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The “Critical Age:” Objective, Patient-Specific Timing of Helmet Therapy In Treatment of Deformational Plagiocephaly and Brachiocephaly
Vinay Rawlani, MD, Roshni Rawlani, BA, Gregory A. Dumanian, MD, Frank Vicari, MD.
Northwestern University, Chicago, IL, USA.

PURPOSE- While several authors have demonstrated the efficacy of cranial helmet molding in infants with deformational plagiocephaly, there is weak evidence regarding the age at which initiate helmet therapy. Current recommendations to start helmet therapy at 4-6 months of age are based upon small clinical trials that lack objective outcome measures, appropriate time for follow-up or bias from commercial influence. We have developed a method to calculate the "critical age," or age which helmet therapy must be initiated to achieve complete correction, based upon volumetric data obtained from 3D surface scanning.
METHODS- Utilizing a 3D surface scanner, the "critical age" is calculated by determining the volume of deficiency, which must be corrected to achieve a normal cranial shape. Understanding that helmets direct all cranial growth in the area of deficiency, one can calculate the amount of time needed to fill a cranial volume void by extrapolation from a modified head growth curve. If the desired age of complete correction is known, the "critical age" for initiating helmet treatment can be determined by subtracting the time needed to correction from the desired age of treatment completion. To test this concept, we conducted a retrospective review of a prospectively-maintained database of all infants treated for deformational plagiocephaly or brachiocephaly with cranial helmets between 2004-2010. All infants were followed until cure or 18 months of age. Data was gathered using objective 3D laser surface scanning, and complete correction was defined as a cranial ratio<0.85 and/or diagonal difference<5mm.
RESULTS: 1,531 infants were enrolled in the study and met inclusion criteria. Overall, complete correction was achieved in 95% of infants. The average critical age was 10.8 months (range 7.3-14.8 months. Complete correction was achieved in 98% who initiated helmet therapy prior to their "critical age," compared to a 44% complete correction rate in those who started helmet therapy after the critical age (p<0.005). In addition, 78% of infants between the age of 4 and 6 months, and 62% of infants between the age of 6 months and the critical, were able to achieve complete correction with physical and repositioning therapy alone, while only 27% of infants above the critical age were able to achieve complete correction with physical and repositioning therapy.
CONCLUSION: Current recommendations to initiate helmet therapy at 4-6 months of age may be overly aggressive and unsupported by strong evidence. The "critical age" allows clinicians to objectively calculate the infant-specific age at which helmet therapy must be initiated to achieve complete correction with a helmet.


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