Positional flattening is very common, affecting up to 40% of infants since the Back to Sleep campaign began in 1992. There is now prospective, randomized control trial evidence that helmeting is no better at improving head shape in mild to severe positional flattening compared with physical therapy and providing general positioning recommendations such as maximizing tummy time while awake, and limiting time in swings and car seats. New guidelines from the Congress of Neurological Surgeons, following a systematic literature review including a review of the randomized trial mentioned above, consider helmeting as an option for severe cases of positional flattening. The prevalence of positional flattening in teens from the era following the Back to Sleep campaign but before helmets were widely used was less than 2%, suggesting that regardless of both the intervention used and the severity of the flattening, the vast majority of cases of positional flattening will cosmetically normalise. The cost of helmeting is also significant; a helmet costs thousands of dollars, and requires frequent adjustments over several months to adjust to an infant’s growing head. There are also risks associated with helmeting, including pressure sores and interference with parental attachment. With its associated high cost and only very weak evidence of benefit in treating positional flattening, there is no clear additional value in recommending helmets for infants with mild to severe positional flattening in addition to traditional positioning recommendations and physiotherapy.
Sources:
Kmietowicz Z. Expensive helmets do not correct skull flattening in babies. BMJ. 2014 May 1;348:g3066. PMID: 24791750.
Roby BB, et al. Prevalence of positional plagiocephaly in teens born after the “Back to Sleep” campaign. Otolaryngol Head Neck Surg. 2012 May;146(5):823-8. PMID: 22241785.
Tamber MS, et al. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline on the Role of Cranial Molding Orthosis (Helmet) Therapy for Patients With Positional Plagiocephaly. Neurosurgery. 2016 Nov;79(5):E632-E633. PMID: 27776089.
van Wijk RM, et al. Helmet therapy in infants with positional skull deformation: randomised controlled trial. BMJ. 2014 May 1;348:g2741. PMID: 24784879.