Comparative analysis of goal attainment for helmet therapy versus conservative management for positional plagiocephaly in infants

Positional plagiocephaly (PP) is a common cranial asymmetry of infancy. Its treatment options include conservative management and helmet therapy. However, the efficacy of each, particularly at achieving a normal cranial shape, remains uncertain. This study aimed to compare the efficacy of conservative management and helmet therapy for PP. We retrospectively analyzed 199 infants with PP treated in 2015-2024. A total of 72 patients with a minimum treatment duration of 90 days and minimum plagiocephaly severity level of 2 (Children's Healthcare Atlanta Plagiocephaly Severity Scale) were included. Of them, 36 received conservative management and 36 received helmet therapy. Each infant underwent three-dimensional surface scanning of the cranium (StarScanner). The mean±standard deviation age at treatment initiation was 31.9±6.6 weeks in the helmet group versus 21.0±5.7 weeks in the conservative management group (P<0.001). The average treatment duration was 21.9 (interquartile range [IQR], 15.3-31.4) weeks vs. 20.6 (IQR, 14.1-26.6) weeks (P=0.171), respectively. The monthly correction speed of the cranial vault asymmetry index (CVAI) was comparable between groups (0.66±2.09 vs. 0.64±0.55, P=0.964). Plagiocephaly degree was reduced to level 1 in 9 of 36 patients (25%) who received helmet therapy versus 4 of 36 patients (11%) in the conservative management group (P=0.220), whereas a reduction in severity level was observed in 24 of 36 (67%) versus 15 of 36 (42%), respectively (P=0.058). In the helmet group, an earlier treatment initiation was significantly associated with a greater severity level reduction (r=-0.480, P=0.003). A longer treatment duration showed a trend toward a greater reduction in CVAI (r=0.331, P=0.052). In the conservative management group, both earlier treatment initiation (r=-0.537, P<0.001) and longer treatment duration (r=0.381, P=0.022) correlated significantly with improved outcomes. Conservative management and helmet therapy reduced cranial asymmetry with no significant difference in correction speed. An early treatment initiation was the strongest predictor of improvement, while a longer treatment duration was associated with better outcomes. A trend toward a greater reduction in severity level was observed with helmet therapy, suggesting its potential benefits in more severe cases.