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Helmet therapy in infants with positional skull deformation: randomised controlled trial

BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g2741 (Published 01 May 2014) Cite this as: BMJ 2014;348:g2741

Re: Helmet therapy in infants with positional skull deformation: randomised controlled trial

As highlighted in the editorial of Collet in The BMJ, the rising incidence of head deformities represents an important health problem of infants in developed countries. With the introduction (and marketing) of orthotic therapy the answer to head deformities seemed to be: "Treatment, not prevention.”


Van Wijk and coworkers have to be congratulated to have undertaken the burdensome task testing helmet therapy in a randomized clinical trial. Results of the study show not only ineffectiveness of helmet therapy but also, that in only one infant out of four head deformities disappear within the first two years of life – regardless of the intervention. Whereas head deformities are found in about 20% of term infants, a much higher prevalence is found in preterm infants1. We have recently shown head deformities in about 30% of preterms at a corrected age of 6 months, suggesting no spontaneous improvement2. Considering the high prevalence, the associated risk of long term sequel and the missing effect of a therapy, the principal of dealing with head deformities has to be changed into: Treatment not, prevention!


Prevention however does have some prerequisites. Firstly, a widely applicable measure of head shape is needed, that provides standardized and reproducible data with appropriate reference values. Whereas the method used by van Wijk is good for research purposes, it will be less appropriate as a standard screening tool for head deformities and represents only a 2-dimensional measurement3. Thus, research is required to develop and test handy and affordable surface imaging systems, which provide standardized 3-dimensional measures and to define age dependent reference values (percentiles). Secondly, early prevention – starting already during neonatal care – is required to reduce the high prevalence of head deformities in preterm infants. Up until now, neonatal care is focused on other morbidities – clinical studies are needed to establish effective preventive interventions. Thirdly, an active educational program for parents is needed to prevent the development of head deformities by simple measures. Whereas special devices have been shown to be effective in preventing deformities in neonates born at term4. More research on the efficacy of non-invasive methods is required.


1 Ifflaender S, Rüdiger M, Konstantelos D, et al. Prevalence of head deformities in preterm infants at term equivalent age. Early Human Development 2013;89:1041–7. doi:10.1016/j.earlhumdev.2013.08.011


2 Ifflaender S, Rüdiger M, Konstantelos D, et al. Individual course of cranial symmetry and proportion in preterm infants up to 6months of corrected age. Early Human Dev Published Online First: 18 April 2014. doi:10.1016/j.earlhumdev.2014.03.008


3 van Adrichem LNA, van Vlimmeren LA, Cadanová D, et al. Validation of a simple method for measuring cranial deformities (plagiocephalometry). J Craniofac Surg 2008;19:15–21. doi:10.1097/scs0b013e31815c93cb


4 Wilbrand J-F, Seidl M, Wilbrand M, et al. A Prospective Randomized Trial on Preventative Methods for Positional Head Deformity: Physiotherapy versus a Positioning Pillow. J Pediatr 2013;162:1216–1221.e1. doi:10.1016/j.jpeds.2012.11.076

Competing interests: No competing interests

11 May 2014
Mario Rüdiger
Professor of Paediatrics, Head of Department for Neonatology and Paediatric Intensive Care
Sascha Ifflaender
Medizinische Fakultät Carl Gustav Carus an der TU Dresden
Fetscherstr. 74, 01307 Dresden, Germany