For nearly 25 years, pediatricians have been recommending that parents place their newborns and young infants to sleep on their backs. The AAP’s “Back to Sleep” campaign was a reaction to studies that showed the prone (belly-down) sleep position to be associated with Sudden Infant Death Syndrome (SIDS). One common unintended consequence of positioning young infants in the supine (back) position to sleep is that it puts more pressure on the soft bones of the head, sometimes causing flattening of the side(s) (positional plagiocephaly) or back (brachycephaly) of the skull. Sometimes the flattening is mild and simple reassurance that the head will return to its normal, round shape as the baby gets older is all that is necessary. Sometimes the flattening is exacerbated by torticollis, when the neck muscles on one side are tight, preventing the infant from easily turning the head from side-to-side. Neck-stretching exercises — taught to parents by a pediatrician or even a physical therapist — usually minimizes the effect of this on the shape of the skull. However, when the flattening of the bones of the skull is moderate-to-severe, babies are frequently referred to a pediatric neurosurgeon or pediatric craniofacial plastic surgeon and, after a thorough evaluation to rule out other rare causes of head deformities (like craniosynostosis), fitted with a helmet. The idea is that if a young infant wears this hard helmet nearly 24 hours a day for several months, the head will return to it’s normal shape better than if nothing is done.
A new study in the British Medical Journal put this idea to the test. The authors found that using a fitted helmet vs. simply observing the natural course of plagiocephaly/brachycephaly and doing nothing resulted in the identical outcome: the flattening subsides and the head shape returns to normal:
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.
More studies will need to be done to see if helmets help those babies with the most severe skill deformities. Catherine Saint Louis found skepticism and worry:
Helmets to treat flattened skulls range in price from $1,300 to $3,000, and parents are told to make sure infants wear them around the clock. Dr. [James J.] Laughlin said the paper provides pediatricians and worried parents “reassurance that not doing helmet therapy will give you the same results as doing helmet therapy, which is expensive” and can be “stressful for the family.”
Makers of custom helmets questioned the study’s results. Tim Littlefield, a spokesman for Cranial Technologies, called it “inherently flawed.” William Gustavson, a spokesman for Orthomerica, called it “alarming” that nearly three-quarters of parents whose children received helmets in the study reported that the helmets shifted or rotated on their infants’ heads.
“The value of this research is fully reliant upon the quality of the fit,” said James Campbell, the vice president of the American Orthotic and Prosthetic Association, a trade group.
Some surgeons worried that the finding would be applied too broadly, jeopardizing insurance coverage for severely affected children who could benefit from helmets.
“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,” said Dr. Alex A. Kane, the director of pediatric and craniofacial surgery at UT Southwestern and Children’s Medical Center in Dallas.
Read the AAP’s position on the “Prevention and Management of Positional Skull Deformities in Infants” here.