Helmets don't help infant skull deformations

- Jennifer Middleton, MD, MPH

If you're a family physician, chances are you've seen your fair share of infants with skull deformations. Whether it's plagiocephaly (unilateral occipital flattening) or brachycephaly (symmetrical occipital flattening), approximately 1 in 5 infants will have one of these two conditions by age 4 months. Repositioning (especially "tummy time" to help with the flattening due to placing infants on their backs to sleep) often helps, but many infants with persistent plagiocephaly or brachycephaly will end up with a helmet (cranial orthosis) by age 6 months if these deformations persist.

The British Medical Journal published a randomized controlled trial (RCT) from the Netherlands this month investigating the utility of these helmets. The researchers enrolled 84 infants between the ages of 5-6 months with plagiocephaly and brachycephaly who were born after 36 weeks gestation and who didn't have any other dysmorphic features. 42 of them wore a cranial orthosis for 6 months, and 42 of them did not wear a helmet or do any other sort of treatment. Follow-up measurement at ages 8,12, and 24 months showed no difference between groups in the number of infants who had resolution of their skull deformation: 26% of helmet group infants vs 23% of non-helmet group infants for an odds ratio of 1.2 (95% confidence interval 0.4-3.3). Motor developmental outcomes were identical between groups, quality of life scores were the same for both groups, and parents' satisfaction with the shape of their child's head were also the same for both groups. Additionally, every single parent of an infant in the helmet group reported at least one side effect (discomfort, itching, sweating, helmet odor, and/or "feeling hindered from cuddling their child").

This RCT's primary outcome, skull measurement, is admittedly a disease-oriented outcome. Several of the secondary outcomes, though, were patient-oriented evidence that matters: motor development, quality of life, parental satisfaction, and side effect frequency. An accompanying editorial states that this RCT is the first to compare helmets to observation.

AFP published an article on "Diagnosis and Management of Positional Head Deformity" in 2003. While the BMJ RCT provides an updated perspective on the use of helmets, the AFP article still provides some excellent pictures and references to aid family physicians in counseling parents. Another AFP article (this one from 2004), "Craniosynotosis," provides a useful review of how to differentiate plagiocephaly and brachycephaly from craniosynotosis (premature fusion of the cranial sutures) which necessitates surgical referral.

Will this RCT change how you counsel parents about treatment for infant skull deformations?