Flat head? Helmets aren’t the answer

The Pediatric Insider

© 2014 Roy Benaroch, MD

International campaigns to reduce the incidence of Sudden Infant Death Syndrome (SIDS) have been very successful, with reductions of 50% or more in just about every country that’s pursued public education campaigns. Putting babies “back to sleep” is now ingrained in the public psyche. It’s saving lives.

But an unintended consequence has been an increase in babies with flattened heads. Doctors, who need a different word for everything, call this “plagiocephaly”, and it’s almost always caused by prolonged periods of unequal pressure on the growing cranium. If Junior sleeps on his back with his head turned to his right, the back/left of his head will always be pressed down into the bed. Over time, that side will become flatter. Over more time, if steps aren’t taken to correct this, the left ear and the left side of the forehead will shift forward. Viewed from above, the head of a baby with this kind of “positional plagiocephaly” will look like a parallelogram.

This kind of plagiocephaly—caused by pressure on the head, in the shape of a parallelogram—does not cause any developmental or brain problems. The significance is entirely cosmetic. If severe, it can be quite noticeable, but mild to moderate plagiocephaly has minimal if any cosmetic impact and no health consequences whatsoever.

Still, moderate-to-sever plagiocephaly is noticeable, and parents and pediatricians have been eager to find ways to correct it. One treatment that’s become very common is the use of a custom-made, lightweight fiberglass “helmet” that’s worn throughout the day and night. As baby’s head continues to grow, the thinking goes, it will grow into the nice round shape of the inside of the helmet. Problem solved?

But what seems to work, or what you think is likely to work, might not really work. That’s what practicing medicine is all about. We have to test our therapies and ideas, studying them objectively and impassively. We want it to work, it seems like it works, it makes sense that it does work. But does it really make any difference?

Researchers from The Netherlands just published a randomized clinical study, “Helmet therapy in infants with positional skull deformation: randomised controlled trial”. 84 infants who were already enrolled in conservative programs to address moderate-to-severe skull deformity were randomized at 5 months of age to either get fitted with a molding helmet, or to just continue monitoring alone. Helmets were worn for 23 hours a day for six months, with the helmets being re-fashioned and adjusted as the children grew.

Some red flags popped up early on. 403 infants were deemed eligible for the study, but only 21% of their parents agreed to participate—most of the parents did not want to consider joining a study where there child could be randomized to not receiving a helmet. And as the study went on, 100% of the helmet children reported what were considered significant side effects, including skin irritation, pain, decreased cuddling, and unpleasant odors from the helmets.

Still, almost all of the families assigned helmets completed the study and were compliant with therapy, and almost all of them had a full reassessment at 24 months of age to compare helmeted children with those that were just watched. What was found was stark. Use of the helmet made no difference in any measure of head shape. Unbiased observers, who didn’t know which treatment group the children were in, found that measures of head asymmetry were identical. The helmets just didn’t make any difference. Among children who wore a helmet versus those who didn’t, the same degree of improvement was seen, though complete resolution of head asymmetry was seen in only about 24% of patients in both groups. Overall, parents from both groups were equally satisfied with the improvement in their childrens’ head shape.

So what really should be done to deal with positional plagiocephaly? First, a fear of plagiocephaly should not discourage parents from setting their babies down to sleep on their backs. Safe sleeping is preventing thousands of SIDS deaths. But are ways to encourage safe sleep that won’t increase your baby’s risk of a flat head. Rotate the position of sleep, by putting Junior’s head on alternating nights and naps first at one end, then the other end of the crib. Junior will turn his head to look into the room, at the interesting parts. If his head is always on top of the bed, he’ll be looking over the same shoulder all of the time. Sometimes, place him with his head at the bottom of the crib.

Don’t use any sleep positioners—they’re not needed, and make sleep more dangerous. Don’t routinely sleep your child in a car seat, bouncy seat, or sling-shaped positioner—these can all increase the risk of plagiocephaly, and are not safe. Encourage tummy time when infants are young, and upright/sitting play when they’re a little older and ready for it.

Some children with plagiocephaly have a physical problem with the muscles in their necks, which prevents equal rotation to either side. These babies sit with their heads cocked to one side, and sometimes have a thickening you can feel in the muscle along one side of the neck. This is called “torticollis,” and can usually be treated with physical therapy.

If you’re concerned about your child’s head shape, make sure to bring it up with your doctor. Rarely, head shape problems can be a sign of a medical problem that needs to be addressed. Usually, though, a few simple steps at sleep and play times can help head shapes improve—apparently, just as much as an expensive, sweaty, unpleasant head helmet. Sometimes less is more. You don’t have to have your child helmeted for six months to get a fine looking head. Nice to know, and one less thing to worry about!

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9 Comments on “Flat head? Helmets aren’t the answer”

  1. araikwao Says:

    So I just enthusiastically shared this on Facebook, as I’m a big fan, and this is a population I have worked with in the past, and one of my orthotist colleagues linked me to the original article, which I have looked through…and I think that having only 10 of 30 complete the helmet therapy to 12 months, and the unknown compliance make drawing firm conclusions from this impossible. (Although what do you think about the potential for impact on head shape between the ages of 10 and 12 months? Is it likely it would make much difference?) It just looks to me like another sketchy study that doesn’t add a huge amount to the existing body of sketchy literature on the topic.


  2. Dr. Roy Says:

    araikwao, I linked to the study in the post (it’s available to all, free access, way to go BMJ!). Link also here: http://www.bmj.com/content/348/bmj.g2741

    Overall compliance w/ followup was excellent, with 75 of the 84 randomized children getting full re-evals at 12 mos after conclusion.

    Tho only 10 of 30 kept using the helmets until 12 mos, the most common reason to stop was that parents were satisfied w/ head shape. The average use was until ~ 10 mos of age. So there was plenty of time for the helmets to help, if they did.

    I don’t think this is a “sketchy” study. It’s a realistic study looking at how these interventions are used in the real world.


  3. So do you ever feel these helmets are appropriate for children? As a mother, I have seen many friends get these helmets for their children- almost to the point of them seeming ‘trendy’, which is concerning. I do wonder if there are populations that legitimately need them in your opinion? (Ie, preemies who spend lots of time in NICU)


  4. Dr. Roy Says:

    There do seem to be babies who benefit from these– especially babies with special needs, neuromuscular conditions, torticollis, and preemies with narrow heads. We need better studies to figure out who benefits most. That they don’t benefit the kinds of babies that underwent this study doesn’t mean they couldn’t help in some circumstances.

    And you’re right– these helmets are being marketed directly to families to prey on parental fears, and they do seem to be becoming a trend. Imagine that, something that is a genuine health issue for a few becomes marketed in such a way that lots of people jump on the bandwagon. Gluten, anyone?


  5. Lulu saber Says:

    I’ve noticed my dd flathead when she was about 2 months she hated tummy time and as she stared to sit play and crawl the results were not that pleasant to me maybe her head is less flatter just a bit idk ,she’s 10 month now and I’m terrified I haven’t seen babies with flat head and what calms me that I’ve never seen grownups with flat head , her flat spot isnt disturbing to me but what’s really really disturbing is that her left side of the head is pointy . In my country there is no helmet therapy or craniosacral therapy or physical therapy to help torticollis but her neck muscles are fine I knew how to deal with it when i first realized that she wouldn’t move her neck the the other side sorry for the long post but I’m really lost I’m afraid that it’s too late for my baby head to get normal I don’t want it to effect her


  6. Stephanie Says:

    My son was using the helmet for three months, and just like braces, as soon as it came off, his head shape went right back to the shape it was before 😔 It’s super flat on the right side and now I don’t know what to do, he is 13 months


  7. Roberta Whatelli Says:

    My daughter has been in a helmet for 12 months. She started at 5 months and is now 17 months. She has worn is exactly as directed the entire time. She is still in the “severe” category for both plagio and brachycephaly, and, while I wouldn’t say she looks severely disfigured, she does have noticeable wideness and flatness to her head. She is about to get helmet #3, but they have told us there is less than 50% chance of it doing anything at her age. HELP! What else can we do? You say that most children improve regardless of helmet therapy or no helmet therapy. What do you do about the ones who DON’T improve in spite of helmeting? Craniosynostosis was ruled out on visual observation, so we know that’s not a contributing factor. What else can we do? There HAS to be something…..


  8. Dr. Roy Says:

    Roberta, these are questions for your physicians. Ask them. If you’re not getting satisfying answers, ask for a referral for a second opinion or a specialist (eg neurosurgeon).


  9. Roberta Whatelli Says:

    So, what if you’re the parent of a child who didn’t improve, and you are very much NOT happy with the outcome!? Nowhere have I seen this issue addressed. My daughter is 17months. She has been in a helmet for over a year. She tolerates it well, and I would not say any of the “side effects” have been significant. In fact, I’m kind of glad she has it sometimes because I don’t worry about her falling as much. But, she is still in the borderline severe category for both brachy and plagio, and it is noticeable! We’re trying to find a plastic surgeon, but none will treat children who do not have craniosynostosis. We are now looking overseas for a plastic surgeon who is willing to treat children for cosmetic skull reshaping with burr reduction and hydroxyapetite cement augmentation.


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