To helmet or not to helmet

Managing clients with Plagiocephaly and Brachycephaly: Using 3d scanning technology to educate and empower families to decide whether to helmet or not to helmet?

Introduction

Positional Plagiocephaly and Brachycephaly, also referred to as Flat Head Syndrome, is primarily cosmetic condition. The risk factors include muscular torticollis, back sleeping, delayed milestones, prematurity, uterus/labour position and multiple gestations. The risk of not intervening may affect the physical appearance of the client including head, ear and jaw asymmetry and may provoke social and psychological concerns. Researched intervention strategies include repositioning techniques, physical therapy and cranial helmeting (Congress of Neurological Surgeons, 2016; Graham et al., 2019). Plagiocephaly is measured by the Cranial Vault Asymmetry Index (CVAI) and Brachycephaly is measured by the Cephalic Index/Ratio (CI, CR). The ideal age to helmet is from 4-10 months due to rapid head growth (Congress of Neurological Surgeons, 2016), taking into account each individual client presentation. At NovitaTech, our service aims to provide support for families who have concerns relating to their child’s head shape and offer 3D scanning for assessment for clients from 3- 12 months of age and for monitoring and/or helmeting purposes for clients aged 4-10 months.

Before introducing this service in 2019, a rapid review was conducted by Novita’s Knowledge and Innovations department to determine the clinical effectiveness of cranial helmeting for positional flat head syndrome. It found cranial reshaping orthoses can be useful and effective, however acknowledged there is conflicting evidence as to the necessity of these. Research conducted by found 3D printed helmets were better tolerated, and had increased compliance compared to traditional manufacture, and thus facilitated better clinical outcomes. It was therefore decided that Novitatech would offer a 3D cranial scanning and helmeting service.

Clinical assessment

Baby C came into our clinic at 7 months old (4.5 months adjusted) for a cranial assessment. He was born 10 weeks premature and spent his first 6 weeks of life in NICU. Due to his prolonged hospital stay he spent an increased amount of time on the back of his head, and also developed mild left side torticollis which had been resolved.

Upon initial assessment, Baby C’s guardian reported trialling repositioning techniques and pillows to reduce time on the flat spot

of his head, with minimal success. Initial observations included forehead bossing, asymmetrical ear positioning in both transverse and coronal planes and posterior one-sided flattening. The first scan indicated moderate Plagiocephaly with a CVAI of 7.90) and a normal CI (Children’s Healthcare of Atlanta, 2015). The guardian’s goal of accessing services was “ Our service aims to provide to encourage a more symmetrical head shape support for families who have and improve ear alignment. concerns relating to their Helmet or Monitor? child’s head shape and offer 3d scanning for assessment Managing expectations and anxiety is an important part of our service delivery. Families for clients from 3- 12 months express valid and real concerns about the of age and for monitoring and/ cosmetic outcomes that may occur if they don’t or helmeting purposes for intervene. The social and psychological effects clients aged 4-10 months.” could potentially be experienced by both the child and the parent (Congress of Neurological Surgeons, 2016). Simply providing support, patience and education can significantly reduce families’ anxiety and facilitate a positive clinical experience (Van Allen, Mott, McGrath & DeGrazia, 2020). This enables families to be better equipped to make the decision to monitor head shape or helmet.

Clinical justification

NovitaTech utilise the Atlanta Children’s Severity Scale (Children’s Healthcare of Atlanta, 2015) as a guideline, in conjunction with individual evaluation, including risk factors and subjective assessments, to determine if a helmet is an appropriate intervention. The treating Orthotist provides decision making guidance, but as cranial head shape is primarily a cosmetic concern, the final decision to helmet is up to the parents or

guardians. Given Baby C’s CVAI and clinical presentation, the clinical recommendation was repositioning or a cranial helmet (Children’s Healthcare of Atlanta, 2015). As the family had already trialled repositioning techniques, had real concerns about the future cosmetic outcomes, and presented with multiple risk factors, the Orthotist supported the Guardian’s decision to helmet.

Treatment plan

NovitaTech Orthotists work collaboratively with Serkel® to design treatment plans and manufacture 3D print helmets. Baby C’s helmet was designed to redirect growth by applying a gentle pressure on his high spots (Q2, Q3) whilst allowing space for growth in his flat spots (Q1, Q4). Nine days after the initial scan, the helmet was fit. Minor initial adjustments were made to the right neck nape anchor point. No further adjustments were required during the treatment period. To accurately capture Baby C’s growth, the helmet needed to be worn for 23 hours a day. The length of treatment was determined by the amount and speed of growth Baby C experienced. NovitaTech’s orthotics team would like to thank those who contributed to the establishment of the Cranial Therapy Service and to the Serkel® team for their support and guidance

Client outcomes

Baby C wore his helmet for four months and he and his guardian were compliant with wear time with no complications. Review appointments were conducted at the 1 month and 4 month mark. At 1 month, a CVAI of 5.49, mild, was measured and the family decided to continue wearing the helmet. At 4 months Baby C’s helmet no longer fit, and a final scan was obtained. His CVAI reduced to 2.68, classifying him in the normal category (Children’s Healthcare of Atlanta, 2015) and he had grown 28mm. Reduced forehead bossing, improved ear alignment and a more symmetrical head shape were observed, and this was confirmed by the results of the scan. His Guardian was very happy with the outcome and she had “no regrets”. This appointment marked that treatment had concluded.

Our primary goal providing these services is to empower families to access objective data, a thorough subjective assessment and education to make an informed healthcare decision. Many families access our services for monitoring or assessment only purposes, which offers peace of mind and awareness to the intervention options available to them.