Pediatric Custom Made Cranial Orthesis (Helmet)

Asymmetric or deformed cranial shape constitutes an important problem among infants and small children. This situation is frequent and usually recognised by pediatricians and primary health care professionals or other healthcare personnel, working in routine health controls of children. In most situations parents may also notice this problem. In general practice, the term "plagiocephaly" is used for most of the cranial shape asymmetries usually. This term comes from the Latin words plagio = bent or leaning to one side, askew and cephalus= head.

Asymmetric or deformed cranial shape should be evaluated by a specialist. In this field, the most recommended specialists are neurosurgeons, the ones especially experienced in pediatric cases. Pediatric neurosurgeons do successfully recognize this situation.

There are two main causes that result in asymmetric or deformed cranial shape.

The first cause is a disease called "craniosynostosis". This is a condition in which the infant skull's joints or sutures close prematurely or born as fused. This condition is usually diagnosed early and needs to be corrected surgically.   

The second main cause is the deformation of the cranium (head) due to external forces, which is called as positional molding. Positional molding is a skull deformity developing due to exposure to mechanical factors in the mother’s womb and/or early period following the birth. One needs to distinguish whether an abnormal head shape in an infant is primarily due to craniosynostosis or associated with positional molding in terms of the appropriate treatment. In positional skull deformities, the cranial sutures are open and functional and there is no evidence of intracranial pressure increase. During an infant's first four to six months of life, the skull is naturally thin and flexible. It can easily change shape. When an infant at this stage, and regularly sleeps with his or her head in the same position, a flattening a part of the skull may occur.

Concerns of the parents and the primary care pediatricians is of paramount importance for the early diagnosis of the condition. The most important fact to know is whether the infant has a head positional preference which, results in positional molding . So, in terms of differential diagnosis, cranial deformation secondary to head positional preference or the primary disease craniosynostosis should be eliminated first by a pediatric neurosurgeon preferably. 

1- Position in the Womb: The way a baby is positioned in the womb may place pressure on the head. This is a common cause among multiple births, where space is limited.

2- Prefer to Lay Infants on Their Back: Popularized in the early 90s, back sleeping has resulted in 50% fewer sudden infant death syndrome-related deaths, yet more cases of positional molding. This usually results in plagiocephaly (asymmetric deformity as flattening of the one side of the skull) or brachycephaly (flattening of the whole back of the head).

Asymmetric or deformed cranial shape due to sleep position is seen in 1 of every 10 infants. 

3- Prematurity: Premature babies have especially soft skulls and often spend time in the neonatal intensive care unit with the head in a fixed position. Usually seen deformity is called as positional scaphocephaly, in which the head appears as pressed from both sideways and seems longer, taller and narrower than normal. 

4- Congenital Torticollis: In this situation, where one side of the neck muscles contract abnormally, the infant has a head positional preference. This results in plagiocephaly deformation and is commonly seen as an early manifestation of congenital muscular torticollis.

Plagiocephaly, or “flat head syndrome,” is expressed through three abnormal head shapes, one of which is also called plagiocephaly. These shapes can range from mild to severe and even occur in combination with one another. Plagiocephaly occurs when there are one or more areas of flatness on the baby’s head. Typically, it is also accompanied by a combination of facial asymmetry, ear shifting and forehead sloping or bulging.

The major types of cranial shape deformities are shown below. Please click on pictures to see in detail.

In mild cases or in very early stages of deformation some simple preventive measures may be applied under supervision of a medical specialist. These include:

• Active head repositioning during sleep time.
• Changing the sleeping position.
• Encouragement of ‘tummy time’ as to decrease time spend in back laying position when awake.

In moderate and prominent cases or in patients refractory to those conservative measures helmet therapy can be instituted.