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Singh and Wacogne are to be congratulated on a succinct and well researched account of the current evidence for and against helmet moulding therapy.1 They have highlighted the preponderance of uncontrolled cohort studies in this field and the absence of evidence one way or the other for this treatment due to lack of randomised controlled trials (RCTs).
There are several important considerations in the management of children with plagiocephaly:
Positional plagiocephaly in most cases represents one extreme of a physiological spectrum. The condition tends to self-correct which limits assessment of the efficacy of treatment methods.
There is little, if any, class 1 evidence that helmet moulding for plagiocephaly improves its course compared to simple positional measures. We do not have the evidence largely because of the difficulty in generating control groups for prospective RCTs.
Equally, there is little, if any, class 1 evidence that helmet moulding does not work for positional plagiocephaly. Lack of evidence of effect is not the same as evidence of lack of effect.
Finally, 15–20% of babies sent to my paediatric neurosurgical clinic with presumed plagiocephaly in fact turn out to have something else.
Anyone analysing activity in the paediatric neurosurgical clinic in Frenchay Hospital, Bristol would be justified in concluding that the surrounding region was in the midst of an epidemic of positional plagiocephaly. As Singh and Wacogne point out, this may in part be explained by positional factors such as the “back to sleep” campaign and the increased survival of premature neonates. But increasing awareness is also a contributory factor, with the public perception being that there is a new plague which the NHS is ignoring.