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managing head deformity in infancy


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I seek help from members for managing head deformity in 6 months old baby. It was a preterm 1500gm at 32 gestation, cs done for iugr. the infant has deformity head depressed on oneside and prominent on other . now the metopic suture is also prominent. it seems whole head is rotated by 30 degrees.

Head growth is normal but parent are wprried about further increase in deformity and cosmetic regions.i had read an article on craniostenosis where they mention putting specail helmets for head , can any body tell me where to get them OR how they managed similar cases

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Hi!

It seems that this child may have a rather prominent deformity, and it may not correct itself at this late age. It is difficult to tell from the description whether is it position related (baby sleeping with head on one side) or whether it is truly a craniosynostosis.

Although very rare but if we feel treatment can be necessary, we get a second opinion from neurosurgeons specialised in craniosynostosis surgery. A plain x-ray is usually done to look at bone mineralisation in the sutures.

Although surgery is done for cosmetic reasons, I think a "cosmetic" indication is good enough in cases with progressive cranial deformity.

Have not heard of any experience of the helmet treatment you refer to.

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  • 2 weeks later...

We just had a father on our unit, who develops these helmets. He told me that they have good outcomes, but i don^t know if the procedure is limited by a certain age or a certain degree of deformation....If you like i can see if i can get in touch with him again, or if he can direct me to a homepage or something like that..

regards Norbert

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  • 9 months later...
... mention putting specail helmets for head , can any body tell me where to get them OR how they managed similar cases

I quote from the article regarding the treatment of Deformational plagiocephaly:

1. van Vlimmeren LA, Helders PJM, van Adrichem LNA, Engelbert RHH. Torticollis and plagiocephaly in infancy: therapeutic strategies. Pediatric Rehabilitation. 9(1):40-6.

The effort of an orthotic device is to use the remaining skull growth to redirect head shape, by allowing enough space in the helmet at the flattened areas. A molding helmet is worn 15–22 hours per day and, after improvement following 3–4 months of therapy, it is worn only at night . Helmet treatment is generally recommended between 6–18 months of age . Some authors mentioned the use of Dynamic Orthotic Cranioplasty (DOC) , by application of a dynamic band, which mildly pressures to the apexes of the frontal and occipital prominences, while creating voids over the adjacent areas so that growth of the normal areas is held constant. This treatment starts at 3–4 months of age . The reason to indicate helmet treatment or DOC seems to be subjective, because the measuring methods are different and not always clearly described. No strict indications for this treatment are found. A uniform, easy applicable, valid and reliable measuring-instrument does not exist

The authors in the same study have also proposed an algorithm for management of plagiocephaly. I again quote from their study

Persisting severe deformation of the skull at the age of 5–6 months requires specific attention; differential diagnostics which indicate orthotic device or follow-up. However, in the vast majority of cases a differential diagnosis is possible by means of clinical examination at an earlier follow-up (3–4 months of age). Radiological examination will help to identify the pathology. A delayed diagnosis could lead to a worsening of the prognosis. At 12 months of age, there is a final follow-up. When an obvious asymmetry in position and/or movements persists, possibly with any dysmorphism, diagnostics concerning possible vertebral column anomalies are indicated. Mainly cosmetic considerations will determine the outcome whether skull growth is acceptable or not

Refer to the article for the algorithm

Also you will find lot of information at

1. Bruner TW, David LR, Gage HD, Argenta LC. Objective outcome analysis of soft shell helmet therapy in the treatment of deformational plagiocephaly. The Journal of Craniofacial Surgery. 2004 Jul ;15(4):643-50.

ABSTRACT

Deformational plagiocephaly, cranial asymmetry secondary to positioning, continues to be a leading cause of head shape abnormalities in infants. Treatment recommendations include nonintervention, positioning therapies, and helmet therapy. ... The purpose of this prospective study is to use an objective outcome analysis tool, computerized tomography, to assess the efficacy of a soft shell helmet therapy. ... Soft shell helmet therapy is an effective technique to decrease cranial asymmetry based on objective outcome measurements. Additionally, it is cost-effective, with the total cost of therapy for the helmet and office visits ranging from 600 dollars to 700 dollars. This therapy compares favorably with other more expensive and time-consuming therapies that have been reported in the literature

I again quote from this study

The technique used in this study is completely independent of observer bias or patient compliance with obtaining measurements. Other measurement techniques described in the literature, such as anthropometric measurements, head tracings, clinical experience, and parental assessment, are observer dependent and potentially introduce a subjective component to the measurement process. By eliminating any subjectivity from the measurement process, CT scanning could be considered a more accurate technique for the assessment of efficacy of treatment. Although serial application of this measurement technique would expose infants to significant radiation exposure, and thus would not be recommended as a standard part of patient follow-up, the technique of using intracranial volumetric measurements is ideal to validate efficacy of soft shell helmet therapy. There are numerous orthotic devices available for the treatment of deformational plagiocephaly. Several require infants to be followed in clinic on a

frequent basis throughout the course of treatment. Soft shell helmet therapy does not necessitate frequent clinical visits and is a noninvasive technique that is well tolerated by infants. Additionally, it is cost-effective and economical, with the total cost of therapy ranging from $600 to $700. This therapy compares favorably with other more expensive and time-consuming therapies that have been reported in the literature.

You will find a nice write-up on the broader topic of abnormal skull shapes at

1. Nield LS, Brunner MD, Kamat D. The infant with a misshapen head. Clinical Pediatrics. 2007 May ;46(4):292-8.

I quote from this study

An ounce of prevention is definitely worth a pound of cure when it comes to deformational plagiocephaly, and ideally parents should be counseled right from the start about varying the baby’s head position during feeding or sleeping. As little as 5 minutes per day of supervised “tummy time” beginning in the first 6 weeks of life may be beneficial in preventing the development of an odd-shaped head. Parents should avoid prolonged car seat, swing or “bouncy” seat time and should make attempts to encourage the baby to look to both sides by varying

room decorations, activities, and crib placement. The importance of early recognition and treatment of torticollis is paramount in the prevention of deformational plagiocephaly.

The treatment of deformational plagiocephaly may include strict enforcement of the re-postioning suggestions described above, physical therapy, and/or molding helmet therapy. Surgery is rarely needed except for cosmetic, orthodontic, or orthognathic concerns, which will be determined on a case-by-case basis. Craniofacial surgeons and pediatric neurosurgeons have the crucial role of determining the optimal management of a particular patient. The pediatrician, however, can begin intervening at the first sign of any occipital flattening and make the appropriate referral when necessary. Parents should be advised to vary the head position from side to side during sleep and feedings and ensure at least 5 minutes/day of prone play. Physical therapy that includes neck stretching and strengthening exercises is important when torticollis is present.

Molding helmet therapy may be necessary if repositioning and physical therapy do not improve the situation. Helmet therapy is most effective in children aged 4 months to 12 months because of the great malleability of the young skull and rapid brain growth during that time frame. Yasuda and colleagues recommend that referral for helmet therapy should occur if there is progression or no improvement of the condition after 2 to 3 months of repositioning and physical therapy or if the child is older than 6 months. Graham and colleagues recommend helmet therapy if the CI is > 90% at age 5 months and recommend reassurance for infants with CI <90% at age 5 months. A DD of greater than 1 cm at age 6 months is also another suggested criterion for helmet therapy.The normal target DD is 0.3 cm. One group of investigators reported that the institution of helmet therapy at an earlier age is more effective than initiation at a later age and may also be more effective than repositioning.However, the authors of a systematic review of the research and literature were not able to draw conclusions as to the relative effectiveness of repositioning vs. helmet therapy. Both interventions were found to effectively reduce skull deformity though.Helmet therapy may also be instituted after reconstructive surgery in certain cases as determined by the pediatric neurosurgeon.

Abbreviations:

Diagonal difference (DD)

Cranial index (CI)

There is a nice illustrated write-up on this on the web LINK

Edited by JACK
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  • 5 weeks later...

There are two new articles on this topic.

1)Effect of Pediatric Physical Therapy on Deformational Plagiocephaly in Children With Positional Preference

A Randomized Controlled Trial

Leo A. van Vlimmeren, PhD, PT; Yolanda van der Graaf, MD, PhD; Magda M. Boere-Boonekamp, MD, PhD; Monique P. L’Hoir, PhD; Paul J. M. Helders, PhD, PT; Raoul H. H. Engelbert, PhD, PT

Arch Pediatr Adolesc Med. 2008;162(8):712-718.

2)Nonsurgical Treatment of Deformational Plagiocephaly

A Systematic Review

James J. Xia, MD, PhD, MS; Kathleen A. Kennedy, MD; John F. Teichgraeber, MD; Kenneth Q. Wu, BS; James B. Baumgartner, MD; Jaime Gateno, DDS, MD

Arch Pediatr Adolesc Med. 2008;162(8):719-727.

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  • 3 months later...
We just had a father on our unit, who develops these helmets. He told me that they have good outcomes, but i don^t know if the procedure is limited by a certain age or a certain degree of deformation....If you like i can see if i can get in touch with him again, or if he can direct me to a homepage or something like that..

regards Norbert

it´s been a while, but guess who i met today. The father, mentioned above and so i asked him about the helmets and he gave me the adress of his former employer as follows:

STASTNY Orthopädie- und

Rehatechnik AG (Ortho- Team)

Rosenbergstrasse 16

CH-9000 St. Gallen

FON: 071 222 63 44

FAX: 071 222 73 29

stgallen(at)ortho-team.ch

The person who`s responsible for helmets is: Mr. Roth

just in case you still want to get in touch with theese guys...

hope that this helps..

Regards Norbert

Edited by Skysurfer
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