What are the guidelines for using a baby helmet for positional plagiocephaly in a well-term baby?

Guidelines for Baby Helmet Therapy in Positional Plagiocephaly

Helmet therapy should be reserved for infants with persistent moderate to severe positional plagiocephaly after a trial of conservative treatment (repositioning and/or physical therapy), or for those presenting at an advanced age with moderate to severe deformity. 1

Initial Management Approach

First-Line Treatment: Conservative Therapy

• Physical therapy is superior to repositioning alone and should be the primary conservative treatment for infants 7 weeks of age or older with positional plagiocephaly. 1

• Repositioning education alone is less effective than physical therapy, though it remains a valid treatment option for mild cases. 1

• Physical therapy should be prioritized over positioning pillows to ensure safe sleeping environments in compliance with AAP recommendations, even though both have comparable efficacy. 1

Diagnosis and Assessment

• Clinical examination alone is sufficient for diagnosing positional plagiocephaly in most cases; imaging is rarely necessary except when clinical diagnosis is equivocal. 1

• When clinical examination is uncertain, three-dimensional surface imaging or stereophotogrammetry can be used for objective assessment. 1

Indications for Helmet Therapy

Primary Indications

Two specific clinical scenarios warrant helmet therapy: 1

1. Persistent moderate to severe plagiocephaly despite a course of conservative treatment (repositioning and/or physical therapy)

2. Moderate to severe plagiocephaly in infants presenting at an advanced age (typically older than 6 months)

Severity Considerations

• Helmet therapy demonstrates superior outcomes in moderate to severe cases compared to conservative therapy alone, particularly achieving faster correction in a fraction of the treatment time. 1

• The evidence shows more significant and faster improvement of cranial asymmetry with helmet therapy versus conservative approaches when deformity is severe. 1

Optimal Timing for Helmet Therapy

Age at Initiation

• The optimal starting age is 5 to 6 months of life, with significantly better outcomes when therapy begins before 6 months compared to after 6 months. 2

• Early initiation (before 6 months) results in:

  • Shorter treatment duration (14 weeks vs. 18 weeks for those starting after 6 months) 2
  • Better absolute outcomes with Cranial Vault Asymmetry Index reduced to normal values (<3.5%) 2
  • Superior relative improvement in asymmetry (75.3% vs. 60.6%) 2

• Infants helmeted early in infancy tend to achieve better correction and even normalization of head shape compared to those treated later. 1

Treatment Duration

• Duration of helmet therapy correlates positively with age at initiation, meaning older infants require longer treatment periods. 1

• Average treatment duration with helmets (approximately 21.9 weeks) is significantly shorter than active counterpositioning alone (63.7 weeks) while achieving comparable outcomes. 3

Clinical Outcomes and Effectiveness

Expected Results

• Helmet therapy achieves significant reduction in cranial asymmetry, with studies showing reduction in Cranial Diagonals Difference from an average of 1.50 cm to 0.72 cm. 4

• For bilateral plagiocephaly, cranial indexes improve significantly from ranges of 94.4-124.2% to 86.8-121.4%. 4

• Severity classification improves substantially: at treatment end, 40.2% of children have mild deformity, 44.3% moderate, and only 15.5% severe, compared to 77.9% severe at baseline. 4

• Facial symmetry improves from 13.7% pre-treatment to 66.7% post-treatment. 4

Comparative Effectiveness

• Helmet therapy produces greater reduction in diagonal difference compared to no helmet therapy in severe cases. 5

• Success rates for acceptable cranial shape may reach as high as 92% following appropriate treatment. 6

• Surgical intervention is rarely needed, required in only 0.2% of cases when helmet therapy fails. 4

Important Clinical Caveats

Common Pitfalls to Avoid

• Do not delay helmet therapy while waiting for prolonged physiotherapy trials in severe cases—the often-practiced regimen of starting helmet therapy only after physiotherapy should be replaced by combined therapy in severe presentations. 2

• Early recognition is essential—delaying onset of treatment significantly deteriorates outcomes, particularly when treatment is postponed beyond 6 months of age. 2

• Avoid positioning pillows as primary treatment due to safe sleep concerns, even though efficacy may be comparable to physical therapy. 1

Strength of Evidence

• The recommendations carry Level II strength (uncertain clinical certainty) based on one prospective randomized controlled trial, five prospective comparative studies, and nine retrospective comparative studies. 1

• While specific criteria for measurement quantification and the most appropriate treatment window remain somewhat elusive, the evidence consistently supports helmet use in moderate to severe cases. 1

Practical Management Algorithm

For well-term infants with positional plagiocephaly: 1, 2

• Mild cases: Start with repositioning and physical therapy
• Moderate to severe cases diagnosed before 5-6 months: Consider combined physical therapy and helmet therapy
• Moderate to severe cases diagnosed after 6 months: Proceed directly to helmet therapy given advanced age
• Persistent moderate to severe cases after conservative trial: Transition to helmet therapy