Head Shape & Helmets

This is a conversation between myself (Brooke, OTR/L) and Becki, an orthotist in Canada that specializes in cranial helmets for infants.

Brooke: Okay, I am so excited to talk about all things head shapes and helmets with y'all. I'm going to let Becki in the meeting and then we're going to get started. I am so excited to talk about head shapes and helmets! If you don’t know me — I'm Brooke. I'm a mom of a very busy little 10 month old boy. And I'm an occupational therapist licensed in the United States. My baby developed some plagiocephaly flat head) and then I saw a need for parents to understand prevention and correction with conservative management. Check out my services for head shape here! And so that's kind of the bulk of my work. Becky and I communicate a lot. So I'll let her introduce herself. I'll kind of talk about the format of the live and then we'll get started.

Becki: So my name is Becki. I'm a certified orthotist, which most people don't know what that is, because there's so few of us. But I am a Canadian board certified orthotist, who has taken specialization courses in the US. I have two daughters who are eight and 10. And my story is very similar to Brooke’s where my youngest developed some flattening, and obviously became a lot more concerned and heightened and being it's part of what I do. You know, I felt that there was a void in parental education and the parents that are going through their helmet journey needed more support. So that's part of what I do and what my mission is in developing my program as well.

Brooke: Yeah, and Becky is so knowledgeable. So I get a lot of information about helmeting and parent education from her. So I'm excited for y'all to learn from her as well. So, let's talk a little bit about why this matters. Since, 1992, back to sleep is a really big push for safe sleep in babies, right? And so it's really important for us to consider their head shape because their heads are so soft. And they spent a lot of time lying on them now, right? So plagiocephaly and/or brachycephaly affects one in 10 babies. And that's a lot of babies, right? So it used to affect one in 400 before back to sleep push. And this sleep position encouragement has been worldwide. Every country pretty much has a very large encouragement of placing your baby on their back to sleep. So talk a little bit, Becki, the differences in the head shape, and then kind of which one the helmet is best in fixing.

Becki: So there's three main types of deformation of the skull and then there's one kind of medical type that is extremely rare and I don't think we're going to touch on that today. But the two main types are head shapes that are affected in asymmetry, meaning that the right is different than the left, and vice versa. We want to see symmetry in a head shape. This asymmetrical head shape is called plagiocephaly. The other head shape would be brachiocephalic, which just basically means that there's a symmetrical deformation of flatness straight across the back of the head. And the head has becomes excessively wide, due to the deformation on the back of the head. So those are the two main types. There's another head shape, that's not as common. It's called scaphocephaly. Sadly, I've really only treated a handful of cases in my career. This is a long and narrow head shape. So the length of the baby's head is very narrow and long. And the width of the baby's head is very, very small. But far less common. And then what head shapes do we consider helmetting. So I mean, any baby who has a moderate to severe head shape, in any three of those that I described, could be a potential helmet candidate. If they're involved enough and are the appropriate age, as well as if the parents are interested in changing the shape of their baby's head and other conservative measures have not worked to that point.

Brooke: I like that you said conservative measures first, right? Because you and I are kind of on the same page with that, you know, once you've really tried repositioning strategies correct the head shape, it's very important that you, at the end of the day, get your baby the help that they need. And that's why the bulk of my business is repositioning to correct mild to moderate head shapes. But, in severe or upper end of moderate cases a helmet is really necessary. And so tell me, Becki, what are your definitions for for mild, moderate, and severe because this is something that is very confusing among parents, right? Because I think we have to remember that, you know, it's a continuum. And everybody's kind of definition is different. And so I trust you, as a clinician and as an orthotist. So I want you to educate my followers on that.

Becki: Yeah. And you know what, I wish that it was really straightforward. A lot of times, it's not. The thing that we need to consider is the clinical features. So it is very common to have a baby come into the office, who maybe presents not so bad, and then we put them in the digital scanner, and their numbers are severe. So the question is, well, what do we do? They don't look so bad, but they're measuring pretty bad. And so I think that it's kind of more of a holistic decision making. And I will define it a little bit. But I just wanted to say across the board that, you know, it does come down to how does the baby present? What clinical features are they exhibiting is their head shape and is it a concern for the parents from a cosmetic perspective. And is there a potential for it to get worse, is there a potential for it to get better? So when I do my assessments, obviously, virtually I can't do a scan. So I rely on a severity scale that is qualitative in nature. It's the same scale that the pediatricians use to generate referrals to orthotics for head shape management, consultations, and so on. We're talking about plagiocephaly, which is the one where there's asymmetry the left is different than the right, we can see sometimes that there's facial involvement, so one eye may appear higher, bigger than the other. One forehead may look more full. One ear may shift so when there's involvement on the front of the face, typically, that puts someone in the moderate to severe category. Now, when there's been a good physio involved or occupational therapist involved, sometimes you guys can correct the back of the head so nicely through repositioning and your exercise programs, but then the front of the face doesn't correct. So that baby may measure mild in nature, but has a significant deformation left over on the front of the head. Right. So this is an example of what I'm talking about where, you know, it's their total presentation. Then for the babies that are flat straight across the back, for lack of a better term, they look like they have a conehead, when you look at the side profile, there is a pretty significant high, we call it a cranial vault where the forehead slopes straight up, it goes quite high. And when we see that, that typically slots them into the moderate to severe category.

Brooke: Okay, talk a little bit more about the the breakdown of the numbers as far as mild, moderate to severe kind of how you got your clinical reasoning. During a helmet assessment.

Becki: Yeah. So a lot of that is based on some research evidence. And the truth is, is that there is no universal consensus on what is mild, moderate or severe. But what we've done is we've taken the best available research. And I personally use a little bit more of a conservative scale. So I'm a lot more lenient, I might see a head shape and say, You know what, that's pretty mild, whereas some other clinicians may say, No, that's pretty moderate. And we should do something about it. So when we're talking about the asymmetry, the head shapes where the left is different than the right. Typically, we use what's called the CVAI, or the CVA, they're essentially the same number ones just relative to how big your baby's head is. But the CVAI is our gold standard. And it is the diagonal difference. So this length, minus the short quarter length, and the difference between those two lengths tells us how severe it is. So a normal head shape may have a difference in those two numbers between zero and five millimeters, you'll hear some people say between zero and three, that's pretty narrow. But zero and five would be normal. Five to 10 millimeters would be mild, 10 to 15 would be moderate, and then anything greater than 15, we typically classify as severe.

Brooke: What about the brachycephaly babies?

Becki: Those numbers are a little more tough. I find that they are less reliable, because the length of their head can change depending on the tilt of their head. But in general, a normal cephalic ratio, which is simply the width of the head, divided by the length of the head, is usually between 76% and 91%. We've actually kind of been reevaluating that since the back to sleep program has come into play. And we're actually seeing a lot more wider heads than we saw 20 years ago. So we're reevaluating that, but that is still used is pretty common. So normal would be between 76 and 91%. There are normal head shapes that sit outside of those, for sure. But that is the guideline. Mild would be 91 to 94%, moderate would be 94 to 97%. And then anything greater than 97, we typically classify as severe.

Brooke: Yeah, I love that. I think that's so good, too, for just parents that maybe have had a helmet assessment or going into a helmet assessment. I think this is something we really have to talk about. And I think it's so important for parents that maybe don't have babies yet to know that this is a thing, right? Because especially since we see a lot of celebrities now placing their babies in helmets and the pediatrician at the sixth or four month mark are encouraging a helmet assessment. So you know, this is something that is very common, and it's only going to become more common because Back to Sleep is not going away. I mean, this sleeping position has limited and reduce the amount of SIDS so significantly, that it will be around forever. Because at the end of the day, we want to keep our baby safe. And that's all that matters. So, talk a little bit, Becki, about before we move on from the numbers, let’s talk about the goal for measurements after helmetting. What's like the average in measurements?

Becki: Yeah, for sure. So again, it's not 100% clear, we're always aiming for normal or normal numbers in all of the the numbers that I just described. That is always the goal. Now, obviously, if a baby is a lot older, when they begin helmet therapy, maybe nine or 10 months old, that may not be achievable, depending on where they're starting. So a severe head shape that is helmeted at four months, where, you know, the parents are educated and supported, and they're able to wear their helmet with no issues, can expect full correction. That doesn't always happen. Because they maybe don't understand how the helmet works, they don't understand the importance of compliance. So there's so many factors that play into that. But if there's full compliance, and relatively no major medical events, in that infants life, like a surgery, for example, heart surgery, babies go through these things, then I think you can expect full correction of the head shape. When they're severe, and they're nine months beginning their helmet journey, that may not be the case, but certainly a lot better. You know, if they're severe, we can get them, you know, close to the mild category, in which case, they're not a helmet candidate anyway. So, in my opinion, we've achieved our goal. A lot of parents tend to be pretty happy when their babies hit the mild categories, and some of them will opt to not complete treatment, because they're just so happy that they got that much better.

Brooke: Yeah, yeah. That's great. Yeah, that isn't exactly right. We definitely want to talk about how the helmet works just mechanically. So let's talk about that for a second. Because just really fast, repositioning targets the neural head, so the back of the head. So really in truly repositioning targets the areas on the back head that the helmet would block. Okay, so talk me through like how the helmet works just mechanically, and I'll elaborate just a little bit more on repositioning as well.

Becki: So I think that repositioning and how helmetting essentially do the same thing, it's just one is a little bit more aggressive at doing it because it's a circumferential. So what the helmet does is where we want no more growth to occur, I always explain it that we hug it, we give it a little bit of a helmet hug. When that forehead is excessively forward, the helmet is just holding that forehead, giving it a hug. And then there's a void or an air pocket inside the helmet where we want the new growth to occur. So the helmet just gently hugs the high points and redirects the growth of the head into those flattened areas that where there is a void inside the helmet that is there to help encourage normal growth. So we're redirecting the baby's natural biological rate of growth, we're not speeding it up, we're not slowing it down. We're just redirecting their growth into the areas that we want it to go to, just like the surface that they were sleeping on, redirected it in the areas. So we're kind of reversing the process just with a little bit more hold because it's a total head hold.

Brooke: And that's kind of how I explain it to my parents is repositioning fixes the head that's already there, right? Whereas helmet therapy, waits for the head to grow through that hug. So I think that was a great way to explain it and just kind of the difference. So with repositioning, I have found most success with mild to moderate when that facial asymmetry is not significant. Now, if the baby's forehead is like a millimeter forward, you know, no one's ever gonna look at them from a bird's eye view, right? They're not gonna say, when they're 16 years old, “let me look at your head from the top.” Right. So mild facial asymmetry. I mean, even sometimes I look at my baby's ears, and I'm like, I can't tell if they're a little off. Maybe they are, but it's not significant. If they are significant though, that's when they're entering that moderate to severe category. But truly, I find that repositioning has worked for babies zero to nine months, when they're in that mild to moderate category. So tell me kind of your thoughts on how much repositioning should they try before the helmet journey? What is kind of the latest they can be helmeted and still see that good progress?

Becki: Okay. And so I typically feel that if we're seeing benefits from repositioning, then let's keep doing that. Unless the baby is presenting excessively severe, right? Or they're excessively old, you know, greater, I typically say seven months, just because I don't want parents to lose out on an opportunity. So and then we also, the orthotist, tend to try to helmet a bit early. The only reason is because there needs to be time for education, insurance paperwork, and it takes about two weeks to make the helmet and get a baby into a helmet. So we tend to kind of want to educate you, and just get the ball rolling, and then you can always decline later. So we typically will say, you know, closer to seven, maybe even six months. So talking about the other questions, I would say no later than 7 months if repositioning hasn’t been working. So if a parent is going through more conservative measures, the repositioning is showing beneficial improvements, what I like to do is offer them to be scanned at about four week intervals. And as soon as we stopped seeing improvements on the scans, that's when the baby is older maybe, six months, then the parents may want to change the shape for cosmetic reasons. Then it's time to start talking about a helmet. But if we're not seeing improvements, and the baby has mild flattening then I usually ask them to talk to their therapist, to maybe try some different things, maybe a different method, maybe let's try something, you know, a little bit different positionally. These babies, some of them respond really well to repositioning and certain types of stretching. And some of them, not quite as well, because their biology isn't as loose and soft, so there's that variable as well. Yeah, yeah.

Brooke: And that's what I really respect about you and like about you is that you are conservative in your approaches. I think it's fair to the educate the parent to at least try repositioning before just putting them in a helmet. And I actually have talked with a parent recently. And she was a little frustrated, because she went to the six month appointment, and they never mentioned, physical therapy, chiropractic care, OT, anything. They just said, okay, go to the helmet assessment. And of course, they're gonna get a helmet, because they had never tried any alternative approaches. So I think that's really good. And I agree with you in there is times where a helmet is very necessary. Because at the end of the day, we just want to make sure your baby's head is round. And that's the goal for both of us. So let's talk really quickly about the elongated head shape and helmetting.

Becki: You want to know what outcomes look like for the scaphocephaly? I actually did an assessment this morning for a little one, and was explaining to mom, you know, the helmet doesn't always work that great with this type of shape. You know, I never really promised a whole lot. But basically, when you look at the head shape, to correct them, we basically need the sides to come out. And when you look at how long the sides are, it's just such a huge surface area to get both sides of the head to come out. And it just takes a lot of growth for that to occur. So with a baby growing an average of about a centimeter a month, between four and eight months, you have to spread out the, you know, four centimeters over a huge surface area, in order to get equal correction across both sides of the head so the outcomes are pretty poor for those ones. Doesn't mean I don't try and doesn't mean that I don't think you should try if you want to. I just want you to know what your expectations should be so that you're not disappointed if you're paying out of pocket.

Brooke: Talk a little bit about a basic helmet assessment, like what would you expect and how many appointments? What does a quick summary of the helmet journey look like.

Becki: So the assessment would involve the history, I always want to know what the parents main concerns are. So we have to clarify what their main concern is. So main concern, then we do a clinical assessment of the clinical features. So what do we see with our eyes that are typical for that head shape and what would we mark as excessive or abnormal, or atypical, and then we use the scan data. So we'll take a 3D image of the head shape, and then use the computer as a tool. The scanners are excellent at measuring the head shapes, they're very accurate. They're really good at making helmets or providing the means to make a helmet and also monitoring changes in head shapes, either with conservative therapy or helmet therapy. But we do consider the whole picture when we're doing the assessment. And then usually your helmet has to be fitted within 14 days. That is an FDA mandated policy for all helmet companies. So you should have your helmet within 14 days. Now there are extenuating circumstances where babies are sick, or the helmet just doesn't arrive in time and orthotist do know how to manage that. But in general, 14 days or less. I always aim for seven if I can. There's a quick check in, in case there's little anxieties questions in that first week, and then we should see you, depending on the age of your baby, every two to four weeks. So in the beginning, when they're younger and growing faster every two weeks. I would say the average number of appointments that one of my patients has would probably be about seven total. I do have some distance patients where we plan and prepare for them not to be able to travel so you can you can get away with less. But you have to monitor them virtually.

Brooke: Talk about because I know there's different versions of helmets.

Becki: There are many different options In the US, you have DOCband, STARband, more recently there is something called myCRO - ottoboc, and another compant called Tali. The last two are the newest options. Personally, I think I could make any helmet and make it work well within reason. One helmet is not sig better than the others. The important part is that the person your’e working with has the knowledge and expertise, you comfortable, and they are listening to your concerns. True outcomes, experience, and shorter treatment times are the factors that really matter. Alot are made well enough so they can work.

Brooke: Talk about your services and what you provide online for their parents and babies through their helmet journey.

Becki: I find myself most useful to the parent who needs a second opinion and I’m not selling them a helmet. I am more coaching for helmets, helping them take their anxieties and concerns and applying to their baby and situation. I’m not benefiting if they take the helmet or not. The second void is the parent and baby that has just received their helmet and are struggling a little bit. Maybe they weren’t educated and supported well. That may impact the long term outcomes and the baby may be in the helmet longer.

Brooke: The support is great for parents. All of this is very important. Back to sleep is so importannt and when you leave the hospital they say
”Here is your swaddle!” They don’t mention head shape. Let’s answer some questions.

Becki: Too late to helmet at 5 months? If they have tried positioning and have seen changes then keep trying. I want to know the history. Has it gotten worse, 5 months not too late if it getting worse. If repostioning is working then keep doing that. Important to monitor to head shape at this age though through manual measurements or a series of photos.

Brooke: Several of the questions is it too late if they are x. 7-8 months check on head shape. If the head has not improved with repositioning, then good candidate for helmet if they are moderate to severe in severity.

Becki: When a baby is in clinic at 12 months, regardless if they are mild or severe, I’m not going to promise a ton as far as improvement goes. We absolutely cannot helmet after 18 months. Very few of my patients that make it to 16 months. I have only had a few start at 12 months, and had some significant changes. But, the parents were happy with even a small amount of progress. Even if it was just a 1/2 cm of change. Definitely too late at 18 months. 12 months things aren’t looking so good.

Brooke: I am with you. If mild, 9-10 months and the baby has a tiny asymmetry, then I will be willing to help the parent implement a positioning program. But if the shape is moderate to severe and that takes time to fix, then it is probably best if you do the helmet and be done with it. One question about club foot and bracing or if your baby is in harness for hip dysplasia. At that point, from a therapist perspective, a helmet is the best option if your baby is going to be braced for a prolonged period of time. I have seen a couple babies after they are out of the hardness for hip dysplasia. If the bracing is extended, past the point of 7-8 months, then helmetting is the best option.

Becki: Yeah, every family is different. We may helmet early if the baby hip dysplasia, club foot with boots and bar, low tone, not meeting milestones, heart surgery, or the head shape is getting worse, and then the whole family situation. One family had 6 kids. Baby had a flat spot and was a twin. Physically, the baby wouldn’t keep repositioned, we opted for the helmet because their lives were too busy.

Brooke: I tell parents that alot. If they have tried to repositioning, and I have 96-97% success with my program, but when they have tried so hard and its wearing on them, I say put your baby in a helmet. You don’t have to worry about where they lay, what they are doing, and you can relax. You did everything you could and the helmet will make the head shape better. I so enjoyed this.

Check out my conservation head shape correction course here with a heavy focus on repositioning to keep your baby out of a helmet.

Find Becki on Instagram here!