Child's Nervous System

, Volume 31, Issue 9, pp 1547–1552 | Cite as

Long-term outcomes in treatment of deformational plagiocephaly and brachycephaly using helmet therapy and repositioning: a longitudinal cohort study

  • Sybill D. Naidoo
  • Gary B. Skolnick
  • Kamlesh B. Patel
  • Albert S. Woo
  • An-Lin Cheng
Original Paper



Deformational plagiocephaly and/or brachycephaly (DPB) is a misshapen head presenting at birth or shortly thereafter, caused by extrinsic forces on an infant’s malleable cranium. There are two treatment methods available for DPB: helmeting and repositioning. Little is known about the long-term outcomes of these two treatment options. The purpose of this study was to examine children who received helmeting or repositioning therapy for DPB as infants and compare the long-term head shape outcomes of the two groups.


A longitudinal cohort study design was used to evaluate change in head shape of the two groups. One hundred children (50 helmeted, 50 repositioned) were initially evaluated at 6 months or younger for DPB. Anthropometric skull measurements taken as infants before treatment were compared with measurements taken for this study. Inclusion criteria included initial clinic visit at age 6 months or younger, evaluation by the same practitioner, and current age 2–10 years. Cephalic index and cranial vault asymmetry were calculated based on caliper measurements.


Data from 100 children were evaluated for this study. Significant differences between the treatment groups in the mean change in cephalic index (p = 0.003) and cranial vault asymmetry (p < 0.001) were found; the children that used helmet therapy demonstrated greater improvement.


This is one of the larger published long-term outcome studies comparing children that used helmets and repositioning to treat their DPB as infants. The data suggest that infants will have more improvement in head shape with a helmet than with repositioning.


Deformational plagiocephaly Brachycephaly Positional plagiocephaly Non-synostotic plagiocephaly Long-term outcomes Plagiocephaly treatment 



Mary Michaeleen Cradock, PhD

Maithe Enriquez, PhD, RN, ANP

Alex A. Kane, MD

Patricia J. Kelly, PhD, MPH, APRN


This study was funded by grants from the National Association of Pediatric Nurse Practitioners (NAPNAP) Foundation and St. Louis Children’s Hospital Foundation.

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    NIH. US Department of Health and Human Services. National Institutes of Health. Eunice Kennedy Shriver National Institute of Child Health and Human Development. Safe to Sleep Public Educaion Campaign.
  2. 2.
    Barnes-Josiah DL, Eurek P, Huffman S, Heusinkvelt J, Severe-Oforah J, Schwalberg R (2007) Effect of "this side up" T-shirts on infant sleep position. Matern Child Health J 11:45–48CrossRefPubMedGoogle Scholar
  3. 3.
    Colson ER, Levenson S, Rybin D, Calianos C, Margolis A, Colton T et al (2006) Barriers to following the supine sleep recommendation among mothers at four centers for the Women, Infants, and Children Program. Pediatrics 118:e243–e250CrossRefPubMedGoogle Scholar
  4. 4.
    Ray BJ, Metcalf SC, Franco SM, Mitchell CK (1997) Infant sleep position instruction and parental practice: comparison of a private pediatric office and an inner-city clinic. Pediatrics 99:E12CrossRefPubMedGoogle Scholar
  5. 5.
    Goetter MC, Stepans MB (2005) First-time mothers' selection of infant supine sleep positioning. J Perinat Educ 14:16–23PubMedCentralCrossRefPubMedGoogle Scholar
  6. 6.
    de Ribaupierre S, Vernet O, Rilliet B, Cavin B, Kalina D, Leyvraz PF (2007) Posterior positional plagiocephaly treated with cranial remodeling orthosis. Swiss Med Wkly 137:368–372PubMedGoogle Scholar
  7. 7.
    Gill D, Walsh J (2008) Plagiocephaly, brachycephaly and cranial orthotic devices: misshapen heads and helmets. Arch Dis Child 93:805–807CrossRefPubMedGoogle Scholar
  8. 8.
    Lee WT, Richards K, Redhed J, Papay FA (2006) A pneumatic orthotic cranial molding helmet for correcting positional plagiocephaly. J Craniofac Surg 17:139–144CrossRefPubMedGoogle Scholar
  9. 9.
    Xia JJ, Kennedy KA, Teichgraeber JF, Wu KQ, Baumgartner JB, Gateno J (2008) Nonsurgical treatment of deformational plagiocephaly: a systematic review. Arch Pediatr Adolesc Med 162:719–727CrossRefPubMedGoogle Scholar
  10. 10.
    Kane AA, Mitchell LE, Craven KP, Marsh JL (1996) Observations on a recent increase in plagiocephaly without synostosis. Pediatrics 97:877–885PubMedGoogle Scholar
  11. 11.
    Saeed NR, Wall SA, Dhariwal DK (2008) Management of positional plagiocephaly. Arch Dis Child 93:82–84CrossRefPubMedGoogle Scholar
  12. 12.
    Seruya M, Oh AK, Taylor JH, Sauerhammer TM, Rogers GF (2013) Helmet treatment of deformational plagiocephaly: the relationship between age at initiation and rate of correction. Plast Reconstr Surg 131:55e–61eCrossRefPubMedGoogle Scholar
  13. 13.
    Lipira AB, Gordon S, Darvann TA, Hermann NV, Van Pelt AE, Naidoo SD et al (2010) Helmet versus active repositioning for plagiocephaly: a three-dimensional analysis. Pediatrics 126:e936–e945CrossRefPubMedGoogle Scholar
  14. 14.
    Mawji A, Vollman AR, Hatfield J, McNeil DA, Sauve R (2013) The incidence of positional plagiocephaly: a cohort study. Pediatrics 132:298–304CrossRefPubMedGoogle Scholar
  15. 15.
    Najarian SP (1999) Infant cranial molding deformation and sleep position: implications for primary care. J Pediatr Health Care 13:173–177CrossRefPubMedGoogle Scholar
  16. 16.
    McGarry A, Dixon MT, Greig RJ, Hamilton DR, Sexton S, Smart H (2008) Head shape measurement standards and cranial orthoses in the treatment of infants with deformational plagiocephaly. Dev Med Child Neurol 50:568–576CrossRefPubMedGoogle Scholar
  17. 17.
    van Vlimmeren LA, van der Graaf Y, Boere-Boonekamp MM, L'Hoir MP, Helders PJ, Engelbert RH (2007) Risk factors for deformational plagiocephaly at birth and at 7 weeks of age: a prospective cohort study. Pediatrics 119:e408–e418CrossRefPubMedGoogle Scholar
  18. 18.
    Argenta L, David L, Thompson J (2004) Clinical classification of positional plagiocephaly. J Craniofac Surg 15:368–372CrossRefPubMedGoogle Scholar
  19. 19.
    Bialocerkowski AE, Vladusic SL, Howell SM (2005) Conservative interventions for positional plagiocephaly: a systematic review. Dev Med Child Neurol 47:563–570CrossRefPubMedGoogle Scholar
  20. 20.
    Blaser SI (2008) Abnormal skull shape. Pediatr Radiol 38(Suppl 3):S488–S496CrossRefPubMedGoogle Scholar
  21. 21.
    Bialocerkowski A (2008) Physiotherapy reduces the risk of deformational plagiocephaly in infants who have a preferred head position when lying supine. Aust J Physiother 54:283CrossRefPubMedGoogle Scholar
  22. 22.
    Looman WS, Flannery AB (2012) Evidence-based care of the child with deformational plagiocephaly, part I: assessment and diagnosis. J Pediatr Health Care 26:242–250, quiz 51-3 CrossRefPubMedGoogle Scholar
  23. 23.
    Losee JE, Mason AC, Dudas J, Hua LB, Mooney MP (2007) Nonsynostotic occipital plagiocephaly: factors impacting onset, treatment, and outcomes. Plast Reconstr Surg 119:1866–1873CrossRefPubMedGoogle Scholar
  24. 24.
    Oh AK, Hoy EA, Rogers GF (2009) Predictors of severity in deformational plagiocephaly. J Craniofac Surg 20(Suppl 1):685–689CrossRefPubMedGoogle Scholar
  25. 25.
    Graham JM Jr, Gomez M, Halberg A, Earl DL, Kreutzman JT, Cui J et al (2005) Management of deformational plagiocephaly: repositioning versus orthotic therapy. J Pediatr 146:258–262CrossRefPubMedGoogle Scholar
  26. 26.
    Lee RP, Teichgraeber JF, Baumgartner JE, Waller AL, English JD, Lasky RE et al (2008) Long-term treatment effectiveness of molding helmet therapy in the correction of posterior deformational plagiocephaly: a five-year follow-up. Cleft Palate Craniofac J 45:240–245CrossRefPubMedGoogle Scholar
  27. 27.
    Carter MR (2008) Head moulding for plagiocephaly. Arch Dis Child 93:809–810CrossRefPubMedGoogle Scholar
  28. 28.
    Singh A, Wacogne I (2008) What is the role of helmet therapy in positional plagiocephaly? Arch Dis Child 93:807–809CrossRefPubMedGoogle Scholar
  29. 29.
    Teichgraeber JF, Seymour-Dempsey K, Baumgartner JE, Xia JJ, Waller AL, Gateno J (2004) Molding helmet therapy in the treatment of brachycephaly and plagiocephaly. J Craniofac Surg 15:118–123CrossRefPubMedGoogle Scholar
  30. 30.
    Rogers GF (2011) Deformational plagiocephaly, brachycephaly, and scaphocephaly. Part I: terminology, diagnosis, and etiopathogenesis. J Craniofac Surg 22:9–16CrossRefPubMedGoogle Scholar
  31. 31.
    Tatum SA, Jones LR, Cho M, Sandu R (2012) Differential management of scaphocephaly. Laryngoscope 122:246–253CrossRefPubMedGoogle Scholar
  32. 32.
    Kluba S, Schreiber R, Kraut W, Meisner C, Reinert S, Krimmel M (2012) Does helmet therapy influence the ear shift in positional plagiocephaly? J Craniofac Surg 23:1301–1305CrossRefPubMedGoogle Scholar
  33. 33.
    Robinson S, Proctor M (2009) Diagnosis and management of deformational plagiocephaly. J Neurosurg Pediatr 3:284–295CrossRefPubMedGoogle Scholar
  34. 34.
    Rogers GF, Miller J, Mulliken JB (2008) Comparison of a modifiable cranial cup versus repositioning and cervical stretching for the early correction of deformational posterior plagiocephaly. Plast Reconstr Surg 121:941–947CrossRefPubMedGoogle Scholar
  35. 35.
    Bruner TW, David LR, Gage HD, Argenta LC (2004) Objective outcome analysis of soft shell helmet therapy in the treatment of deformational plagiocephaly. J Craniofac Surg 15:643–650CrossRefPubMedGoogle Scholar
  36. 36.
    Hutchison BL, Stewart AW, Mitchell EA (2011) Deformational plagiocephaly: a follow-up of head shape, parental concern and neurodevelopment at ages 3 and 4 years. Arch Dis Child 96:85–90CrossRefPubMedGoogle Scholar
  37. 37.
    Steinbok P, Lam D, Singh S, Mortenson PA, Singhal A (2007) Long-term outcome of infants with positional occipital plagiocephaly. Childs Nerv Syst 23:1275–1283CrossRefPubMedGoogle Scholar
  38. 38.
    van Wijk RM, van Vlimmeren LA, Groothuis-Oudshoorn CG, Van der Ploeg CP, Ijzerman MJ, Boere-Boonekamp MM (2014) Helmet therapy in infants with positional skull deformation: randomised controlled trial. BMJ 348:g2741PubMedCentralCrossRefPubMedGoogle Scholar
  39. 39.
    Block SL (2012) 'Skull-duggery' and the management of positional plagiocephaly. Pediatr Ann 41:497–501CrossRefPubMedGoogle Scholar
  40. 40.
    Kluba S, Kraut W, Calgeer B, Reinert S, Krimmel M (2014) Treatment of positional plagiocephaly—helmet or no helmet? J Craniomaxillofac Surg 42:683–688CrossRefPubMedGoogle Scholar
  41. 41.
    Mendonca DA, Naidoo SD, Skolnick G, Skladman R, Woo AS (2013) Comparative study of cranial anthropometric measurement by traditional calipers to computed tomography and three-dimensional photogrammetry. J Craniofac Surg 24:1106–1110CrossRefPubMedGoogle Scholar
  42. 42.
    Skolnick GB, Naidoo SD, Patel KB, Woo AS (2014) Analysis of digital measures of cranial vault asymmetry for assessment of plagiocephaly. J Craniofac Surg 25:1178–1182CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2015

Authors and Affiliations

  • Sybill D. Naidoo
    • 1
  • Gary B. Skolnick
    • 1
  • Kamlesh B. Patel
    • 1
  • Albert S. Woo
    • 1
  • An-Lin Cheng
    • 2
  1. 1.Cleft Palate and Craniofacial Deformities Institute, Division of Plastic and Reconstructive SurgeryWashington University School of MedicineSt. LouisUSA
  2. 2.School of Nursing and Health StudiesUniversity of Missouri–Kansas CityKansas CityUSA

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