Helping Babies With Plagiocephaly Through Cranial Helmet Treatment

When the American Academy of Pediatrics implemented the Back to Sleep Program in 1992 to decrease the risk of sudden infant death syndrome, researchers and clinicians began to see a rise in the number of infants with asymmetrically shaped skulls. Autumn Tatum, CO, Hanger Clinic, Dayton, Ohio, has spent her career treating infants with congenital muscular torticollis, plagiocephaly, brachycephaly, and other conditions. While there has been a decrease in sudden infant death syndrome since the Back to Sleep Program was launched, “[there has been] an increase in head shape asymmetries,” Tatum says. “It’s been noted that nearly half of the infants born today will have some positional asymmetry, although this does not always mean a need for cranial treatment.” The O&P EDGE reached out to two families with children under Tatum’s care to share their experiences with torticollis, plagiocephaly, and brachycephaly through discovery, diagnosis, and treatment. Dorene Ritchie Dorene was born prematurely in Trenton, Ohio, on Christmas Day 2020, at 35 weeks of gestation. “I had so much amniotic fluid that it was actually pressing on her, sending nutrients and blood supply back to me and not allowing her to move around much,” her mother, Bethany Ritchie, recalls. [caption id="attachment_235962" align="alignright" width="300"] Dorene. Photograph courtesy of Bethany and Kevin Ritchie. [/caption] Ritchie says her husband, Kevin, noticed almost immediately after Dorene was born that her head appeared to be misshapen. “Her head was flat on one side,” Ritchie says. “But I thought it would eventually pop out.” Ritchie noticed her infant daughter seemed to favor one side over the other but wasn’t immediately concerned. “I really didn’t think anything of it because everyone has a favorite side,” she says. “I assumed once she became more active and started crawling, her head shape would change since she wasn’t on it as much.” By the time Dorene was six months old, however, there was little improvement. She was diagnosed with plagiocephaly and torticollis, began physical therapy, and was measured for a cranial remolding orthosis—commonly referred to as a cranial helmet. Ritchie followed up with Dayton Children’s Hospital where neurosurgery was considered to rule out any fusion of the skull. Ritchie says the thought of neurosurgery frightened her and her husband. “I was never all right with that second option,” she says. “Neurosurgery on an infant? Super scary thought. So we chose the helmet.” At Hanger, Dorene began seeing Tatum, who is studying to become a prosthetist/orthotist. Tatum specializes in pediatric patients with orthotic management needs, including cerebral palsy, spina bifida, and cranial molding orthoses. “I love working with my youngest patient population and their families,” she says. “One of the most rewarding aspects is being able to tell families that their child is growing in their orthoses and improving.” The average length of treatment with a cranial molding orthosis for deformational plagiocephaly is three to six months, depending on the severity of the patient’s asymmetry, Tatum says, as well as how old the patient is at the start of treatment. As Dorene waited for her helmet to be ready, Ritchie says she helped her daughter with stretches and other exercises. “I would put all of her toys on the other side that she didn’t want to lay on,” she says. “I would hold her in different positions that would force her to lay on the other side. I would try to lay her down toward the wall so she would have to lay on the other side to look at the other things.” That didn’t work for Dorene. “She would always flip and roll onto the side she liked,” says Ritchie, who chose for Dorene to wear the cranial helmet because she says the neurologist “almost guaranteed it would work since her suture lines hadn’t fused yet and it [the helmet] had a high percentage rate of success.” An infant’s long diagonal measurements typically fall within zero to three millimeters if they do not present with a visible cranial asymmetry, Tatum says. When Dorene started wearing her helmet at six months old, she started at a measurement of 21. She wore the helmet 23 hours a day, every day of the week, for seven months, and at an appointment near the end of 2021, her measurement had dropped to six millimeters. “Dorene has done an amazing job with the helmet,” Ritchie says. “Autumn has told me that going from 21 to six is astonishing. We’re hoping for a four at her next appointment and to begin tapering down use of the helmet, which means hopefully within the next two months she will be done wearing the helmet.” At the following appointment on February 16, which turned out to be Dorene’s last, her measurement was a five. “That’s it,” Ritchie says. “We graduated. We’re done. No more helmet, no more checkups.” Landen Russell While the experience of torticollis, plagiocephaly, and cranial helmets was something the Ritchies never had with their other children, it was not the first time for Makayla and Makayla Russell. [caption id="attachment_235963" align="alignright" width="300"] Landen. Photograph courtesy of Makayla and Makayla Russell. [/caption] The couple’s baby boy, Landen, was born at 41 weeks in Franklin, Ohio, in the summer of 2021 with congenital torticollis. He was also born with congenital asymmetry on the same side that has the torticollis, which he still has. “Within a few weeks after birth, we noticed he was developing plagiocephaly,” Russell says. The couple was able to recognize their son’s condition almost as soon as he was born. Russell is a licensed social worker and carried Landen. Her wife is a registered nurse who works in a transitional care unit and has extensive experience with cranial helmets. She cares for chronic patients with extended hospital stays. “One of our foster kids was born at 24 weeks and remained in the hospital until she was six months old,” Russell says. “As a result, she had severe brachycephaly. She had physical therapy, which was successful.” Landen was referred to physical therapy when he was six weeks old to work on correcting the torticollis, Russell says. Typically, by restoring muscular balance at the neck there is passive correction of plagiocephaly noted. “There was limited improvement with physical therapy,” she says. “So, we decided to inquire about the helmet.” Landen was seen for a neurosurgery consult and received a referral to the Hanger Clinic as he was in the severe range of brachycephaly, Russell says. “We started physical therapy and began working on stretches to correct the torticollis,” she says. “We also limited time on his back and implemented frequent use of a floor seat.” Russell says she and her partner decided to use a helmet because no significant changes were noted during physical therapy. “We knew a helmet would fix his condition,” she says. “It wasn’t guaranteed that without a helmet his brachycephaly would correct on its own.” They take their son to Tatum every three weeks for his appointments. Landen’s head shape has already started to improve and is beginning to round out, Russell says. When he was first seen by neurosurgery, his brachycephaly with a cephalic index was 99.6 percent. At Landen’s five-month follow-up, his cephalic index was 95.8 percent, at six months it was 92.4 percent, and following his latest appointment in February, it was 91 percent. Landen will continue to wear his helmet 23 hours every day until his cephalic index is between 80 and 84 percent. There have been a few hiccups in the journey as Landen was potentially allergic to the foam in his first helmet. “He developed some kind of weird rash,” Russell says. Tatum made a new helmet with a different type of foam, which Landen is able to tolerate better. What Causes Plagiocephaly? There are several potential causes of deformational plagiocephaly, Tatum says, such as restrictive intrauterine positioning, being a twin or triplet, cervical abnormalities, birth trauma, or torticollis. Torticollis is typically associated with plagiocephaly as torticollis causes limited range of motion to the sternocleidomastoid muscle on one side of the infant’s neck, Tatum says. Torticollis can be caused by intrauterine positioning and/or birth trauma. “Torticollis, like plagiocephaly, may be identified by parents first, but then is typically diagnosed by their pediatrician during a well-baby visit,” Tatum says. “No matter how old the patient is, the first step for treating their torticollis is to begin physical therapy to address the limited range of motion of the baby’s head and neck.” Every Baby Is Unique Every presentation is different for this time-sensitive patient population, Tatum says, and should be treated as such. “As an experienced cranial clinician, I have the discussion with each of my patients to establish expectations prior to beginning treatment,” she says. There are additional standards for a specialist in Hanger’s Cranial Asymmetry Remolding Experts (CARE) network, Tatum says. Hanger gives clinicians additional cranial education for treatment of plagiocephaly and requires them to complete additional training and mentorship prior to providing independent care to infants, she says. “I am thankfully a part of this network.” With the use of a cranial remolding orthosis compliance is key for treatment outcomes and the orthosis should be worn for 23 hours per day, Tatum recommends. The Ritchies and the Russells only remove their children’s helmets when they bathe them and to wash the helmets. In addition to compliance, ensuring patients attend follow-up appointments with their orthotists to ensure the helmet is fitting properly is paramount, Tatum says. “This includes taking measurements and making adjustments as needed,” she says. “A family’s rapport with their orthotist, whose job includes discussing how their child is doing and clarifying questions as they come, is also critical,” Tatum says. “If all four aspects come together, typically great results can be achieved.” Betta Ferrendelli can be contacted at betta@opedge.com.

Helping Babies With Plagiocephaly Through Cranial Helmet Treatment

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