Helmet Versus Active Repositioning for Plagiocephaly:
A Three-Dimensional Analysis
WHAT’S KNOWN ON THIS SUBJECT: Orthotic helmets and active
repositioning are the most common treatments for
deformational plagiocephaly. Existing evidence is not sufficient to
inform decisions between these options.
WHAT THIS STUDY ADDS: A 3D, whole-head asymmetry analysis
was used to compare treatment outcomes. This is the most
rigorous and comprehensive outcomes study to date on the
subject.
abstract
BACKGROUND AND PURPOSE: Orthotic helmets and active reposition-
ing are the most common treatments for deformational plagiocephaly
(DP). Existing evidence is not sufficient to objectively inform decisions
between these options. A three-dimensional (3D), whole-head asymme-
try analysis was used to rigorously compare outcomes of these 2 treat-
ment methods.
PATIENTS AND METHODS: Whole-head 3D surface scans of 70 infants
with DP were captured before and after treatment by using stereopho-
togrammetric imaging technology. Helmeted (n ⫽ 35) and nonhel-
meted/actively repositioned (n ⫽ 35) infants were matched for sever-
ity of initial deformity. Surfaces were spatially registered to a
symmetric template, which was deformed to achieve detailed right-to-
left point correspondence for every point on the head surface. A ratio-
metric asymmetry value was calculated for each point relative to its
contralateral counterpart. Maximum and mean asymmetry values
were determined. Change in mean and maximum asymmetry with
treatment was the basis for group comparison.
RESULTS: The helmeted group had a larger reduction than the reposi-
tioned group in both maximum (4.0% vs 2.5%; P ⫽ .02) and mean
asymmetry (0.9% vs 0.5%; P ⫽ .02). The greatest difference was local-
ized to the occipital region.
CONCLUSIONS: Whole-head 3D asymmetry analysis is capable of rigor-
ously quantifying the relative efficacy of the 2 common treatments of
DP. Orthotic helmets provide statistically superior improvement in
head symmetry compared with active repositioning immediately after
therapy. Additional studies are needed to (1) establish the clinical
significance of these quantitative differences in outcome, (2) define
what constitutes pathologic head asymmetry, and (3) determine
whether superiority of orthotic treatment lasts as the child matures.
Pediatrics 2010;126:e936–e945
e936 LIPIRA et al
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AUTHORS: Angelo B. Lipira, MD,a Shayna Gordon, BS,a
Tron A. Darvann, PhD,b,c Nuno V. Hermann, DDS, PhD,b,c,d
Andrea E. Van Pelt, MD,a Sybill D. Naidoo, RN, CPNP,a
Daniel Govier,a and Alex A. Kane, MDa
aDivision of Plastic and Reconstructive Surgery, Washington
University School of Medicine, St Louis, Missouri; b3D
Craniofacial Image Research Laboratory and dPediatric
Dentistry and Clinical Genetics, School of Dentistry, Faculty of
Health Sciences, University of Copenhagen, Copenhagen,
Denmark; and cIMM Informatics, Technical University of
Denmark, Copenhagen, Denmark
KEY WORDS
deformational, positional, nonsynostotic, plagiocephaly, orthotic,
helmet, active, repositioning, outcomes, asymmetry
three-dimensional
ABBREVIATIONS
DP—deformational plagiocephaly
2D—two-dimensional
3D—three-dimensional
CVA—cranial vault asymmetry
AP—asymmetry of a point P
www.pediatrics.org/cgi/doi/10.1542/peds.2009-1249
doi:10.1542/peds.2009-1249
Accepted for publication Jun 9, 2010
Address correspondence to Angelo B. Lipira, BS, Division of
Plastic and Reconstructive Surgery, Washington University
School of Medicine, 660 S Euclid Ave, Box 8238, St Louis, MO
63110. E-mail: lipiraa@wusm.wustl.edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2010 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no financial relationships relevant to this article to disclose.

Deformational plagiocephaly (DP) is
the most common head shape abnor-
mality in infants.1 Also known as
positional plagiocephaly or plagio-
cephaly without synostosis, DP pre-
sents as unilateral occipital flatten-
ing, often with ipsilateral frontal
bulging and ear displacement that
results from repetitive, prolonged
external pressure. Etiologies include
sleep position, myoneural dysfunc-
tion, and intrauterine constraint,
and risk factors have been identified
that include birth injury, preterm
birth, male gender, and many oth-
ers.2–5 When viewed from the vertex,
the resulting asymmetric head shape
is a parallelogram.5
The incidence of DP has increased
dramatically since 1992, when the
American Academy of Pediatrics rec-
ommended that infants sleep supine
to reduce the risk of sudden infant
death syndrome.6 Broad adherence
to this recommendation has resulted
in a substantial decrease in the inci-
dence of sudden infant death syn-
drome (from 0.26% in 1986 to 0.1% in
1998),7 but DP has increased at least
10-fold.1,8–10 Before 1992, DP incidence
was estimated at 0.3%,11whereas re-
cent estimates range from 3% to 48%,
varying widely depending on sensitiv-
ity of diagnostic criteria.12
FIGURE 1
A, Direct caliper measurement on a child. B, Illustration of potential error of 2D plane selection. Red and blue outlines illustrate the different shape of
cross-sections obtained from different plane selections. C, Head surface color-coded according to pointwise amount of asymmetry. Red and yellow indicate
flattened area.
PEDIATRICS Volume 126, Number 4, October 2010
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The current standard of care for DP
consists of either active reposition-
ing or cranial molding with a custom
orthotic helmet. The aim of active re-
positioning is to prevent continued,
prolonged pressure on the flattened
side, whereas helmet therapy ap-
plies gentle external pressure to
achieve a symmetric head shape.
Both methods rely on cranial mallea-
bility and rapid brain growth in the
first year of life.13 Either method may
also include stretching and physical
therapy if torticollis (tilting of the
head to 1 side caused by contracted
neck muscles) is present.
The choice of treatment modality is an
active area of research. Helmet ther-
apy is believed to be safe, with no
reported detrimental effect on cranial
growth,14 and has become widespread
since first documented in 1979 by Clar-
ren et al.15 However, orthotic helmets
are expensive ($1500 –$2500), and
third-party insurance payers typically
refuse coverage, citing a lack of com-
pelling evidence for their superior
benefit to active repositioning.16 Active
repositioning is inexpensive but re-
quires strict compliance, and some ev-
idence suggests it is less effective than
helmet therapy.17,18 Although surgical
treatment has been documented,19 it is
ARTICLE
reserved for the most severe or refrac-
tory cases.
Multiple studies have compared the ef-
fectiveness of orthotic helmets and ac-
tive repositioning,2,13,17,18,20–23 but cur-
rent evidence is not sufficient to
objectively guide treatment decisions.
A 2005 Cochrane systematic review24
stated that existing evidence is of mod-
erate to poor methodologic quality,
and an improved measurement bat-
tery is needed to better study treat-
ment effects. Previous studies have
relied on two-dimensional (2D) anthro-
pometric data, which is prone to error
and does not adequately encompass
the three-dimensional (3D) nature of
head shape (Fig 1). Quantifying the
subtle and complex elements that
comprise head shape requires sophis-
ticated whole-shape techniques. By ap-
plying a more comprehensive, 3D anal-
ysis of head asymmetry, this study
aims to thoroughly assess and com-
pare the relative efficacies of active re-
positioning and orthotic helmets in the
treatment of DP.
PATIENTS AND METHODS
Whole-head, 3D surface scans of 70 in-
fants (35 helmeted, 35 actively reposi-
tioned) with DP were captured before
e937
and after treatment with a 4-pod ste-
reophotogrammetric imaging system
(Cranial4 [3dMD, Atlanta, GA]). All pa-
tients were evaluated and followed at
St Louis Children’s Hospital, Washing-
ton University School of Medicine (St
Louis, MO). Treatment decision was
guided by parental preference. All par-
ents of infants treated for DP at our
center were presented both treatment
options and invited to participate in
this study. Seventeen17 additional pa-
tients were initially enrolled in the ac-
tive repositioning arm. Of these, 13
opted to switch to helmet therapy in
the midst of repositioning therapy,
whereas the other 4 were lost to
follow-up. All 17 infants were removed
from the study. To ensure that there
was no statistically significant differ-
ence in initial severity between groups,
helmeted (n ⫽ 35) and actively reposi-
tioned (n ⫽ 35) infants were matched
for cranial vault asymmetry (CVA) at
treatment onset. CVA is the difference
between 2 transverse cranial mea-
surements: from each supraorbital
point to the contralateral parieto-
occipital region. Measurements were
obtained with spreading calipers by
the nurse practitioner at each clinic
visit, and at the end of the treatment
period. Head circumference was also
measured at each visit. Groups were
similar in baseline characteristics (Ta-
TABLE 1 Patient Characteristics
Variable
Gender, n (%)
Male
Female
Race, n
White
Indian
Mean (range) age at intake, mo
Occipital flattening, n
Right
Left
Mean CI at intake
Mean head circumference at intake, cm
Mean CVA at intake
Duration of treatment, mo
CI indicates cranial index.
e938 LIPIRA et al
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FIGURE 2
Custom orthotic helmet.
ble 1). The timing of treatment termi- children wear the helmets for 23
nation was determined by parent and hours/day.
clinician satisfaction.
Helmeted children received custom Once a matched sample of helmeted
helmets from a local provider (Or- (n ⫽ 35) and repositioned subjects
thotic and Prosthetic Lab Inc, St Louis) (n ⫽ 35), a total of 140 surface scans,
(Fig 2). Parents of actively repositioned had been obtained, 3D asymmetry
children received standard instruc- computation was performed by
tions, including moving their child’s using a method recently devel-
head to the nonflattened side while oped25,26 and validated27 for analysis
sleeping, riding in car seats, and of head shape and asymmetry in DP
feeding, as well as increasing “tummy- using stereophotogrammetric 3D
time” while awake and altering envi- surfaces.
ronments to reduce the child’s pref-
erence for the flattened head-side.
The method consisted of 2 main
Parents were advised to have their
parts: (1) establishment of detailed
homologous point correspondence
between all head scans as well as
between left and right side of the
Active Repositioning (N ⫽ 35) Orthotic Helmet (N ⫽ 35)
midsagittal plane; and (2) asymme-
26 (74) 29 (83) try quantification.
9 (26) 6 (17)
34 35
Detailed point correspondence was
1 0 achieved by deforming a symmetric
4.8 (2.8–7.5) 4.9 (2.5–7.3) template head to each scan guided
30 28
by 26 landmarks manually placed by
5 7 a single observer (Table 2) and 40
90.2 91.0 constructed landmarks. The con-
42.4 43.2
0.83 0.84
structed landmarks were the inter-
5.2 3.1 section points between the surface
that correspond to the helmet region
 ARTICLE

TABLE 2 Craniofacial Surface Landmarks An initial rigid alignment of each sur-

Landmark Name Error (Root-Mean-Square) face was conducted using 3 land-
Right ear, junction of tragus/helical root 2.14 marks: left tragion; right tragion; and
Right eye, midglobe 1.24 nasion.
Right mideyebrow 2.09
Right scalp at superior helical rim 2.33 The second step calculated the 3D
Right lateral canthus 1.44 asymmetry of every point in the helmet
Right medial canthus 1.51
Right ala, most lateral rim 1.62
region of the head surface. Asymmetry
Right oral commissure 2.03 of a point P (AP) was defined as the
Nasion 0.99 ratio between 2 distances: (1) the dis-
Nasal tip, most anterior projection 0.80
Upper lip, Cupid’s bow 0.92
tance d from the origin (midpoint be-
Chin, midline most anterior projection 1.46 tween the tragion landmarks) to the
Left ear, junction of tragus/helical root 2.02 surface point P on 1 side of the midsag-
Left eye, midglobe 1.24
ittal plane; and (2) the distance d= from
Left mideyebrow 2.41
Left scalp at superior helical rim 2.18 the origin to the corresponding point
Left lateral canthus 1.69 P= on the contralateral side of the mid-
Left medial canthus 1.63 sagittal plane (Fig 4). The asymmetry
Left ala, most lateral rim 1.42
Left oral commissure 1.61 at points P and P= are by definition
Inion 10.44a equal in magnitude and opposite in
Back of head, most posterior projection 8.75a sign, as defined by:
Top of head, most superior projection 7.47a
Right lobule 1.66 If d ⬎ d=, then AP ⫽ 1 ⫺ (d=/d) and
Left lobule 2.37 AP= ⫽ ⫺AP
Deformation center 16.19a
Surface landmarks were used in this study with error determined from intrarater reliability testing. Error was reported in
If d= ⬎ d, then AP= ⫽ 1 ⫺ (d/d=) and
root-mean-square, calculated as the square root of (sum [d2]/n), where d is the distance between first and second AP ⫽ ⫺AP=.
determination. N ⫽ 30.
a Denoted landmarks were used for calibration purposes only and were not expected to have the precision of the other This provides a detailed spatial map-
surface landmarks. They have no bearing on the asymmetry calculation. ping of asymmetry that may be visual-
ized as a color-coded surface (Fig 5).
(Fig 3) and 40 radial lines (equidistant left-right correspondence into the The final step was to calculate the
in angle) and originate from the mid- template. The deformation was per- mean and maximum values of AP in the
point between the tragion landmarks. formed by using thin-plate-splines fol- entire helmet region (19 679 points; Fig
The symmetric template was created lowed by closest-point deformation.28 3). Mean asymmetry (mean AP) is de-
from a computed tomography scan of Before deformation, the template was fined as the arithmetic mean of all AP
a child without craniofacial abnormal- individualized by scaling its dimen- values in the region, whereas maxi-
ities by mirroring the data across the sions separately in length, height, and mum asymmetry (max AP) is the great-
midsagittal plane, thus incorporating width to best match each surface. est value of AP in the region (Fig 5). The

FIGURE 3
Helmet region (red) shown on the symmetric head template.

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 ration. Statistical significance for all
measures was tested with a paired
2-tailed Student’s t test by using SPSS
16.0 (SPSS Inc, Chicago, IL).

RESULTS
Groups were similar at baseline (Table
1). Fig 6 A and B depict the spatial dis-
tribution of change in asymmetry for
the helmeted and repositioned groups,
respectively. Fig 6C shows the differ-
ence between the change for the 2
groups, thus providing the spatial dis-
tribution of amount of superiority of
either treatment protocol. A binarized
version of Fig 6C is shown in 6D, iden-
FIGURE 4
Schematic illustration of asymmetry calculation based on the ratio between distances d and d= from
tifying regions in which 1 treatment
the origin to the points P and P=, respectively (see text). The template deformation process ensures has a better effect than the other.
that P and P= are anatomically corresponding points on the left and right side of the midsagittal plane
(MSP), respectively. At the time of initiation of therapy, there
was no statistically significant difference
in average mean AP between the hel-
meted (3.5%) and actively repositioned
(3.5%) groups (P ⫽ .27). Comparison of
change in mean AP (over the entire hel-
met region) between groups revealed a
statistically significant greater reduc-
tion in the helmeted group (0.9%) versus
the repositioned group (0.5%) (P ⫽ .02)
(Fig 7). A pointwise t test of all points in
the helmet region localized the area of
statistically significant difference to a
region on the posterior head surface
(Fig 8). Within the statistically signifi-
cant region (red and green; 5% level of
FIGURE 5 significance) the helmeted group
Example of the result of asymmetry calculation in a subject, shown as color-coding on the symmetric
template surface. Red (positive) indicates the flattened area, and blue (negative) indicates asymmetry showed a 2.0% reduction of mean AP
in the contralateral area. Green dots mark the location of maximum asymmetry (max AP). Left, Before versus 1.1% in the repositioned group
treatment; right: after treatment.
(P ⫽ .001).
There was also no statistically signi-
average pretreatment to posttreat- cm. One percent of 7.5 cm is 0.75 mm. ficant difference in average initial max
ment change in mean AP and max AP, Therefore, an 8% reduction in max AP, AP between the helmeted (12.9%) and
expressed as a percentage, was the for example, corresponds to a change actively repositioned (13.0%) groups
basis of comparison between the 2 of ⬃6 mm. (P ⫽ .31). With treatment, helmeted in-
treatment groups. To better under- fants had a 4.0% mean reduction in
stand the meaning of these indices, Change in asymmetry also was as- max AP, versus 2.5% for repositioned
consider that the average cranial di- sessed as the difference between pre- infants (P ⫽ .02) (Fig 9). To visually
ameter for infants of this age group is treatment and posttreatment CVA. compare difference in outcomes, con-
⬃15 cm.29 Halving this value to esti- Head growth during treatment was structed head models with max AP that
mate the distance from the origin to a calculated by dividing total change in correspond to these values are over-
surface point on the head yields 7.5 head circumference by treatment du- laid in Fig 10.

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 ARTICLE

FIGURE 9
Comparison of change in max AP between the
helmeted and repositioned groups.

groups (helmeted: 4.5 mm/month; re-

positioned: 5.9 mm/month; P ⫽ .71)

DISCUSSION
FIGURE 6 This study, which used a novel 3D anal-
Group means and differences. A, Mean change in asymmetry for the helmeted group. B, Mean change ysis, reveals that orthotic helmets
in asymmetry for the repositioned (REPOS) group. C, Difference between mean asymmetry for the 2
groups. D, Binary map of the relative efficacies for each point on the head surface. Red indicates areas yield statistically superior reduction in
of the head on which the helmeted group had superior reduction in asymmetry, and blue indicates overall head asymmetry compared
areas on which the actively repositioned group had superior reduction. with active repositioning in the treat-
ment of DP. The rise in DP incidence
Mean duration of treatment was signif- since the 1992 start of the Back to
icantly shorter for helmeted infants Sleep campaign6 has intensified ef-
(3.1 months) versus repositioned (5.2 forts to determine the relative efficacy
months) (P ⬍ .001). Helmeted infants of orthotic helmet therapy and active
exhibited a mean reduction in CVA of repositioning. In 1997, experts con-
4.5 mm (from 8.4 to 3.9 mm) versus 3.4 vened at the Skull Molding Sympo-
mm for the repositioned group (8.1 to sium30 to attempt to reach a consen-
4.7 mm) (P ⫽ .14). There was no statis- sus, but concluded that there was
tically significant difference in average insufficient evidence to establish deci-
FIGURE 7
sive recommendations. A 2005 Co-
Comparison of change in mean AP (over the en- head growth during treatment
tire helmet region) between the helmeted and chrane systematic review24 similarly
repositioned groups.
(change in head circumference di-
concluded that the relative efficacy of
vided by treatment duration) between
conservative DP treatments could not
be determined because of a lack of
methodologic rigor in previous stud-
ies, and recommended that an im-
proved outcome measurement battery
be developed to better represent pa-
tient outcomes. We have developed a
methodology that eliminates much of
the error associated with 2D assess-
ments of head shape and more appro-
priately describes the 3D problem of
calvarial asymmetry.
Previous studies relied on 2D, direct
FIGURE 8 anthropometric measures to quantify
A pointwise t test assessed the statistical significance of the difference in improvement in mean
asymmetry at every point in the analyzed surface. Colors indicate the significance level (P) of superi- outcomes.2,13,17,18,20–23,31,32 Direct mea-
ority of helmet treatment. Red: P ⬍ .01; green: P ⬍ .05; blue: P ⬍ .1. surements are subject to error be-

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FIGURE 10
Constructed images for visual comparison between the helmeted and repositioned (REPOS) groups.
“Original” is a surface with a 12% asymmetry. “REPOS” represents the average improvement in the
repositioned group (2.5%). “Helmet” represents the average improvement in the helmeted group
(4.0%).
cause of the difficulty of obtaining
accurate, repeatable measures on in-
fants (Fig 1A). Slight differences in the
location of measurements can lead to
substantial variations in acquired re-
sults (Fig 1B). Not only do 2D measures
increase potential error, but such
sparse data also fail to encompass the
inherently 3D nature of head shape. By
applying a more comprehensive 3D
analysis by using captured digital
data, we have attempted to describe
the relative effects of orthotic helmets
and active repositioning in a more
standardized and meaningful way.
We believe the present study repre-
sents the first rigorous comparison of
DP treatment methods with a 3D anal-
ysis of overall head shape, which is a
more thorough assessment of out-
comes. Our method computes asym-
metry at thousands of points on the
head surface (Fig 1C). It has been
shown that DP affects the shape of the
entire head, extending even to the fa-
cial structures and mandible.33,34 Ide-
ally, analysis would include the entire
facial surface; however, nonneutral fa-
cial expressions of infants precluded
this in the present study. Still, incorpo-
rating data from as much of the cra-
nial surface as possible provides a
e942 LIPIRA et al
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more thorough representation of ac-
tual treatment outcomes than do tra-
ditional metrics such as CVA. By ana-
lyzing the entire head surface in 3
dimensions, the error associated with
plane selection is avoided (Fig 1), and
asymmetry is localized visually and
mathematically.
The novel asymmetry indices we have
reported reflect a more holistic ap-
proach to overall head shape analysis
than previous studies. The computed
improvement in mean AP is a robust
measure of change in overall head
shape. Mean AP improvement values
represent the average change in asym-
metry values of all points in an ana-
lyzed surface region as a single value
(Fig 6 A and B). The magnitude of these
values, however, is diluted by many
surface points that undergo very small
changes in asymmetry, making mean
AP incompatible for comparison with
anthropometric data of lesser dimen-
sionality. Calculated change in maxi-
mum asymmetry (max AP) represents
the change in the most asymmetric
point in a region (Fig 5). This value is
more similar in magnitude to tradi-
tional 2D measures, which are taken at
a part of the head most affected by DP.
The results of our 3D analysis suggest
that helmet therapy yields a statisti-
cally significant greater reduction in
asymmetry than does active reposi-
tioning, in both mean AP and max AP. As
described earlier in “Patients and
Methods,” one can better interpret
these indices by considering that the
average cranial diameter for infants of
this age group is ⬃15 cm.29 Halving
this value to estimate the distance
from the origin to a surface point on
the head yields 7.5 cm. Using this value
to estimate the average reduction in
max AP in millimeters yields ⬃3 mm of
reduction for the helmeted group ver-
sus 1.9 mm for the repositioned group.
For purposes of comparison, we re-
corded CVA change as well. There was
a greater average reduction of CVA in
the helmeted group of roughly 1 mm,
which was not statistically significant.
This discrepancy in statistical signifi-
cance suggests that the 3D method is
more sensitive to subtle shape differ-
ences attributable to the greater
amount of information used. Our re-
sults suggest a small advantage in ef-
ficacy for helmet therapy, but the clin-
ical significance of these findings
cannot be concluded without addi-
tional studies to determine what con-
stitutes a clinically significant im-
provement in head shape. The visually
intuitive output of our 3D method sets
the stage for studies of clinical signifi-
cance because head models with spec-
ified amounts of asymmetry could be
constructed and presented to ob-
server panels for visual assessment
(Fig 10).
Previously published cohort studies,
which rely on traditional anthropomet-
ric methods, have reported conflicting
results. Some have reported statisti-
cally superior outcomes for helmeted
infants. A prospective study of 53 in-
fants by Mulliken et al18 concluded that
helmet therapy yielded a statistically
significant greater reduction in CVA

compared with active repositioning
(P ⬍ .001). A retrospective study of 298
infants by Graham et al17 also reported
a statistically significant greater im-
provement in the helmeted group (7.1
mm reduction in CVA versus 5.5 mm;
P ⬍ .001). Rogers et al22 prospectively
compared a custom-made orthotic de-
vice against active repositioning in in-
fants younger than 4 months. Hel-
meted infants’ average CVA decreased
from 11.0 mm to 3.5 mm, versus 9.0
mm to 8.0 mm for repositioned infants
(P ⬍ .001).
Other anthropometric studies have re-
ported no statistically significant dif-
ference between therapies. Loveday
and de Chalain20 prospectively studied
74 infants and found no statistically
significant difference in CVA change
between groups. The authors noted
significant technical difficulties with
the fit and function of the helmets in
this study that may have compromised
their results. Moss21 treated 66 infants
with mild to moderate plagiocephaly
(CVA of ⱕ1.2 cm) with repositioning
and physical therapy only. Moss re-
ported an average CVA improvement
from 9.2 to 4.7 mm, which Moss stated
is equivalent to historical outcomes
for helmeted infants.
The variability in results of these stud-
ies suggests that the difference in out-
comes between orthotic helmets and
active repositioning is small, but it may
also reflect the difficulty in standardiz-
ing anthropometric head measure-
ment techniques. Both treatment mo-
dalities are reasonably effective, as
evidenced by the aforementioned stud-
ies as well as observational studies on
the efficacy of helmet therapy14,31,32
and active repositioning,10,35,36 which
judged efficacy by traditional anthro-
pometric measures31,32,36 and subjec-
tive methods that include parent satis-
faction with the aesthetic result.35,36
Understanding aesthetic outcomes is
critical because the ultimate treat-
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ment goal in DP is satisfactory appear-
ance. However, qualitative information
is difficult to compare and vulnerable
to recall-bias. An ideal quantitative
method for studying outcomes should
describe shape in a complex, holistic
way such as by the human eye, in a
mathematically rigorous way. Out-
comes such as patient and parent
satisfaction should also be studied
and correlated to the quantitative
outcomes.
Contemporary 3D imaging modalities,
in combination with sophisticated shape
analysis techniques, are bridging the
gap between aesthetics and mathemat-
ics. The craniofacial community has rap-
idly adopted digital surface stereophoto-
grammetry, which rapidly acquires
detailed, high-resolution 3D studies and
employs no harmful radiation. The data
has accuracy and precision equal to or
exceeding that of direct anthropome-
try,37– 40 but avoids the difficulty and er-
ror associated with taking direct mea-
surements. The range of analytical
techniques that can be applied to 3D
data is vast, from simple methods
such as linear distance calculation to
3D methods that analyze landmark-
configurations or the entire surface.
Analytical methods that use more sur-
face points provide a richer model that
encompasses more of the subtle con-
tributions that details provide to
shape. Complex shape characteristics
such as contour, which are easily per-
ceived by the human eye, require so-
phisticated mathematical techniques
to quantify. To answer questions of
form in a rigorous, quantitative man-
ner, the craniofacial community must
continue to explore whole-shape anal-
ysis and its application to clinical prob-
lems. Currently, there exists no well es-
tablished framework for interpreting
mathematical values directly as clini-
cal success or improvement in quality
of life. Additional studies that incorpo-
rate parent and patient satisfaction, vi-
ARTICLE
sual responses to measured differ-
ences in shape, and overall change in
quality of life are needed to improve
our understanding of the meaning of
quantitative outcomes such as those
reported in the present study.
Long-term outcomes of DP, which are
perhaps of greatest importance, are
not completely known. A large study by
Boere-Boonekamp et al41 revealed that
9.9% of 7609 Dutch infants had occipi-
tal asymmetry on physical examina-
tion, and 45% of these had persistent
asymmetry at a 2-year follow-up. Addi-
tional evidence of a lasting effect of in-
fantile cranial molding is found in
human remains from cultures in
which intentional head molding took
place.42– 45 This emphasizes the impor-
tance of achieving the best possible
result during infancy because therapy
is generally not efficacious past 12
months of age.13,14,18,31
Treatment selection for individual
patients should take into account
more than efficacy. These treatments
present different demands to patients.
Although active repositioning requires
daily, consistent involvement, and in
our series a longer treatment dura-
tion, helmets are costly and also in-
volve some inconvenience.
As indicated by average pretreatment
cephalic indices, the infants in our
study did tend to be somewhat
brachycephalic, consistent with stud-
ies published previously.17 Our method
focused on asymmetry in patients with
DP and did not take brachycephalic
deformity into account. This is a limita-
tion of our technique because posi-
tional head shape deformity is multi-
faceted and cannot be completely
described by our measure. However,
asymmetry is a very important compo-
nent in the majority of cases of DP and
remains an important indicator of se-
verity and outcomes.
Another limitation of this study is that
the treatment group was dictated by
e943
parental choice, which may introduce
bias. This could be minimized by a ran-
domized controlled trial. In addition,
without a standard definition of “nor-
mal” baseline infantile head asymme-
try, we cannot accurately state what
the ideal outcome would be.
Our results reveal the utility of a 3D
analysis technique to clinical re-
search. We believe that this technique
also holds potential for clinical prac-
tice in its ability to characterize in-
stinctive visual outcomes through a
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e945
Helmet Versus Active Repositioning for Plagiocephaly: A Three-Dimensional
Analysis
Angelo B. Lipira, Shayna Gordon, Tron A. Darvann, Nuno V. Hermann, Andrea E.
Van Pelt, Sybill D. Naidoo, Daniel Govier and Alex A. Kane
Pediatrics 2010;126;e936; originally published online September 13, 2010;
DOI: 10.1542/peds.2009-1249
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright © 2010 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from pediatrics.aappublications.org at Dahlgren Medical Library on March 10, 2015

Helmet Versus Active Repositioning for Plagiocephaly: A Three-Dimensional
Analysis
Angelo B. Lipira, Shayna Gordon, Tron A. Darvann, Nuno V. Hermann, Andrea E.
Van Pelt, Sybill D. Naidoo, Daniel Govier and Alex A. Kane
Pediatrics 2010;126;e936; originally published online September 13, 2010;
DOI: 10.1542/peds.2009-1249

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/126/4/e936.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2010 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from pediatrics.aappublications.org at Dahlgren Medical Library on March 10, 2015