The Beginnings of Helmet Therapy for the Treatment of Deformational Plagiocephaly

Sterling K. Clarren, MD

The notion of using helmets to improve the shape of the head in infants with positional plagiocephaly arose in discussions with students and visitors in our University of Washington, Dysmorphology Clinic led by our teacher Dr. David W. Smith, another of his fellows, Dr. James Hanson, and me in the mid-1970s. The Native Americans in the Pacific Northwest had used helmets to deliberately alter head shape, apparently without harm to their infants. We used that information when we explained to parents that their infant's positional plagiocephaly was the result of either inadvertent or unavoidable prolonged placement of the infant's head against a hard surface. One day, someone said, "Well, if you can make a head asymmetric through molding, why can't you just mold it back?" Why not indeed!

I went home dreaming of how one might accomplish this. It seemed straightforward enough. Take a mold of the child's head and create a positive bust. Add material to the flattened surfaces until the head was symmetric. Make a helmet that was then symmetric and snug where the head was prominent and spacious where the head was flattened. Allow the brain to grow and move the head to the symmetric shape.

It was not long until a family came to the clinic with a 4-month-old infant with severe positional plagiocephaly. We told them we had an idea of how to fix this problem and they were enthusiastic to help. I knew little of orthotics materials or techniques. We plastered the head and made a negative shape. I filled the mold with modeling clay to make a positive-shaped bust and then added clay to build the form to the improved shape. Then we froze the mold so it was stiff enough to avoid distortion as we applied foam rubber and fiberglass and made a helmet. The thing was crude and rather ugly, but the family gave it a try, the baby seemed to accept it well, and the head shape dramatically returned to normal!

This success led me to the Orthotics Departments at the University of Washington and the Children's Hospital and Regional Medical Center where I met Diane Simons. Diane was very interested in this treatment idea. We both felt that the overall concepts were adequate but that more refined materials were needed. Diane suggested making the positive out of plastic and vacuum-forming the helmet to the form. It took a while to find the right plastic that would be rigid over the convexities of the head so the weight of the head would not deform the helmet shape yet stretchy enough to allow for easy on/off placement.

This technical problem solved, we proceeded to treat children as needed. We discussed our experiences and success at academic meetings and published our first results in 1978 and 1981. ^1,2 There was only minimal interest at first. A few of my colleagues in dysmorphology/genetics or craniofacial programs learned our techniques and made helmets available in their clinics. Real interest in plagiocephaly correction did not occur until the mid-1990s with the dramatic increase in positional plagiocephaly at that time.

However, having a treatment that works leads to many other questions. Children present with gradations in head shape distortion from mild to severe. How can we measure and classify the asymmetry accurately and consistently? What is the natural history of the condition? Which infant head shapes will self-correct and which will not? Are there other cofactors or confounders besides the degree of distortion that need to be appreciated in predicting spontaneous recovery? What is the long-term effect on the growth of the craniofacies and on personality development when plagiocephaly is persistent?

What is the right age to begin treatment so that natural improvement has had time to take effect, thus avoiding overtreatment? When is it really too late to treat? How long each day must the infants wear the form?

Is there an increased incidence of mild brain dysfunction in children who had positional plagiocephaly? Is the limited spontaneous movement of the neck in children with plagiocephaly the first sign of developmental trouble? Does the brain shaping that happens as plagiocephaly occurs hurt the brain? Is therapeutic reshaping of the head truly benign?

With the rapid expansion in products designed to reshape the head, there are different assertions about the mechanisms of molding action (active vs. passive) and claims about important design or shape differences in the helmet or band that is used. Can we scientifically and fairly assess these differences?

Finally, the most important question: can we prevent plagiocephaly from occurring in the first place?

It is unfortunate that so little real progress has been made in addressing these questions over the last 20 years. I think a major limiting factor has been our difficulty to accurately and consistently measure the growing cranium. Linear measurements can be inaccurate in a squirming infant, and there are no stable landmarks on the expanding cranium to use for reliable repeated measure with age. Computed tomography and magnetic resonance imaging studies are expensive, have some level of potential harm, and are not otherwise generally medically necessary. New scanning equipment will offer us the opportunity to have consistent measures. There is much active work on this topic now. As these measures are perfected and accepted, hopefully the answers to these questions can be more coherently addressed.

Correspondence to: Sterling Clarren, MD, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA.

STERLING CLARREN, MD, is affiliated with the University of Washington School of Medicine, Seattle, WA.

References:

Clarren SK, Smith DW, Hanson JW. Helmet treatment for plagiocephaly and congenital muscular torticollis. J Pediatr 1979;94:43–46.
Clarren SK. Plagiocephaly and torticollis: etiology natural history and helmet treatment. J Pediatr 1981;98:92–95.