A Parent's Guide to Helmet Therapy

When treated early by experts, only a small percentage of children with plagiocephaly will require helmet treatment. This is our goal at Plagiocare, to treat patients early and help avoid the need for a helmet.

Introduction

“Helmet therapy” refers to the use of a custom fabricated cranial orthosis (helmet). Cranial orthoses are used to treat plagiocephaly otherwise known as “flat head”. Plagiocephaly is the result of abnormal amounts of pressure on the back of the head, resulting in flat or asymetrical head shapes. The helmets are custom fabricated using a 3-D light scan taken of a child’s head.

Before Helmet Therapy

image of child's head before treatment with a starband cranial helemt for plagiocephaly

After Helmet Therapy

The image demonstrates a child's head after treatment with a Starband cranial helmet

How Helmets are Made

In the past, to get an impression a child’s head, a practitioner would need to cover the child’s head with plaster, let it dry, and then remove the plaster. The plaster would then have the impression of the child’s head which could be filled with material to create a replica of the head. Now, all up-to-date centers use some form of 3-D light scanning that produces a digital 3-D model of the child’s head. The ideal, rounded head shape, including any anticipated growth during helmet therapy, is then created from the child’s light scan using special 3-D software. This new, digital rounded head shape is then utilized to create a custom cranial helmet. The helmet is created with an inside foam layer and is covered with a hard, plastic shell. Once the helmet is delivered to the practitioner, they will then fit the helmet on the child and make any final adjustments in their center to make sure it fits properly.

How Helmets Work

Traditionally, helmets used for plagiocephaly do not work by applying pressure to the head in an attempt to reshape it. They work in a passive manner.  The passive helmets take advantage of the rapid growth of an infant’s brain during the first year of life, which almost doubles in size. As the brain grows rapidly, it transmits pressure to the overlying skull bones. In an infant skull there are five skull bones which are connected together by fibrous connections referred to as sutures. These sutures also function as growth centers and allow for the skull bones to grow and expand to accommodate the rapid brain growth. Instead of being one solid piece of bone, as in an adult skull, the infant skull is malleable in the suture areas due to their fibrous consistency. Somewhere between 12-18 months of age, the sutures turn to bone and stop being fibrous. At this point, the skull becomes more rigid and much less adaptable to rapid brain growth. Cranial helmets are designed to take advantage of the rapid brain growth during the period when the skull is still malleable. A cranial helmet is shaped to the desired final rounded position of the head when the child begins wearing it. There are areas where the helmet gently touches the head to prevent further growth and there are areas which are open to allow the skull to expand into these areas. This combination of preventing skull expansion in certain areas and encouraging expansion in other areas results in a guiding of the skull into its desired round shape. In short, growth guided by the helmet creates the ideal head shape. The ideal window of time to begin helmet therapy in order to take advantage of brain growth and skull malleability is around 5-6 months

this image demonstrates how cranial helmets work by guiding the growth of the infant skull

How cranial helmets work

Types of Helmets

There are many types of helmets, and some are used for different purposes.  Most helmets are designed to treat plagiocephaly and some are designed to be used after surgery for craniosynostosis. The STARband® helmet made by Orthoamerica is the most commonly used helmet in the world. It is important to make sure that whichever helmet you choose is FDA approved for the purpose that it is being used for. Some helmets are created with less coverage of the head and a thinner inner layer of foam. When one of these smaller helmets are used, it is important to ask about the chances of requiring a second helmet, if a second helmet will be covered by insurance, and what the total cost of treatment will be.

Starband Helmets

Orthomerica’s STARband® is the most prescribed cranial remolding orthosis in the world

The STARband helmets are lightweight orthoses designed specifically for each child’s unique head shape. The baby’s head becomes more symmetrical as their own growth is directed into the normal contours inside the STARband. The inside of the STARband has a rounded contour that allows a baby to sleep and move around without putting pressure on the flattened areas of the head. The STARband does not interfere with any activities, and most caregivers report that their babies adapt to it quickly. It is an effective treatment for babies between 3 and 18 months of age, and has been successfully used to treat babies with head shape problems since 2001. It is made from materials that are safe to use against the skin. Starband helmets are composed of a plastic outer shell and an inner polyethylene foam that can be adjusted by the practitioner throughout the course of treatment as necessary. A stop gap foam insert fills the space in the side opening to reduce the likelihood of over-tightening the band. Correction usually occurs within 2-3 months from the time treatment is started. However, each case is unique, and treatment could take longer. In older babies, a longer treatment program is necessary because the baby’s head does not grow as rapidly. The twenty-three hours per day wearing schedule is crucial to a successful outcome.

Timing for Helmet Therapy

As discussed in the How Helmets Work section, helmets take advantage of skull malleability and rapid brain growth to guide the shape of the head. There are five main factors to take into consideration when determining the best time for helmet treatment:

  • If the helmet is placed too early, the skull will still be malleable when the helmet comes off, and the child will still be spending a significant amount of time on their backs. This combination can lead to the head becoming flat again, referred to as relapse.
  • The main brain growth spurt takes place somewhere around 6 months. This is an ideal time to take advantage of this growth with helmet therapy.
  • If the helmet is placed at a later age (after 7 months), the process may take longer and the result may not be as good.
  • After 12 months, the chance for total correction is significantly decreased, and treatment may take significantly longer.
  • Treatment is not possible after 18 months.

Types of Helmet Providers

There are two main types of centers that provide helmet therapy.  There are several comprehensive centers around the country like Plagiocare which provide care by doctors, physical therapists, and orthotists. Because almost all children with plagiocephaly have some form of neck imbalance referred to as torticollis[1], it is important to have all children with plagiocephaly evaluated by a physical therapist. These centers will perform an evaluation by both a doctor and a physical therapist to determine if plagiocephaly or torticollis is present. They can then prescribe physical therapy and/or helmet therapy at the same time, and all of the treatment is performed in the center. This not only provides a more cohesive treatment process, but it makes the process more convenient and less time consuming for parents.

The other type of center that provide helmets are “helmet centers”. These are centers which are typically staffed by orthotists or occupational therapists (rarely physical therapists). The only service they perform is helmet therapy. They are not able to diagnose plagiocephaly, and they are required by law to have a doctor prescribe the helmet therapy for them.

Indications for Helmet Therapy

The Congress of Neurological Surgeons (CNS) and the AANS/CNS Joint Section on Pediatric Neurosurgery published an article in the November 2016 edition of Neurosurgery which was titled: “Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines for the Management of Patients with Positional Plagiocephaly: Executive Summary”. The authors reviewed all of the relevant clinical data and produced their official guidelines for the treatment of plagiocephaly and torticollis. These guidelines were endorsed by the American Academy of Pediatrics (AAP) as their official guidelines.

Official Helmet Therapy Recommendations

  • Helmet therapy is recommended for infants with persistent moderate to severe plagiocephaly after a course of conservative treatment (repositioning and/or physical therapy).
  • Helmet therapy is recommended for infants with moderate to severe plagiocephaly presenting at an advanced age.

What this means:

The severity of the plagiocephaly is determined from clinical measurements, as well as measurements calculated when the 3-D scan is analyzed. If the severity is moderate to severe and the child is seen at a young age, then a trial of repositioning or physical therapy is started. In children in which this trial fails to improve the head shape, a helmet is indicated.  In children with moderate to severe plagiocephaly who present late for evaluation (after around 6 months), there is not enough time to try repositioning, and physical therapy and a helmet is recommended at that time.

Initial Helmet Evaluation

The helmet process begins with a 3-D light scan of the child’s head. One of the most common scanners is the Star Scanner produced by Orthoamerica, this is the scanner used at Plagiocare. The Star Scanner is state-of-the-art and does not need to take up a full room like other scanners.  The scan takes 1-2 seconds and uses only light with no radiation. This creates a 3-D image of the head which is then used to manufacture the helmet. The helmet therapy typically begins 1-2 weeks after the scan.

this image demonstrates a typical starscanner report we use for plagiocephaly

3-D scan of a child with plagiocephaly

Helmet Delivery

At the initial helmet delivery visit, any necessary adjustments will be made to the helmet to provide a proper fit. There is then a “ramp-up” phase during which the helmet will be worn for progressively longer incremental times over the course of a week until it is being worn 23 hours a day. A follow-up visit is scheduled one week after the helmet delivery to evaluate the fit of the helmet and the skin on the head to confirm proper fitting. If any adjustments need to be made, they are done at that time. After this appointment, your child will be seen for follow up visits every 2-4 weeks. A follow up scan will be performed after approximately 6 weeks of helmet therapy to evaluate the head shape. The helmet will be worn in total for typically 2-3 months.

This image demonstrates a child with a Starband cranial helemet

Skin Checks During Helmet Treatment

Skin checks should be performed every time the helmet is removed. Notify your practitioner if there are any areas of deep redness that do not fade within one hour after removing the helmet. This redness may indicate a need for an adjustment. If there is any skin breakdown, stop using the helmet and contact your practitioner. The helmet should not be worn until the skin is healed.

Cleaning A Cranial Helmet

Remove the helmet for one hour at bath time each day and use unscented rubbing alcohol to clean the inside foam portion. Use only unscented rubbing alcohol, as other products may be harmful to the baby’s skin. When cleaning, vigorously rub the inside of the helmet with a clean washcloth or a new, soft toothbrush containing the rubbing alcohol. When finished, place the helmet upside down to dry. A fan can be applied after cleaning to help alleviate the odor that sometimes develops inside the helmet. Allowing the helmet to dry in the sun can also help to improve the odor and speed up the drying process.

Shampoo the baby’s head daily when the helmet is off. Reapply the helmet when both the head and helmet are dry. Babies with very sensitive scalps may have less skin irritation using a mild hypoallergenic or herbal shampoo like Aveeno or Jason’s Tea Tree Oil Shampoo.

The helmet should not get wet. If a child goes swimming, their head should be shampooed to remove chlorine, sunscreen, etc., and the helmet should only be reapplied when both the baby’s hair and the helmet are dry.

When to Remove A Helmet

  • If your baby has a fever or the flu. Resume full time wear as soon as possible. If it has not been worn for 48 hours or more, ramp up the wearing schedule slowly over a few days to allow the child to re-accommodate.
  • If physical therapy or home exercises are prescribed for torticollis, the helmet should be removed for the therapy or exercises and replaced as soon as the session is finished.
  • For the first several days, babies may perspire excessively until their body becomes accustomed to the helmet. This is normal, and during this time, the STARband can be removed for a couple minutes throughout the day to dry the head and helmet with a towel or cool hair dryer. Reapply the helmet as soon as both it and the baby’s hair are dry. Do not apply powders, lotions, or wipes on the baby’s head or inside the helmet. These products may contain perfumes and ingredients that can lead to skin irritation. Babies should be placed in cooler clothing if they continue to perspire excessively.
  • If a baby develops heat rash, they should be kept as cool as possible. A towel or a cool blow dryer can be used to dry the baby’s hair and the inside of the helmet throughout the day to prevent moisture buildup. The helmet should be replaced as soon as it and the baby’s hair are dry. The helmet should be off for less than 10 minutes during these times. The child’s doctor should be contacted, as they may sometimes recommend over the counter topical creams.
  • If a child’s hair needs to be cut during helmet treatment, the entire head should not be shaved. A shaved head may cause irritation when the hair grows in, potentially causing skin irritation. It is best to keep the hair the same length throughout the process to prevent fitting problems that may result from an increase or decrease in the amount of hair.

General Instructions for Helmet Use

  • Having the helmet off for more than 48 hours may create problems with the fit since the baby’s head is continuously growing. If possible, limit the child’s time out of the helmet, and seek assistance when something prevents the baby from wearing it.
  • Each time you place the helmet on, check the chafe, strap, and stop gap foam insert to make sure that  they are secure. Loose parts can be a choking hazard, and they can result in asphyxiation if the parts are swallowed.
  • When the helmet is off, keep it away from pets. Dogs have been known to chew the plastic and foam liner.
  • Continue to wear the helmet for 23 hours a day until the physicians, practitioners, and caregivers agree that treatment is complete.
  • Early discontinuation of treatment against medical advice may result in incomplete correction of the head shape.
  • Continued use of the STARband against medical advice may restrict skull growth and may impair brain growth and development.
  • Explain the purpose of the helmet to other caregivers, and train them in the proper application, removal, and treatment schedule. Training is important for any other person taking caring of your baby.
  • If you have questions or concerns about your baby’s care, contact your practitioner so that any issues can be resolved quickly.
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