Cranial Helmet Therapy for Babies: Can It Really Fix a Flat Head?
What Is Cranial Deformity?
There are three main types of cranial deformities: scaphocephaly, plagiocephaly, and brachycephaly.
- Scaphocephaly (or sagittal synostosis) is a condition in which the middle sutures of the skull are prematurely fused together. This causes a high midline appearance. The brain thus grows from front to back, giving the appearance of an elongated head.
- Plagiocephaly is a condition in which flattening occurs on either the left or right back of the head. This is sometimes called "Flat Head Syndrome." Facial features like the ears, forehead, and eyes can also be misaligned or assymmetrical.
- Brachycephaly is a condition in which the entire back of the head is flattened. The head thus has a widened appearance in the back. Sometimes the forehead can also bulge.
What Causes Cranial Deformities?
Some deformities are caused by genetic abnormalities. Other conditions occur in utero, at birth, or during infancy.
As mentioned, scaphocephaly is typically caused by prematurely fused sutures in the skull. It is the most common form of craniosynostosis. Craniosynostosis is a blanket term for any cranial deformity that is directly attributed to early closure of cranial sutures. Sometimes other birth defects may accompany this syndrome. Craniosynostosis is usually a result of a genetic mutation. However, there are also links to maternal use of an epilepsy medication, valporic acid, during pregnancy.
Plagiocephaly is the most common cause of cranial deformity. It can be caused by a number of factors. Torticollis is a condition in which a baby's neck muscles are abnormally tight on one side. This causes a baby to hold its head to one side and to rest only on that side, thus flattening the head. Positioning or lack of space in the womb may also cause plagiocephaly. This is often the case with multiple births. Prematurity can be a factor too. Babies who are premature may have especially soft heads. They may also spend hours in neonatal intensive care settings, lying quite still and possibly on a respirator.
The most common form, positional plagiocephaly, occurs when a baby develops a flat spot due to pressure on that area. Often this happens when a baby is allowed to sleep for prolonged periods of time in a car seat, swing, bouncer, rock and play, or other device.
Brachycephaly is closely related to plagiocephaly. Often, it is caused by situations similar to positional plagiocephaly in which a lack of movement or pressure on a baby's head causes flattening. It can, however, also be caused by congenital conditions. The front and side bones of a baby's skull may join together in utero. It may also be associated with other abnormalities or developmental disorders.
"Back to Sleep Campaign"
Perhaps the most common overall cause of flat heads stems from infants sleeping on their backs. In the early 1990s, the American Academy of Pediatrics (AAP) began a campaign in an effort to reduce infant deaths caused by SIDS (Sudden Infant Death Syndrome). This campaign, called the "Back to Sleep Campaign", advised parents to place infants on their backs for sleep and to avoid allowing babies to sleep on their stomachs. Suffocation from tummy sleeping was found to be a huge risk factor in babies dying from SIDS. This campaign successfully reduced the incidence of SIDS by 50%, but the AAP has now recognized a correlation between back sleeping and plagiocephaly. Even though a correlation exists, experts still firmly believe babies should always be placed on their backs to sleep.
“The AAP perspective on this is that babies with funny-shaped heads are better than dead babies, from a public-health standpoint.”— Joseph Piatt, Former Chairman of AAP
How to Treat Flat Heads
1) Repositioning: The first line of treatment for positional causes of flattening is to try non-invasive, simple techniques like repositioning. Parents can practice these at home.
- More "tummy time" can be incorporated. Babies should be closely monitored during this time, but allowing babies to play on their tummies helps to take pressure off of the delicate skull while also aiding in developing the baby's neck strength.
- Alternating the side of crib for naps or night sleep can also help.
- Alternating the hip or arm on which baby is carried encourages the baby to turn its head in the other direction.
- Also alternating the direction a baby lies on a changing table encourages movement of the head.
- Placing toys on the outside of a stroller or car seat forces the baby to bend forward and take pressure off the head.
2) Physical Therapy: If a baby suffers from torticollis, physical therapy is often recommended first. States typically offer a free first visit from a licensed physical therapist to gauge whether or not a baby has torticollis. If he or she does, a list of exercises are given for parents to try at home.
3) Helmet Therapy: If repositioning techniques and physical therapy do not seem to help, helmet therapy may be recommended. (In some instances, babies may require surgery to fix craniosynostosis prior to helmet therapy.)
Cranial Helmet Therapy
If a baby meets the criteria, a doctor may refer him/her for an evaluation for helmeting. Sometimes the baby must first go to a craniofacial plastic surgeon for evaluation. Others may be referred directly to a certified orthotist (C.O.)
Measurements are taken using a craniometer which looks something like a protractor. The doctor or orthotist measures the cephalic index (a ratio of the breadth to the length of the head). The measurements are essentially like what one would see if an X was drawn on the top of the baby’s head. The difference between the two measurements determines the severity of plagiocephaly.
Mild plagiocephaly has a difference of up to 9mm. Moderate plagiocephaly is determined by a 10-19mm difference, and severe plagiocephaly exhibits a 20mm or greater difference. These measurements can differ slightly depending on the practitioner. They give a general idea of whether or not a baby would qualify for a helmet.
Mild plagiocephaly might just be treated by repositioning techniques. However, once a baby falls into the moderate to severe range, helmeting is usually recommended.
Fitting for Helmets
The next step is for babies to have a laser scan. It offers a more accurate measurement of the baby's head and degree of skull deformity.
One popular company that specializes in helmet therapy is Starband. On their website starbandkids.com, they explain that the laser scan is completed in less than 2 seconds. The laser captures a 3D picture of the baby's head and gives a measurement accuracy to 0.5mm. This allows for a custom-fit helmet to be made.
The Pediatric Neurosurgery Department at Johns Hopkins explains how helmets work:
Cranial remolding helmets are usually made of a hard outer shell with a foam lining. Gentle, persistent pressures are applied to capture the natural growth of an infant's head, while inhibiting growth in the prominent areas and allowing for growth in the flat regions. As the head grows, adjustments are made frequently. The helmet essentially provides a tight, round space for the head to grow into. So, even if your child continues to rest their head on one side, the helmet will provide a cushioning to prevent the head from further flattening.
Insurance will often cover the cost of the helmet if certain protocols are followed. A prescription from a pediatrician or craniofacial plastic surgeon is needed. Repositioning techniques need to have been attempted for a period of time. Then measurements and accompanying scans need to be submitted. The cost of cranial helmets ranges from $1,000 to $4,000, so insurance coverage is critical for most parents.
Helmet therapy is usually recommended to begin as early as possible, sometime in the 3-6 months of age range. It is critical to wear the helmet during the time of active brain growth. Head growth often slows closer to the 1 year mark. Although cranial helmets can be worn up to 18 months of age, more and quicker improvement is seen when babies receive their helmets earlier. Babies who obtain helmets later must wear them longer and may not see full correction of the asymmetry.
Helmets must be worn 23 hours a day to see maximum effectiveness. They are typically worn for 3 or 4 months, however some babies take much longer to achieve a desired result.
Arguments Against Helmet Therapy
Not everyone agrees that helmets are necessary in the treatment of cranial deformities. Critics cite a study out of the Netherlands, published in 2014. In this study, 84 infants between the ages of 5-6 months were selected. All demonstrated moderate to severe plagiocephaly. 42 were selected for helmet therapy and 42 were selected for no therapy. Babies were evaluated at 8, 12, and 24 months. At the 24 month mark, changes in plagiocephaly were equal among the helmeted and non-helmeted participants. Full recovery was seen in only 26% of the helmeted group and in 23% of the non-helmeted group.
Parents of the participants in the study also cited some side effects. Among the complaints were skin irritation (96 percent), an unpleasant smell (76 percent), sweating (71 percent) and pain (33 percent). Also, 77 percent of the parents said the helmet interfered with them cuddling their baby.
Based on their findings, the study administrators stated the following:
"Based on the equal effectiveness of helmet therapy and skull deformation following its natural course, high prevalence of side effects, and high costs associated with helmet therapy, we discourage the use of a helmet as a standard treatment for healthy infants with moderate to severe skull deformation."
Arguments in Favor of Helmet Therapy
Despite the Netherland's study findings, the vast majority of studies and anecdotal stories find that helmet therapy is quite beneficial and even necessary.
Ellie Boomer, CPO, a cranial helmet expert cites flaws in the 2014 Netherland's study. Among the criticisms she lists are that the study had inconsistencies in helmet brands and the helmets were not the kind used in the USA; fit issues were described by parents, indicating a poor quality; the participants had various types of cranial deformity, so the cross section population was inconsistent; and parent compliance with the helmet was not monitored effectively.
Dr. Alex Kane, a pediatric craniofacial surgeon in Dallas agrees. He worries the Netherland's study may also sway insurance companies. He states:
“What I fear happening is that children with a severe deformity are going to be denied helmets based on this evidence, which is really only talking about moderate cases.”
A study published in 2015, "Treated Versus Untreated Positional Head Deformity" had very different findings. This study followed 81 children over 5 years. 41 were untreated, and 40 were treated with helmet therapy. The findings stated that untreated (non-helmeted) children's asymmetry changed on average from 9.5mm to only 9.4mm. A quite insignificant difference. In the treated category, the overall decrease in asymmetry went from 17.4mm to 3.9mm. A huge difference.
Orthotic companies state that almost 1 in 5 babies (and possibly even as great as 40% of babies) today suffer from some sort of plagiocephaly or cranial deformity. Given the increasingly huge number, orthotists have seen thousands of babies and have noted improvement in myriads of children who have worn helmets. The following video features craniofacial plastic surgeons explaining how prevalent the condition is and how laser scanning and helmet therapy has helped more than 35,000 children.
Babies with mild plagiocephaly may experience no ill effects should treatment not occur. Many of these parents report being satisfied with their son or daughter's head shape at the two year mark.
However, for those with moderate to severe plagiocephaly or brachycephaly, other symptoms or complications may arise if the condition is left untreated.
Some of the possible long term ill effects may be sleep apnea, facial asymmetry, hearing or vision problems, TMJ, neurobehavioral problems or low self-esteem.
So, if the condition meets the criteria for helmet therapy, if the helmet could be covered by insurance, and if the parents are willing to try, babies should be given the option. Given the small window of time for treatment, it's better to be safe than sorry.
“I used to be against helmets but have since changed my mind. They offer the best cosmetic solution for a good many cases of plagiocephaly, and so far, I have seen no adverse effects.”— Stuart Korth, the director of the Osteopathic Centre for Children in London
More Information (Personal Story)
For a personal account, please read my article "Helmet Therapy for Babies: My Son's Story" to learn about my son's experience with helmet therapy.