Child's Nervous System

https://doi.org/10.1007/s00381-019-04215-y

ORIGINAL ARTICLE

A new parameter for the management of positional plagiocephaly:

the size of the anterior fontanelle matters
Danielle S. Wendling-Keim 1 & Y. Macé 1 & H. Lochbihler 2 & H.-G. Dietz 1 & Markus Lehner 1,3

Received: 5 March 2019 / Accepted: 20 May 2019

# Springer-Verlag GmbH Germany, part of Springer Nature 2019

Abstract
Purpose The rate of positional plagiocephaly has increased since guidelines for the prevention of sudden infant death have led to
the recommendation of positioning infants on their back during sleeping. Therapy includes repositioning, physiotherapy, and
helmet therapy. To date, there is no consensus on the treatment of positional plagiocephaly. Therefore, it was the goal of this study
to compare the results of physiotherapy and helmet therapy and to investigate if the size of the anterior fontanelle can be used as
an additional parameter for the indication of the helmet therapy.
Methods We enrolled 98 infants with a diagonal difference of 7 mm or more and plagiocephaly classified as Argenta II or more.
Patients were grouped into infants with a small anterior fontanelle (< 25mm2) and infants with a large anterior fontanelle (≥
25mm2). The patients were observed for at least 18 months. Sixty-eight patients were treated with repositioning and physiother-
apy, whereas 30 infants received helmet therapy.
Results The remolding rate was significantly higher with the helmet therapy than with physiotherapy. In patients with a small
fontanelle, a lower spontaneous remolding rate was seen pointing to their lower correction potential. Especially in these patients,
plagiocephaly was reduced significantly more quickly with the helmet treatment than with physiotherapy, so that they may
benefit from the helmet due to their otherwise reduced spontaneous remolding capacity.
Conclusion The helmet therapy led to a faster reduction of the asymmetry than physiotherapy in this study. In patients with a
small anterior fontanelle and therefore lower remolding potential, the helmet treatment was more effective than physiotherapy.

Keywords Positional plagiocephaly . Fontanelle size . Helmet therapy

Introduction
Deformational plagiocephaly is an acquired flattening of the
infant head, seen as a result of pressure, usually from laying on
that area for periods of time. It is not a result of premature
closure of the sutures [8]. Guidelines for the prevention of
* Danielle S. Wendling-Keim
Danielle.Wendling@med.uni-muenchen.de;
danielleswendling@gmail.com
Markus Lehner
markus.lehner@luks.ch
1
Department of Pediatric Surgery, Dr. von Hauner Children’s
Hospital, Ludwig-Maximilian-University, Munich, Germany
2
Department of Pediatric Surgery, Zentralklinikum Augsburg,
Augsburg, Germany
3
Department of Pediatric Surgery, Kinderspital, Luzerner
Kantonsspital, Spitalstrasse, 6000 Luzern 16, Lucern, Switzerland
sudden infant death syndrome (SIDS) led to the general rec-
ommendation of positioning infants on their back during
sleeping as long ago as 1992, thereby reducing the rates of
sudden infant death significantly [20]. However, an increased
rate of flattening of the occiput has been observed since these
recommendations have been put into action, so that an asso-
ciation of the supine positioning and plagiocephaly has been
suggested, although causality has not been proven to date [5,
28]. Previous studies have found that the percentage of
plagiocephaly decreases as the child becomes older, so that
16% of infants at the age of 6 weeks show signs of
plagiocephaly whereas only 3.3% of 2-year-old children and
1% of 5-year-old children present with skull deformities [10,
28]. Nevertheless, differential diagnoses as well as prevention
and treatment have been subject to many investigations and
discussions [2, 3, 5]. For infants with severe positional
plagiocephaly, the potential psycho-social effects of a non-
satisfying cosmetic outcome play a major role during routine
visits to the pediatrician. To date, there is no consensus on the
management of positional plagiocephaly. Depending on the
 Childs Nerv Syst

age of the child and the severity of the deformity, treatment Table 1 The parameters at first presentations of the treatment group and
the control group in order to demonstrate that the groups are comparable
may include active repositioning therapy, physiotherapy, and
cranial molding orthosis (helmet) therapy. The main points of Parameters at first presentation
discussion are the criteria that need to be met in order to
proceed to helmet therapy and when to start. Interestingly, a No helmet therapy Helmet therapy P value
Mean SD Mean SD
metaanalysis conducted by the Congress of Neurological
Age (months) 5.68 2.07 5.86 1.85 0.677
Surgeons has found that specific criteria regarding the quanti-
Head circumference (cm) 42.61 1.82 42.94 1.89 0.414
fication of the deformity and the appropriate time window for
CI (%) 92.78 8.1 92.48 6.18 0.868
treatment have not been defined. Although children with more
Argenta classification 2.75 0.95 3.43 0.53 0.067
severe plagiocephaly, and who are treated early in infancy,
seem to show better results, these criteria are rather vague CVA (cm) 1.03 0.32 1.66 0.36 < 0.000
[8, 26]. Further, a recent prospective study has come to the CVAI (%) 8.36 2.72 12.58 3.11 < 0.000
conclusion that helmet therapy does not improve the outcome
of positional plagiocephaly [30].
helmet. However, if the CVA was measured between 1 and
Therefore, in the light of these contradictory publica-
1.5 cm after the age of 6 months, children were assigned for
tions, it was the goal of this study to compare the outcome
further physiotherapy or helmet therapy depending on a joint
in patients with positional plagiocephaly who were treated
decision of the parents and the responsible pediatric surgeon.
with repositioning and physiotherapy with patients who
The helmet was worn for 23 h each day for 3 months, and
were treated with helmet therapy and to define criteria
then, the helmet was only worn during sleeping hours.
that indicate the need for helmet therapy.
Helmets were composed of polyethylene foam (Plastazote®)
with a soft lining and were perforated to permit air circulation.
During the treatment, the helmets were regularly readjusted
Methods according to the growth of the child’s head. Follow-up visits
were scheduled every 8 weeks.
In this study, 98 infants with positional plagiocephaly who
Pearson‘s chi-squared test was applied. Statistical analysis
were treated during a time period of 18 months in two centers
was performed using IBM SPSS Statistics 20.0. Statistical
for pediatric surgery were selected for the study. Patients were
significance was set at an alpha level of P = 0.05. All data
either referred from a pediatrician or were presented due to
have been irreversibly made anonymous, and this study has
their parents’ decision. Inclusion criteria were unilateral posi-
been conducted according to the guidelines of the ethical com-
tional plagiocephaly with a cranial vault asymmetry (CVA)
mittee of our institution.
(the difference between the largest and smallest diagonal di-
ameter of the skull [16]) of 0.5 cm or more and a degree of
deformity classified as Argenta type II or more [1, 2].
Exclusion criteria were craniosynostosis, brachycephaly, neu- Results
rological disorders, and hydrocephalus.
Medical history were recorded, and progress was recorded Study population
with particular regard to head circumference, fronto-occipital
diameter, biparietal diameter, the transcranial diagonals For this study, 98 patients were recruited. Of these, 68 children
(frontotemporale-lambdoid), size of fontanella, anterior ear were treated with physiotherapy and repositioning (referred to
shift, forehead shift, and eye orbit shift on the same side of as the control group) whereas 30 patients received the helmet
posterior flattening and rotational deficit of the cervical spine therapy (Fig. 1). There were 31 girls and 67 boys. The mean
which were measured with the STARscanner™ Laser Data age at first presentation was 5.86 ± 1.85 months in the helmet
Acquisition System (Orthomerica) or with a cephalometer and group and 5.68 ± 2.07 months in the control group (Fig. 3a).
tape measure in addition to the Laser. Cranial vault asymmetry The groups are therefore comparable. The mean age at the
(CVA), cranial vault asymmetry index (CVAI), and cranial in- start of the helmet therapy was 6.57± 1.80 months (Fig. 3b).
dex (CI) were calculated [18]. The degree of asymmetry of the To further determine whether the two treatment groups were
skull was classified using the CVA (Table 1a) and the size of the comparable, the circumference of the head, the length of the
anterior fontanelle was also grouped into large (≥ 25mm2) or body, and the weight at birth as well as the gestational age, the
small (< 25mm2), similar to the classification of Pindrik et al. rate of cesarean section, and the twin rate were noted, and
[22], in order to stratify our study population (Fig. 1). postnatally, no significant difference between the groups were
Infants were treated according to Fig. 2. Infants under found. The age at first presentation was almost 6 months and
6 months of age received physiotherapy and repositioning. If the head circumference and the cephalic index (CI) were sim-
the CVA was more than 1.5 cm, infants were treated with a ilar in both groups whereas the cranial vault asymmetry
Childs Nerv Syst

Observational Study
Study Design 18 Months

98 Infants
with a Diagonal
Difference (DD)
>7mm and
Argenta ≥II
Diagonal Difference in Patients before the Start
of the Helmet Treatment

Diagonal Difference (cm)

3
2.5
2
68 Patients
30 Patients 1.5
Positioning and 1
Helmet Therapy 0.5
Physiotherapy
0
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29
Patients with Helmet Treatment

20 measurements 12 measurements
Small Fontanelle Small Fontanelle
(<25mm2) (<25mm2)

Fig. 1 The patients of the treatment group and the control group that were enrolled in the study

(CVA) and the cranial vault asymmetry index (CVAI) differed treated by physiotherapy and positioning or by helmet therapy.
significantly (P < 0.001 each), indicating that these parameters Patients who received a helmet had a slightly higher Argenta
were suitable to be used to decide whether the child was Classification than children that were treated without the

TREATMENT ALGORITHM
Diagonal Difference

< 5mm 5-9mm 10-15mm > 15mm

Positioning,
Observation Physiotherapy Age Age

< 6 Mo ≥ 6 Mo < 6 Mo ≥ 6 Mo

Size of
Positioning, Fontanelle? Positioning,
Helmet Therapy
Physiotherapy Physiotherapy
Helmet Therapy?

Fig. 2 The treatment algorithm that was applied during the study
 Childs Nerv Syst

a Age at first presentation

Number of patients
30
25 Mean Age of Helmet Therapy Patients
20 : 5.86+/-1.85 months
15
10 Mean Age of Patients without Helmet
5 Therapy: 5.68+/-2.07 months
0
1 1 1
1 2 3 4 5 6 7 8 9
0 1 2
Helmet Therapy 0 1 2 7 7 3 6 1 0 2 0 0
No Helmet Therapy 2 2 3 20 17 10 6 1 3 3 1 0
Age (months)

b Age at the Start of the Helmet Therapy

7
Number of patients

6
5 Mean Age at the start of the Helmet
4 Therapy:
3 6.57+/- 1.80 months
2
1
0
1 2 3 4 5 6 7 8 9 10 11 12
Age (months)

Fig. 3 The age at first presentation and the start of the helmet treatment

helmet, but this difference was not significant pointing to the
clinical importance of the CVA (Table 1).
Helmet treatment results in faster reduction
of plagiocephaly
In order to measure the difference between the effect of the
helmet therapy and the treatment with physiotherapy and po-
sitioning only, we captured the decrease of the CVA which
was measured in mm per month over the complete observa-
tion period. This showed that the CVA was reduced by a mean
of 1.61 mm/month in the helmet group and only by 0.86 mm
in the control group, which is a highly significant difference
between the two groups (P < 0.001). This means that the hel-
met therapy is faster in reducing the deformity of the skull than
physiotherapy and positioning (Fig. 4a).
Due to this finding, we analyzed the impact of the
growth rate of the head circumference on the course of
the CVA. In the control group, Pearson’s correlation anal-
ysis resulted in a significant negative correlation between
the reduction rate of the CVA and the growth rate of the
head circumference with a correlation coefficient of −
0.223 (P = 0.023). This finding was confirmed with a re-
gression coefficient of − 0.054 and means that the spon-
taneous remolding of the asymmetry occurs faster in pa-
tients with a higher growth rate of the head if no helmet
therapy is applied (Figure 5a). In contrast, in the helmet
group, we detected no correlation between the head
growth rate and the CVA-reduction (P = 0.238). This
shows that the CVA correction rate is independent of the
growth rate of the head circumference in infants receiving
the helmet treatment (Fig. 5b).

The role of the growth rate of the head circumference Impact of the size of the anterior fontanelle
in plagiocephaly on the course of positional plagiocephaly

In the helmet group, a significantly lower growth rate of the
head circumference was detected. Hence, we measured a
growth rate of 4.72 mm/month in children with the helmet
therapy as opposed to 7.18 mm/month in patients with phys-
iotherapy and positioning only (P < 0.001) (Figure 4b). The
percentiles of the head circumference of the patients with the
helmet therapy were measured at the beginning and at the end
of the treatment and showed a significant reduction (P =
0.0002) after the treatment with the helmet whereas no change
of the percentile was seen in the control group.
Next, we set our focus on the size of the anterior fontanelle. A
significant (P = 0.008) and positive correlation (r = 0.256) be-
tween the growth rate of the head circumference and the size
of the fontanelle was calculated. This confirms that patients
with a large fontanelle have a greater head growth rate.
Patients were classified according to their fontanelle size into
groups with a small (< 25mm2) or a large (> 25mm2) fonta-
nelle (Fig. 1). Expectedly, the CVA decreased at a significant-
ly higher rate in infants with a large anterior fontanelle (P =
0.0359) which demonstrates that the group with the small
Childs Nerv Syst

Reduction rate of the Asymmetry Growth rate of the Head Circumference

* *
Reduction of CVA rate (mm/month) 2.5 12

2 10

Growth rate (mm/month)

1.5 8

1 6

0.5 4

0 2

-0.5 0
No Helmet Helmet Therapy No Helmet Helmet therapy
mm/month 0.86 1.61 mm/month 7.18 4.72

Fig. 4 The remolding rate and the head growth rate of the two study groups. Although the head growth rate of the helmet group is significantly lower
than the control group, the remolding rate is significantly higher in the helmet group

anterior fontanelle has a lower potential of spontaneous difference was significantly lower (0.064 cm/month)
remolding (Fig. 6). without the helmet therapy than it was with the helmet
Therefore, the cases with a small anterior fontanelle (< treatment (0.229 cm/month; p = 0.001; Fig. 7a). This
25mm2) were selected for further studies. Here, no signif- means that the size of the fontanelle is an important
icant difference regarding the head growth rate was found parameter for the indication of the helmet therapy since
between the control group and the helmet group. This the CVA decreased significantly more with the helmet
finding was specific for cases with a small fontanelle treatment when the anterior fontanelle was small while
and in contrast to data of the complete helmet group, for the head growth was comparable.
which a significantly reduced head growth rate had been Therefore, this study showed that the helmet therapy
demonstrated (Fig. 7b). was more effective and led to a faster reduction of the
In order to address the question of the effectiveness CVA than physiotherapy and positioning in children with
and indication of the helmet therapy, the change rate of plagiocephaly classified as Argenta II or more. Especially
the CVA in cases of a small anterior fontanelle was mea- for patients with a small anterior fontanelle, and therefore
sured in both treatment groups. A significant difference lower spontaneous correction potential, the helmet thera-
(P = 0.001) between the helmet group and the control py might be beneficial. Hence, a small fontanelle may be
group was detected. If a small anterior fontanelle was used as an additional parameter for the indication of the
detected, the mean reduction rate of the diagonal helmet therapy.

a) Significant Correlation between Head b) No Correlation between Head growth

growth rate and CVA reduction rate rate and CVA reduction rate

No -,05 Helmet
Helmet Treatment

,20
CVA change rate (cm/month)
CVA change rate (cm/month)

-,10

-,15
,00
y=-0,12-0,1*x

-,20
y=-0,04-0,07*x
-,20
-,25

-,40 -,30
,00 ,50 1,00 1,50 2,00 2,50 3,00 ,20 ,40 ,60 ,80
Head growth rate (cm/month) Head growth rate (cm/month)

Fig. 5. There is no correlation between the head growth rate and the remolding rate in children with the helmet treatment
 Childs Nerv Syst

Fig. 6 In patients who were not Effect of Fontanelle Size on the CVA change rate in
treated with the helmet, the the Control group without Helmet

Mean change rate of CVA (cm/month)

remolding rate was faster if the 0.2
fontanelle was large than in
children with a small fontanelle *
0.15

0.1

0.05

0
Small Fontanelle Large Fontanelle

Discussion and 30 patients that received a molding helmet. We ana-

lyzed the change of the asymmetry and the head growth in
The pathophysiology and influencing factors of the develop- both groups and compared potentially influencing factors
ment of the head shape and positional plagiocephaly are not including the age and the grade of the asymmetry. As a
fully understood to date [5]. Further, the treatment of positional novel approach, we investigated the influence of the size
plagiocephaly has been controversial. The two major options of the anterior fontanelle on the efficacy of both treatment
are on one-hand positioning and physiotherapy on one side and options. The change rate of the CVA and of the head cir-
the molding helmet therapy on the other hand. To date, it re- cumference in children who were treated with the molding
mains unclear if there are more benefits from the molding hel- helmet was measured over time and compared with those
met therapy than from positioning and physiotherapy alone of children who only had physiotherapy and positioning. A
[31]. There have been studies showing the superiority of the significantly higher rate of remolding was found in patients
helmet therapy in the treatment of positional plagiocephaly [27, who had the helmet therapy. This is in contradiction to the
9, 23, 17, 13, 19]. However, other studies did not find statisti- data published for example by Lee, Teichgraeber et al.,
cally significant differences between helmet therapy and posi- 2008 [15] or van Wijk et al. 2014 [30].
tioning [15]. Therefore, identification of factors that change the By analyzing the factors with a potential influence on
growth and shaping of the head with and without the molding the development of the asymmetry of the head, we iden-
helmet therapy will facilitate the establishment of guidelines for tified the anterior fontanelle and the age of the infant as
the indication of the molding helmet therapy. significantly impacting on the course of the asymmetry,
In this observational study, we included 98 patients of since the helmet was more effective in infants with a
which, 68 were treated with positioning and physiotherapy small anterior fontanelle.

Fig. 7 a In patients with a small Reduction rate of the CVA in cases Growth rate of the head
fontanelle and therefore low
a b
with a Small Fontanelle circumference in cases with a
potential of spontaneous 0.2 1 Small Fontanelle
Growth rate of the Head Circumference (cm/month)

remodeling, the asymmetry was

reduced significantly faster if the
patients were treated with the
0.1 * 0.9

p=0.001 0.8
Change rate of the CVA (cm/month)

helmet than if they were treated p=0.395

-1E-15
with physiotherapy. b There was
0.7
no significant difference between
the helmet group and the control -0.1
0.6
group regarding the head growth
rate -0.2 0.5

0.4
-0.3
0.3
-0.4
0.2
-0.5
0.1

-0.6 0
Helmet Therapy No Helmet Helmet Therapy No Helmet
Childs Nerv Syst
In this study, patients were allocated to their treatment
(molding helmet or physiotherapy and positioning) according
to the algorithm set out in Fig. 2. Comparison of the two
treatment groups revealed that the patients from the helmet
group had a slightly greater asymmetry which is in agreement
with the algorithm that we use. The main parameter used to
identify the asymmetry of the head and its course in this study
was the CVA and the rate of change of the CVA (cm/month).
Previous studies have described that younger infants show
a faster head growth rate than older ones, which had led to the
recommendation to treat the deformational plagiocephaly ear-
ly [24], and this recommendation to begin treatment early has
been confirmed by other studies [6]. In this study, we found a
correlation between the head growth rate and the reduction of
the asymmetry (Fig. 5a) in the control group. Although the
growth rate of the head circumference was reduced in the
helmet group in comparison to the control group, the rate of
the reduction of the CVA was higher in the helmet group. This
shows that a high head growth rate is not needed for the
helmet therapy to be effective.
To find novel parameters that influence the development of
the head shape, we investigated the role of the anterior fonta-
nelle. The size of the anterior fontanelle and its function have
been investigated extensively [7, 21, 4]. However, the associ-
ation of the size of the fontanelle with the growth rate of the
head and the rate of the reduction of the asymmetry of the
head has not been investigated previously. We found a posi-
tive correlation between the size of the fontanelle and the
growth rate of the head circumference. Moreover, the reduc-
tion rate of the CVA was also larger in children with a large
fontanelle in the control group without the helmet therapy
(Fig. 6). Naturally, the size of the fontanelle is larger in youn-
ger infants so that the growth rate of the head is also dependent
on the age although the development and age at the closure of
the fontanelle vary [4] among infants. Due to our finding that
the rate of the reduction of the asymmetry is larger in infants
with a large anterior fontanelle, we can use this parameter to
indicate the treatment with physiotherapy and positioning in
these cases due to the increased potential of spontaneous
remolding in comparison with the children with a smaller
anterior fontanelle and plagiocephaly.
Next, we selected infants with a small anterior fonta-
nelle in order to focus on the efficacy of the helmet therapy
in children who have a smaller potential for spontaneous
remodeling of the head asymmetry. Although the head
growth rate was nearly the same in patients with a small
fontanelle who had physiotherapy as in patients with a
small anterior fontanelle who had helmet therapy, we
found that the reduction rate of the CVA was significantly
higher in the helmet group compared with the physiother-
apy group. Therefore, we demonstrated for the first time
that infants with a small anterior fontanelle and therefore
lower spontaneous remodeling potential benefit especially
from the helmet therapy, since the helmet can enable the
remodeling of the head even when the growth rate of the
head is low.
Notably, the growth rate of the head was found to be altered
in patients who had the helmet treatment in this study
(Fig. 4b). Although this finding is in contrast to the results
from another study [12] which state that the head growth is
not affected by the helmet therapy, the routine examinations
by the pediatrician did not reveal any developmental irregu-
larities in these children so far. Previous studies have looked
into the neurodevelopmental impact of plagiocephaly [25, 11];
however, this was not part of the research question of this
study and needs to be investigated in a follow-up study.
Further, the long-term effects on the head growth have not
been examined since the focus was on the asymmetry [19]
so that this will also be an interesting research question for
the future. A follow-up study is needed to reevaluate the im-
pact of the anterior fontanelle in a larger study population.
Limitations of the study
We did not investigate the optimal time to start the treatment
with the molding helmet or the duration of the therapy, and
previous studies are controversial [14, 32]. Since we per-
formed an observational study in which infants with a lower-
grade asymmetry or younger age underwent physiotherapy,
sometimes in addition to the molding helmet therapy (s.
Fig. 2), we could not determine the effect of the helmet ther-
apy alone. However, if an infant presents early enough, which
we recommend, then it will be favorable, in most cases, to start
with physiotherapy so that probably only a prospective study,
with the associated disadvantages, can focus on the effect of
the molding helmet alone. Due to the study design, patients
were not randomized and the helmet therapy was selected for
infants with a slightly greater asymmetry than the patients
with physiotherapy only, but this will be difficult to change
for ethical reasons. Further, two different measurement
methods (laser and cephalometer) were applied; therefore, an-
other study with larger patient numbers and the same measure-
ment method for all patients should follow. Nevertheless, both
methods are valid [29].
Conclusion
Taken as a whole, this study has revealed that the size of the
anterior fontanelle needs to be taken into account for the indi-
cation of the molding helmet therapy. We have demonstrated
that infants with a small anterior fontanelle have a lower
growth rate of the head and a lower rate of spontaneous de-
cline of the asymmetry than children with a large anterior
fontanelle. Further, our measurements revealed that the helmet
therapy is more effective in reducing the asymmetry than

physiotherapy, and this is particularly the case for infants with
a small anterior fontanelle. Therefore, infants with a small
anterior fontanelle may especially benefit from the helmet
therapy. Further studies are needed to confirm our results.
Acknowledgments We are grateful to Nigel Frankland for critically re-
vising the manuscript.
Compliance with ethical standards Principles of ethical and
professional conduct have been followed. This work has been approved
by the Ethical Committee of the institution.
Conflict of interest The authors declare that they have no conflict of
interest.
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