Neurocognitive Outcomes in Deformational Plagiocephaly: Is There an Association between Morphologic Severity and Results?

BACKGROUND: The neurodevelopmental effects of skull asymmetry and orthotic helmet therapy for deformational plagiocephaly (DP) have had limited investigation. This study assessed the long-term neurocognitive outcomes in patients with DP and their association with orthotic helmet therapy and head shape abnormality. METHODS: A total of 138 school-age children with a history of DP, 108 of whom received helmet therapy, were tested with a neurocognitive battery assessing academic achievement, intelligence quotient, and visual-motor function. Severity of presenting plagiocephaly was calculated using anthropometric and photometric measurements. Analysis of covariance was used to compare outcomes between helmeted and nonhelmeted cohorts, unilateral plagiocephaly and concomitant brachycephaly, and left-sided and right-sided plagiocephaly. The association between severity of plagiocephaly and neurocognitive outcome was assessed through a residualized change approach. RESULTS: There were no significant differences in neurocognitive outcomes between the helmeted and nonhelmeted DP cohorts or the unilateral plagiocephaly and brachycephaly cohorts. Participants with left-sided DP had significantly lower motor coordination scores than participants with right-sided DP (84.8 versus 92.7; effect size = -0.50; P = 0.03). There was a significant laterality by cephalic index interaction, with a negative association between cephalic index and reading comprehension and spelling for participants with left-sided DP. No significant associations were found between severity of presenting or posttreatment deformity and neurocognitive outcome. CONCLUSIONS: Pretreatment and posttreatment severity of plagiocephaly were not correlated with neurocognitive function at school age. Helmet therapy was not associated with better or worse long-term neurocognitive function. However, participants with left-sided DP demonstrated worse neurocognitive outcomes than participants with right-sided DP in the domains of motor coordination and some types of academic achievement. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The functional manual therapy intervention in infants with non-synostotic plagiocephaly: a pilot study.

BACKGROUND: The aim of this study was to document the evolution of cranial asymmetries in infants with signs of nonsynostotic occipital plagiocephaly (NSOP) who underwent to many functional manual therapy treatments (in addition to the standard positioning recommendations); as well as to determine the feasibility of this methodology to conduct outcome research investigating the impact of this intervention for infants with NSOP. METHODS: This is a pilot clinical standardization project using pre-post design in which 10 infants participated. Nine infants presented an initial Oblique Diameter Difference Index (ODDI) (over 104%), three an initial Ear Deviation Index (EDI) (over 4%), and three a Cranial Proportional Index (CPI) (over 90%). Infants received three functional manual therapy treatments for week during the first month of intervention and two for week during the second month. RESULTS: Plagiocephalometric measurements were administered at the first assessment preintervention (T0), after 30 days (±5) (T1) and at a third time after 60 days (±5) of treatment (T2). Nine out of ten participants showed a significant decrease in ODDI under 104% between T0 and T2 assessments. Five out of ten infants showed an EDI under 4%, and 3/10 showed a value about 0%. 3/10 maintained their CPI over 90% with a considerable decrease. CONCLUSIONS: These clinical findings support the hypothesis that functional manual therapy treatments contribute to the improvement of cranial asymmetries in infants younger than 6.5 months old presenting with NSOP.

Rethinking Farkas: Updating Cephalic Index Norms in a Large, Diverse Population.

BACKGROUND: Cephalic index, the ratio of head width to length, is one normative indicator used by insurers to derive criteria for plagiocephaly helmet authorization. Current norms were established by a small sample of white children in the 1987 Farkas and Munro data set. This study establishes updated cephalic index values for infants and children in a large, diverse patient population. METHODS: Children aged 0 to 3 months, 3 to 6 months, 9 to 12 months, 2 to 3 years, and 12 to 14 years were recruited at their well-child appointment. Cephalic index was calculated for each age group and compared to previously established norms. RESULTS: Eight hundred seventy patients met inclusion criteria. The means for boys and girls between 0 and 6 months were 83.5 (n = 155, SD 6.01) and 83.5 (n = 191, SD 5.80), respectively. Established means for boys and girls between 0 and 6 months were 74.4 (n = 38, SD 5.2) and 74.3 (n = 49, SD 6.1), respectively. The difference between norms is highly statistically significant (p < 0.0001). For this age range, insurance criteria for a helmet is >83.7 for boys and >82.7 for girls. Using previous norms, 74 boys (44.6 percent) and 104 girls (54.5 percent) would meet criteria for a helmet under current guidelines. CONCLUSIONS: The mean cephalic index of children has changed. The reasons could include diversifying populations in the United States and the introduction of the Back to Sleep campaign. Over 50 percent of children may inappropriately meet criteria for a helmet based on prior norms. Updating norms could change the definition of plagiocephaly for a helmet orthosis.

Positional plagiocephaly from structure to function: Clinical experience of the service of pediatric osteopathy in Italy.

OBJECTIVE: Aim of the study is to evaluate disorders related to positional plagiocephaly and introduce a new model of early intervention based on the osteopathic integrated approach. METHODS: We review clinical experience of the "Program for Neurodevelopmental Follow-up and Pediatric Osteopathy", a service dedicated to newborns at risk for developmental disorders. RESULTS: We present clinical data of 310 newborns followed during first years of life. Data analysis examines perinatal history, general features and disorders that could be related to plagiocephaly. CONCLUSIONS: The experience confirms that plagiocephaly is not only a problem regarding the shape of the head, it involves the functions. In our Service most babies (81%) with positional plagiocephaly showed isolated or associated disorders that had an impact on growth, behavior and development. The early intervention based on the osteopathic integrated approach is addressed not only to the cranial shape but consider the baby as a whole, and the environment where he lives.

Characteristics and Treatment of Pediatric Patients in an Osteopathic Manipulative Medicine Clinic.

CONTEXT: Osteopathic manipulative medicine (OMM) is recognized as an adjunctive medical approach for the treatment of pediatric patients, but few studies have detailed the pediatric conditions that prompt the use of osteopathic manipulative treatment (OMT) or the types and frequency of OMT used. OBJECTIVE: To present descriptive data of pediatric patients receiving OMT from a neuromusculoskeletal medicine/OMM outpatient clinic. METHODS: Data were drawn from electronic health records from a single outpatient specialty clinic for pediatric clinical encounters involving OMT that took place between January 1, 2014, and December 31, 2016. Encounter notes and billing records were reviewed for demographic information, presenting complaints, clinical assessments, somatic dysfunction assessments, OMT techniques used, and payment method. Data were categorized by patient age and analyzed. RESULTS: Five hundred thirty-seven pediatric patients (321 girls, 216 boys) received OMT during the study. These patients accounted for 1688 clinical encounters (1106 for girls, 582 for boys). Mean (SD) number of encounters was 2.7 (1.3) encounters for boys and 3.5 (1.1) encounters for girls. A higher percentage of patients younger than age 2 were boys, while a higher percentage of patients older than age 2 were girls (both P=.005). Musculoskeletal complaints and assessments were the most common for children aged 6 years and older; misshapen head, feeding difficulties, and colic were the most frequently reported for children younger than 6 years. There were 8557 somatic dysfunction assessments documented; thoracic and cervical somatic dysfunction were most commonly assessed. There were 8485 OMT techniques documented, and myofascial release was most frequently used. Encounters with self-pay patients (n=72) involved fewer somatic dysfunction assessments (P<.001) than encounters with patients using private insurance (n=1060) or Medicaid (n=542). CONCLUSION: The electronic health records reviewed in the current study revealed descriptive data of pediatric patients presenting to an OMM clinic; these data were rarely documented in previous literature. They may be used by clinicians to better understand the role of OMM as a pediatric adjunctive medical approach and to identify conditions to target for future outcome studies based on common presenting complaints.

Cranial orthosis after cochlear implantation in an infant: Helmet modifications.

We present an infant with bilateral sensorineural hearing loss caused by bacterial meningitis, and moderate/severe plagiocephaly requiring simultaneous treatment of cochlear implantation for hearing loss and cranial orthosis for plagiocephaly. A helmet modification was created, so that the infant was able to be treated for his plagiocephaly while bilateral cochlear implants were in place, bringing attention to serve needs of those patients requiring cochlear implant and cranial orthosis concurrently. While this case was the first time such a modification was required, which was due to the young age at implantation, the occurrence of the concurrent need may increase as we continue to push the boundaries of early implantation.

Effect of head orthoses on skull deformities in positional plagiocephaly: Evaluation of a 3-dimensional approach.

PURPOSE: The positional non-synostotic plagiocephaly represents a cranial asymmetry affecting all 3 dimensions. The aim of this study was to evaluate volumetric indices to assess the efficiency in improving non-synostotic cranial asymmetries in treatment with head orthoses. MATERIAL AND METHODS: A total of 96 infants were included in this observational retrospective study. The cohort was further divided into subgroups according to age of helmet supply (younger/older than 7.5 months) and duration of therapy (less/more than 150 days). With 3-dimensional photogrammetry data sets, the skull volume was separated into quadrants and set in relation to each other to create an Anterior Cranial Asymmetry Index (ACAI) and a Posterior Cranial Asymmetry Index (PCAI) as 3-dimensional parameters. RESULTS: Treatment with head orthoses led to a significant reduction of ACAI (p < 0.0001) and PCAI (p = 0.001). Cranial asymmetry was more severe in the occipital region and significantly improved mainly during the first 75 days with a 40.08% decrease of PCAI value in the short-term therapy in the younger treatment subgroup (p = 0.003). CONCLUSIONS: The introduced parameters sufficiently reproduce the improvement of asymmetry during helmet therapy, following the trend of already established parameters. Asymmetry was significantly improved in the occiput region, and helmet therapy was highly effective in younger infants and in the early treatment period.

Head shape at age 36 months among children with and without a history of positional skull deformation.

OBJECTIVE In this study, the authors examined head shape through age 36 months for children with and without a history of positional plagiocephaly and/or brachycephaly (PPB). METHODS Infants with PPB (cases) were identified through a craniofacial clinic at the time of diagnosis. Infants without diagnosed PPB were identified through a participant registry. Clinician ratings of 3D cranial images were used to confirm the presence or absence of PPB. The cohort included 235 case infants (diagnosed PPB, confirmed with 3D imaging), 167 unaffected controls (no diagnosed PPB, no deformation detected), and 70 affected controls (no diagnosed PPB, discernible skull deformation). Participants were seen in infancy (age 7 months, on average) and again at ages 18 and 36 months. At each visit, automated 3D measures of skull deformation quantified posterior flattening and generated an absolute asymmetry score. The authors also used automated 2D measures to approximate overall asymmetry (approximate oblique cranial length ratio) and calculate the cephalic index. They used linear regression to compare cases to unaffected controls and to compare affected versus unaffected controls on all measures. They also calculated the proportion of children in each group with "persistent PPB," defined as one or more head shape measures above the 95th percentile relative to unaffected controls at 36 months. RESULTS Head shape became more rounded and symmetric for children with and without PPB, particularly between infancy and age 18 months. However, children with PPB continued to show greater skull deformation and asymmetry than unaffected controls at age 36 months. These differences were large in magnitude, ranging from 1 to 2 standard deviations (SDs), and in most (85.6%) of the cases, there was evidence of persistent PPB at 36 months. Similarly, although differences were more modest (i.e., 0.26-0.94 SD), affected controls continued to exhibit skull deformation on most measures relative to unaffected controls and approximately 30% had persistent PPB. Within the case group, head shape at 36 months was similar for untreated patients with PPB and for those who received helmet treatment and for patients with and without a history of torticollis. CONCLUSIONS Although head shape continues to improve, children with a history of skull deformation in infancy continue to exhibit measureable cranial flattening and asymmetry through age 36 months.

[Postural deformities of the skull. Advantages of protocolization in its treatment]. / Deformidades craneales posturales. Ventajas de la protocolización en su tratamiento.

INTRODUCTION: Since 2007, we have examined in our medical practice children with cranial deformities. The increasing demand and lack of professionals dedicated to it has forced us to assume the treatment of this disease. We present our experience. MATERIAL AND METHODS: Retrospective study of patients with cranial deformities treated from 2010 to 2015. We collected data as age at the first visit and at discharge, sequential measurements of the skull and cranial index, type of treatment prescribed (postural, orthosis or both) and consultation requested to other specialties. In the first stage (2010-2012), each surgeon prescribed the treatment he considered appropriate. Since November 2012 a protocol has been implemented, it includes guideline sheets for the surgeon and parents with information on postural therapy and graphs to record the measurements. RESULTS: We have treated 261 patients. Two were diagnosed with craniosynostosis. From the rest, only 151 possessed complete quantitative data and were included in the study with 105 men and 46 women and a mean age of 5.8 months (± 1.9 months). There were 23 pure brachycephaly, 126 mixed forms and 2 pure plagiocephaly. A significant disparity between observers' measurements was noticed. All patients underwent a protocolized postural treatment. In 36 patients who did not improve with postural treatment, cranial orthosis was prescribed with good response: 66.8% became mild forms. Those who maintained only postural treatment also improved to milder forms in 64.4%. CONCLUSIONS: The implementation of a protocol has enabled us to unify the care and follow-up of these patients. Cranial measurement techniques should be more precise and reproducible. Good postural treatment and empathy with the family reduce the use of orthosis in carefully selected cases.

INTRODUCCION: Desde 2007 hemos valorado en consulta a niños con deformidades craneales. La creciente demanda y la falta de profesionales dedicados nos obligaron a asumir el tratamiento de esta patología. Presentamos nuestra experiencia. MATERIAL Y METODOS: Estudio descriptivo retrospectivo de los enfermos con deformidades craneales atendidos desde 2010 a 2015. Recopilamos datos sobre edad en la primera visita y al alta, medidas secuenciales del cráneo, tipo de tratamiento prescrito (postural, ortesis o ambos) e interconsulta a otras especialidades. En la primera etapa (2010-2012), cada cirujano prescribía el tratamiento que consideraba oportuno. Desde noviembre de 2012 se implementó un protocolo que incluye una hoja de actuación para el cirujano y otra para los padres con información sobre medidas posturales y gráficas para anotar las mediciones. RESULTADOS: Hemos atendido a 261 pacientes afectos de deformidades craneales. Dos fueron diagnosticados de craneosinostosis. Del resto, solo 151 disponían de datos cuantitativos completos y se incluyeron en el estudio. Fueron 105 varones y 46 mujeres con edad media de 5,8 meses (± 1,9 meses). Veintitrés presentaban una braquicefalia pura, 126 formas mixtas y 2 presentaban plagiocefalia pura. Existía una importante disparidad entre observadores en la toma de medidas. Todos fueron sometidos a un tratamiento postural protocolizado. En 36 enfermos que no mejoraban se pautó ortesis craneal con buena respuesta: 66,8% pasaron a formas más leves. Los que se mantuvieron solo con tratamiento postural también mejoraron evolucionando a formas más leves en el 64,4%. CONCLUSIONES: La introducción de un protocolo asistencial nos ha permitido unificar la atención y el seguimiento de estos enfermos. Las técnicas de medición craneal deben ser más precisas y reproducibles. Un buen tratamiento postural y empatía con la familia reducen la utilización de ortesis a casos muy seleccionados.

Positional plagiocephaly reduces parental adherence to SIDS Guidelines and inundates the health system.

BACKGROUND: This study sought to better understand parent, grandparent and clinician views of prevention, treatment and costs of plagiocephaly. METHODS: A qualitative study was conducted using focus groups and semi-structured interviews. A grounded theory approach was taken to build theories from the qualitative data collected. A subjectivist epistemological orientation was taken under the paradigm of positivism. RESULTS: Ninety-one parents, 6 grandparents and 24 clinicians were recruited from the community as well as primary and tertiary care clinics. Plagiocephaly worried most parents because it could permanently affect their child's 'looks' and some thought it would affect a child's development. Parents were 'willing to do anything' to prevent plagiocephaly including using products or sleeping positions that are contraindicated under sudden infant death syndrome guidelines. Parents found the care pathway convoluted and inconsistent messages were given from different health providers. For clinicians, the high prevalence of flat head is 'clogging up their patient pool', taking up time they used to spend with children with more severe conditions. CONCLUSION: There is a need to re-emphasize sudden infant death syndrome guidelines for families when they present with an infant with plagiocephaly. Stronger messaging regarding the lack of safety of current pillows marketed to prevent flat head may be useful to decrease their use. Increasing education for all health professionals including general practitioners, allied health and complementary health providers and standardizing assessment and referral criteria may allow the majority of diagnosis and treatment of positional plagiocephaly to occur at points of first contact (e.g. general practitioners, community nurse) and may prevent further burden on the health care system.

Impact of severity and therapy onset on helmet therapy in positional plagiocephaly.

Although helmet therapy is a widely established method in the treatment of positional plagiocephaly, therapeutic regimens remain contentious, especially regarding starting age. Hence, this study investigated the impact of starting age and severity on the effectiveness of helmet therapy. A total of 213 pediatric patients treated for positional plagiocephaly with an orthotic device were enrolled in this study. Pre- and post-treatment calvarial asymmetry was measured according to the Cranial Vault Asymmetry Index (CVAI) using 3D-Photogrammetry. Patients were classified by age at which treatment was started: Group 1 was comprised of patients younger than 24 weeks (n = 82); Group 2, those aged 24-32 weeks (n = 75); Group 3, those aged >32 weeks (n = 56). Additionally, groups were categorized by severity (mild: CVAI 3-7%; moderate: CVAI 7-12%; severe: CVAI > 12%). Mean initial CVAI was 9.8%, which reduced to 5.4% after helmet treatment. Group 1 (<24 weeks) showed the highest absolute and relative rate of correction. Within the groups, severity correlated positively with relative and absolute reduction of the asymmetry. A significant difference in the reduction of the CVAI depending on age was only seen in moderate and severe cases of plagiocephaly- but not in mild plagiocephaly. The present study confirms the effectiveness of helmet therapy for positional plagiocephaly. The use of an orthotic device is an appropriate treatment option particularly in infants with severe plagiocephaly and a start of helmet therapy before the age of 6 month is advisable.

PURLs: helmets for positional skull deformities: a good idea, or not?

Probably not. Helmets appear to be no more effective than waiting for natural skull growth to correct the shape of an infant's head.

Increasing value in plagiocephaly care: a time-driven activity-based costing pilot study.

BACKGROUND: Process management within a health care setting is poorly understood and often leads to an incomplete understanding of the true costs of patient care. Using time-driven activity-based costing methods, we evaluated the high-volume, low-complexity diagnosis of plagiocephaly to increase value within our clinic. METHODS: A total of 59 plagiocephaly patients were evaluated in phase 1 (n = 31) and phase 2 (n = 28) of this study. During phase 1, a process map was created, encompassing each of the 5 clinicians and administrative personnel delivering 23 unique activities. After analysis of the phase 1 process maps, average times as well as costs of these activities were evaluated for potential modifications in workflow. These modifications were implemented in phase 2 to determine overall impact on visit-time and costs of care. RESULTS: Improvements in patient education, workflow coordination, and examination room allocation were implemented during phase 2, resulting in a reduced patient visit-time of 13:25 (19.9% improvement) and an increased cost of $8.22 per patient (7.7% increase) due to changes in physician process times. However, this increased cost was directly offset by the availability of 2 additional appointments per day, potentially generating $7904 of additional annual revenue. Quantifying the impact of a 19.9% reduction in patient visit-time at an increased cost of 7.7% resulted in an increased value ratio of 1.113. CONCLUSIONS: This pilot study effectively demonstrates the novel use of time-driven activity-based costing in combination with the value equation as a metric for continuous process improvement programs within the health care setting.

Results of posterior cranial vault remodeling for plagiocephaly and brachycephaly by the meander technique.

OBJECTIVE: Several techniques to remodel the posterior calvarium in order to increase intracranial volume (ICV) and to improve cosmetic appearance are reported. This study presents the results of meander technique in patients with brachycephaly and posterior plagiocephaly. METHODS: During December 2011 and July 2013, a total of 12 children (median age: 15 months) underwent posterior cranial vault remodeling by the meander technique (brachycephaly, n = 6; posterior plagiocephaly, n = 6). The available pre- and postoperative MRIs were assessed with regard to ICV, cranial index (CI) and asymmetry index (AI) as well as the position of the cerebellar tonsils. RESULTS: No intra- or postoperative complications were observed. Blood transfusions were necessary in nine of 12 patients. A significant increase of the ICV from 1,178.4 ± 134.5 to 1,293.0 ± 137.5 cm(3) (p < 0.05) is demonstrated. In the patients with brachycephaly the CI was significantly improved from 0.97 ± 0.12 to 0.89 ± 0.12 postoperatively (p < 0.05). The AI in patients with posterior plagiocephaly was significantly ameliorated from 0.83 ± 0.04 to 0.92 ± 0.02 postoperatively (p < 0.05). There was a significant effect on cerebellar tonsil position in relation to foramen magnum level for patients with brachycephaly (right tonsil: 11.9 ± 9.2 to 7.0 ± 9.1 mm, p < 0.05; left: 10.8 ± 9.5 to 9.7 ± 10.6 mm; p < 0.05) as well as in posterior plagiocephaly for the ipsilateral tonsil (3.2 ± 3.5 to 1.6 ± 3.5 mm; p < 0.01). CONCLUSION: The presented surgical technique is considered to be safe. The technique is capable to significantly increase ICV and improve cosmetic appearance of the remodeled calvarium. Further evidence that posterior cranial vault remodeling influences the position of the cerebellar tonsils is added by the results of the study.

Helmet therapy in infants with positional skull deformation: randomised controlled trial.

OBJECTIVE: To determine the effectiveness of helmet therapy for positional skull deformation compared with the natural course of the condition in infants aged 5-6 months. DESIGN: Pragmatic, single blinded, randomised controlled trial (HEADS, HElmet therapy Assessment in Deformed Skulls) nested in a prospective cohort study. SETTING: 29 paediatric physiotherapy practices; helmet therapy was administered at four specialised centres. PARTICIPANTS: 84 infants aged 5 to 6 months with moderate to severe skull deformation, who were born after 36 weeks of gestation and had no muscular torticollis, craniosynostosis, or dysmorphic features. Participants were randomly assigned to helmet therapy (n=42) or to natural course of the condition (n=42) according to a randomisation plan with blocks of eight. INTERVENTIONS: Six months of helmet therapy compared with the natural course of skull deformation. In both trial arms parents were asked to avoid any (additional) treatment for the skull deformation. MAIN OUTCOME MEASURES: The primary outcome was change in skull shape from baseline to 24 months of age assessed using plagiocephalometry (anthropometric measurement instrument). Change scores for plagiocephaly (oblique diameter difference index) and brachycephaly (cranioproportional index) were each included in an analysis of covariance, using baseline values as the covariate. Secondary outcomes were ear deviation, facial asymmetry, occipital lift, and motor development in the infant, quality of life (infant and parent measures), and parental satisfaction and anxiety. Baseline measurements were performed in infants aged between 5 and 6 months, with follow-up measurements at 8, 12, and 24 months. Primary outcome assessment at 24 months was blinded. RESULTS: The change score for both plagiocephaly and brachycephaly was equal between the helmet therapy and natural course groups, with a mean difference of -0.2 (95% confidence interval -1.6 to 1.2, P=0.80) and 0.2 (-1.7 to 2.2, P=0.81), respectively. Full recovery was achieved in 10 of 39 (26%) participants in the helmet therapy group and 9 of 40 (23%) participants in the natural course group (odds ratio 1.2, 95% confidence interval 0.4 to 3.3, P=0.74). All parents reported one or more side effects. CONCLUSIONS: Based on the equal effectiveness of helmet therapy and skull deformation following its natural course, high prevalence of side effects, and high costs associated with helmet therapy, we discourage the use of a helmet as a standard treatment for healthy infants with moderate to severe skull deformation. TRIAL REGISTRATION: Current Controlled Trials ISRCTN18473161.

Parents' decision for helmet therapy in infants with skull deformation.

PURPOSE: Helmet therapy is regularly prescribed in infants with positional skull deformation. Evidence on the effectiveness is lacking, which complicates decision making. This study aims to assess the relation between parents' decision for treatment of skull deformation in their infant and their level of anxiety, decisional conflict, expectations of treatment effect, perceived severity of deformation and perceived side effects. METHODS: Parents of 5-month-old infants with skull deformation were invited to participate in a survey. Data collection included background characteristics, anthropometric assessment, parent-reported outcomes, decision for treatment (helmet therapy or awaiting natural course), decisional conflict scale and questions about perceived (side) effects of helmet therapy. Factors significantly correlated with treatment decision (p < 0.1) were tested in a multiple logistic regression analysis. RESULTS: The results of 186 respondents were included in the analysis. Parental satisfaction with their infant's head shape (adjusted odds ratio (aOR) 0.2; 95 % confidence interval (CI) 0.1 to 0.4), expected effect of helmet therapy compared to natural course (aOR 13.4; 95 % CI 5.0 to 36.1) and decision uncertainty (aOR 1.0; 95 % CI 0.9 to 1.0; p = .03) were related to the decision for helmet therapy in infants with skull deformation. CONCLUSION: With the outcomes of this study, we can better understand parental decision-making for elective 'normalizing' treatments in children, such as helmet therapy in infants with skull deformation. Health care professionals should address the parents' perception of the severity of skull deformation and their expectations of helmet therapy. Furthermore, they can support parents in decision-making by balancing medical information with parents' expectations, values and beliefs.