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Response to BMJ

#plagiocephaly

Response to BMJ

BY Jon W

09 May 2014 For years we have been asking for a randomised blind controlled study on the effect of cranial remoulding treatment versus no therapy. And last week finally this was published, so why now all the bad press about cranial helmets? We welcome research in this field. We are evidence-based practitioners and as healthcare professionals, we are continually learning and developing our care pathways and treatment regimes. Whilst evidence is good, one study is unfortunately not enough. The fundamental limitations of this study are its size and that the subjects in the comparison study had moderate-severe head shape deformities. This is not our patient group. At The London Orthotic Consultancy, we mostly treat babies with severe head shape deformities where other treatments such as repositioning and manual therapies have failed.

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Brent Collett, a craniofacial specialist at the Seattle Children’s Research Institute wrote in an editorial in the BMJ that future studies, including larger samples, would be helpful in determining whether some infants respond more favourably than others. In particular, it would be of interest to learn whether children with the most severe positional plagiocephaly and brachycephaly, who were excluded from this trial, show meaningful improvement. Ari Brown, a paediatrician from Texas said she sees an area for future research on children with more severe plagiocephaly. ‘This is where helmets make the most difference’. The study reports that no infants with torticollis or dysmorphic features were included. However, many of the babies we see in our assessments have these clinical presentations and once again have not responded to repositioning and manual therapy techniques. We also assess infants who have moderate-severe head shape deformities. Following assessment of each infant, correct repositioning advice is provided so that many of this group goes onto achieve natural correction without orthotic intervention. It is reported that in neither group did the head shape normalise at the end of the trial and at 2 years old only about a quarter in both groups reached a normal head shape. We disagree, all infants we treat achieve statistically significant improvements to their head shapes and many progress to a head shape within the normal range at the end of their treatment. Much was reported on the side effects of helmet treatment. Side effects of helmets are minimal and temporary. Skin irritation reported as the major side effect in the study is usually nothing more than a mild sweat rash where Sudocrem is all that is required to treat it. We discuss all possible side effects with parents at the beginning of the treatment so they are fully aware of what can happen before making a decision. Unfortunately, this has been hugely exaggerated in the press surrounding the research last week.

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What is Positional Plagiocephaly? Plagiocephaly Brachycephaly Plagiocephaly Treatment     We cannot ignore the influx of parents contacting us for help, who have children of primary and even secondary school age where their children’s head shapes have not improved, despite the advice they received from their GP and health visitors that it would self-correct. Unfortunately, we cannot help these families when the child is older than 18 months. But when a child is less than 18 months we can offer help with correct repositioning advice and cranial remoulding therapy where clinically appropriate. Treatment is most effective when it is started between 4 and 7 months and we are concerned that bad press about this research may lead to parents delaying treatment. Mrs. Sally Hews
BSc (Hons) SROtho MBAPO
Orthotist

FAQs:

How frequently do we need to attend reviews?

This is very much dependent on how fast your baby is growing. The faster the growth, the more frequently your baby will be seen so that the helmet can be adjusted. In general, reviews will happen at two to four-week intervals.

What does the price of the treatment cover?

The price of treatment covers: all your baby’s required appointments from start to the end of treatment, no matter how many are required to achieve the improvement in head shape that you are happy with; the cost of manufacturing the LOCband and supply of appropriate cleaning fluid for the band; all reports to your GP/paediatrician/ cranial osteopath/physiotherapist, including a final scan report with objective measurements of change achieve; full telephone support from your clinician during treatment, and, if necessary, extra review appointments at short notice.

Does cranial remoulding therapy really work?

Yes - All babies that have completed their course of treatment with us have achieved a measurable improvement in head shape. However, you don’t have to take our word for it.
Recent independent research conducted by a University Hospital in Germany has endorsed the treatment for babies with moderate or severe plagiocephaly. A larger, retrospective study has just been published that found complete correction was achieved in 94.4% of babies treated with helmet therapy. The results were conclusive: repositioning achieved acceptable correction in 77.1% of cases, but 15.8% were moved onto helmet therapy because re-positioning was not working. Meanwhile, 94.4% of the infants who started in the helmet-treated group achieved full correction, as did 96.1% of those who were transferred from the repositioning group into the helmet-treated group. Further information can be found on our Plagiocephaly Research page.

What should I do if my baby is ill or has a temperature?

If your baby has a temperature or a fever due to illness you must remove the band. The band can be put back on once the temperature has returned to normal.

What is the best age to start treatment?

The optimum age for treatment is between four and seven months. This is because the skull is most malleable at this age and improvements to head shape tend to take less time and are more dramatic. That is not to say that helmet therapy should be ruled out if the baby is older than seven months. Routinely, babies up to the age of 16 months can be treated very successfully. The cut off age is around 18 months when the fontanelles (soft spots on the head) are no longer malleable. As babies grow and develop at different rates, it is always worth checking if you are not sure. There have been cases where a baby’s fontanelles have not fused yet by the age of 18 months, who have achieved successful, but less-marked results with cranial remoulding therapy.

What is torticollis?

Torticollis is a condition in which a tight or shortened muscle in one side of the neck causes the head to tilt or turn to one side, resulting in the infant resting its head in the same position. In 2013, we analysed the data from all first appointments in our Kingston clinic and found that 20% of the babies examined had some kind of neck condition that was causing head immobility.

Why should I choose LOC in preference of another clinic?

The clinics and clinicians that provide this treatment in the UK will have received similar training and experience. However, we are the only clinic that manufactures its own helmet and our clinicians are closely involved with the process for each individual helmet that we produce. In addition, we do not restrict review appointments to a set number, we are extremely flexible and respond to individual parents' needs so that the best outcome can be achieved for each baby.

How does helmet therapy work?

The LOCband is non-invasive and works by applying gentle, constant pressure over the areas of the baby’s skull that are most prominent while allowing unrestricted growth over the flattened areas. The band consists of a soft foam layer inside a thermoplastic shell. As the baby grows, the band will be adjusted frequently to gently guide the skull into a more symmetrical shape.