brachycephaly 1
   • Involves varying the infant's head position when putting them to sleep 2
   • Parent education on proper positioning techniques is essential 1
   • However, repositioning alone is inferior to physical therapy and helmet therapy based on Class I and Class II evidence 1

2. Physical Therapy

   • Superior to repositioning alone based on randomized controlled trials 1
   • Particularly effective for mild to moderate deformity 1
   • Should be implemented early, ideally in the first year of life 3
   • Focuses on neck stretching exercises and supervised tummy time 1

Second-Line Interventions

1. Cranial Orthotic Devices (Helmets)
   • More effective than repositioning for correcting asymmetry, especially in moderate to severe cases 1, 2
   • Corrects asymmetry more rapidly and to a greater degree than repositioning 1
   • For severe brachycephaly (cranial index ≥90%), helmets are significantly more effective 2
   • Best results when initiated before 6 months of age 3
   • Treatment typically lasts 2-4 months depending on severity and age at initiation 3

Special Considerations

• Timing is critical - interventions are most effective when implemented in the first year of life 3
• Severity should guide treatment decisions - mild cases may respond to repositioning and physical therapy, while moderate to severe cases often require helmet therapy 2, 3
• While a European randomized trial suggested bedding pillows might be beneficial, they are not recommended due to the American Academy of Pediatrics' warnings against soft positioning devices in the sleeping environment 1
• For infants with underlying conditions like osteogenesis imperfecta that limit positioning options, cranial orthotic devices may be the preferred first-line treatment 4

Prevention

• Preventive measures include:
  • Regular supervised tummy time when the infant is awake 5
  • Alternating the infant's head position during sleep 2
  • Minimizing time spent in car seats, swings, and bouncy seats when the infant is awake 5
  • Early recognition and intervention for torticollis, which can contribute to skull deformations 5

Common Pitfalls

• Delaying treatment beyond the first year of life, when cranial growth is most rapid and interventions are most effective 3
• Failing to distinguish between positional brachycephaly and synostotic brachycephaly (which requires surgical intervention) 1
• Relying solely on repositioning for moderate to severe cases, which is less effective than combined approaches or helmet therapy 1, 2
• Using soft positioning devices during sleep, which contradicts SIDS prevention guidelines 1