***TASK*** the task is to summarize an input biomedical literature in six sentences 
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    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: Background : Deformational occipital flattening is the most common cause of abnormal head shape . Current treatment calls for repositioning and cervical stretching in infants younger than 5 months . The authors assessed the effectiveness of a modifiable cranial cup compared to repositioning and cervical stretching to correct early deformational plagiocephaly . Methods : This nonr and omized , prospect i ve clinical trial used historical controls . The treatment and control groups consisted of infants , younger than 4 months , referred for deformational posterior plagiocephaly . The control children were managed by repositioning and cervical stretching exercises . An adjustable concave cranial cup was used in the treated group . Infants were examined at the initial and final visits by a single examiner . Calvarial asymmetry was measured using a large cranial caliper . Active head rotation and degree of rotational asymmetry were estimated to the nearest 10 degrees . Results : There were no statistically significant differences between the control ( n = 23 ) and treatment groups ( n = 24 ) with respect to gestational age at birth , age at initial visit , initial head rotational asymmetry , initial transcranial difference , final head rotational asymmetry , and age at final evaluation . Mean time between initial and final evaluation was 56.3 days for the treatment group and 61.6 days for the control group . The mean transcranial difference decreased from 11.2 to 3.5 mm in the treatment group , and from 9.0 to 8.0 mm in the control group ( p = 0.000 ) . Conclusion : The cranial cup , a modifiable concave resting surface , is significantly more effective than repositioning and physical therapy for correcting early deformational plagiocephaly OBJECTIVE To study the effect of pediatric physical therapy on positional preference and deformational plagiocephaly . DESIGN R and omized controlled trial . SETTING Bernhoven Hospital , Veghel , the Netherl and s. PARTICIPANTS Of 380 infants referred to the examiners at age 7 weeks , 68 ( 17.9 % ) met criteria for positional preference , and 65 ( 17.1 % ) were enrolled and followed up at ages 6 and 12 months . INTERVENTION Infants with positional preference were r and omly assigned to receive either physical therapy ( n = 33 ) or usual care ( n = 32 ) . MAIN OUTCOME MEASURES The primary outcome was severe deformational plagiocephaly assessed by plagiocephalometry . The secondary outcomes were positional preference , motor development , and cervical passive range of motion . RESULTS Both groups were comparable at baseline . In the intervention group , the risk for severe deformational plagiocephaly was reduced by 46 % at age 6 months ( relative risk , 0.54 ; 95 % confidence interval , 0.30 - 0.98 ) and 57 % at age 12 months ( 0.43 ; 0.22 - 0.85 ) . The numbers of infants with positional preference needed to treat were 3.85 and 3.13 at ages 6 and 12 months , respectively . No infant demonstrated positional preference at follow-up . Motor development was not significantly different between the intervention and usual care groups . Cervical passive range of motion was within the normal range at baseline and at follow-up . When infants were aged 6 months , parents in the intervention group demonstrated significantly more symmetry and less left orientation in nursing , positioning , and h and ling . CONCLUSION A 4-month st and ardized pediatric physical therapy program to treat positional preference significantly reduced the prevalence of severe deformational plagiocephaly compared with usual care . CLINICAL TRIAL REGISTRATION is rct n.org Identifier : IS RCT N84132771 OBJECTIVE To evaluate the impact of stretching exercises versus available bedding pillows on positional head deformities . STUDY DESIGN Fifty children aged 5 months or younger with positional head deformity were included in this prospect i ve clinical trial ( n=20 plagiocephaly , n=10 brachycephaly , n=20 combination ) . A r and om distribution was performed for treatment with the bedding pillow alone ( n=25 ) or with stretching exercises ( n=25 ) for 6 weeks . Anthropometric caliper measurements were done before and after that interval . Cranial vault asymmetry index ( CVAI ) and cranial index ( CI ) were calculated and analyzed using a descriptive statistical general linear model . RESULTS ΔCVAI in the stretching group was 2.09 % for plagiocephaly and 2.34 % for combined head deformities . Using the bedding pillow , ΔCVAI was 3.01 % in plagiocephal children and 2.86 % for combined head deformity . The ΔCI in the stretching group was 0.94 % for isolated brachycephal children and 2.24 % for combined head deformity . ΔCI in the pillow group was 3.63 % for brachycephaly and 3.23 % in children with combined head deformities , respectively . CONCLUSIONS Bedding pillows and stretching exercises both result ed in improvements in positional cranial deformation . For children with combined plagiocephaly and brachycephaly , improvement in cranial asymmetry was slightly greater when using bedding pillows versus stretching A total of 105 infants with nonsynostotic posterior plagiocephaly were treated using a helmet or by head positioning . Effect of treatment was scored using a cosmetic outcome score ( 0 - 10 points ) assigned by the parents . The onset of the observed skull deformity correction was not different for the helmet vs. nonhelmet treatment . Improvement was significantly better and faster in the helmet group compared with nonhelmet treatment ( p < 0.01 and p < 0.001 , respectively ) Appropriate management of posterior plagiocephaly requires differentiation of occipitoparietal flattening caused by lambdoid synostosis from that caused by deformational forces . In a 2 1/2-year prospect i ve study of 115 infants presenting with unilateral posterior cranial flattening , only one child had synostotic posterior plagiocephaly ( lambdoid synostosis ) , whereas 114 infants had deformational posterior plagiocephaly . Deformational occipitoparietal flattening was more common on the right ( 61 percent ) than on the left ( 30 percent ) , and minor contralateral frontal flattening was not unusual ( 52 percent ) . The ipsilateral ear was anteriorly displaced in virtually all infants ( 97 percent ) . Some infants had ipsilateral torticollis ( 19 percent ) ; a few had contralateral torticollis ( 8 percent ) . Gender ratio was 3:1 , male : female . A total of 114 infants with deformational posterior plagiocephaly were treated conservatively either by head positioning in the crib ( n = 63 ) or with a molding helmet ( n = 51 ) . Outcome was assessed by pretreatment and posttreatment anthropometry on 53 of these infants , who were either positioned ( n = 17 ) or helmeted ( n = 36 ) . Improvement occurred in 52 of 53 patients ( mean follow-up 4.6 months ) , i.e. , the difference in length between the long and short transcranial axis diminished in 52 infants ( mean 1.2 to 0.7 cm ) , did not progress in any child , and was unchanged in one infant . At an average age of 10 months , posterior cranial symmetry was better in infants treated with a helmet ( mean difference 0.6 cm ) than in those managed by positioning ( mean difference 1.0 cm ) ( p < 0.001 ) . Age at initiation of helmet therapy ( from 2 to 9 months ) was unrelated to rate of improvement . In a 10-year retrospective study , the authors identified 12 infants who had an operation for posterior plagiocephaly . All but one had confirmed premature lambdoid fusion ; thus , this condition accounted for 3.4 percent of all primary operations performed for craniosynostosis during this decade ( n = 323 ) . In retrospect , the physical findings of synostotic posterior plagiocephaly were not clearly different from those of deformational posterior plagiocephaly . Plain radiography was sometimes used to confirm the clinical diagnosis . Neither sutural narrowing , deep interdigitations , nor perisutural sclerosis indicated lambdoid synostosis . Computed tomography ( CT ) was necessary if the physical findings were suspicious for lambdoid synostosis or if plain films did not give a definitive diagnosis . Axial CT scans ( n = 7 ) showed a symmetric forehead in all but one patient with lambdoid synostosis . CT studies also demonstrated that auricular position was indeterminate in synostotic posterior plagiocephaly , being anterior , posterior , or symmetric , whereas the ipsilateral ear was virtually always anterior in deformational posterior plagiocephaly OBJECTIVE The management of infants with posterior plagiocephaly has been controversial both because of widely differing estimates in the literature of the relative frequencies of true lambdoidal synostosis vs positional molding and because of divergent approaches to treating this problem in different institutions . Based on our experience , we hypothesized that the vast majority of children with posterior plagiocephaly did not have true synostosis and that the cosmetic impairment in such patients could be effectively treated with nonsurgical modalities . METHODS Between 1992 and 1995 , we prospect ively applied in 71 infants a consistent management philosophy for these malformations that has incorporated a detailed evaluation of sutural anatomy as the basis for a physiologic approach to treatment . This approach has been directed at distinguishing true synostosis from deformational plagiocephaly and at avoiding surgery for patients with deformational abnormalities by using a combination of nonsurgical modalities to restore normal cranial growth dynamics . All children first underwent skull radiographs to determine whether the lambdoidal sutures were patent . In equivocal cases , computed tomography was also performed . Patients without true synostosis were enrolled on a course of positional therapy . In patients that did not improve after 2 to 3 months , a custom-fitted orthoplastic molding helmet was applied to facilitate passive skull recontouring . RESULTS Forty children had patent sutures based on skull radiographs , and 29 others , in whom the radiographs were equivocal , had open sutures based on computed tomography , thus establishing the diagnosis of deformational plagiocephaly in 69 . Predisposing factors for this deformity included a strong positioning preference during early infancy ( n = 67 ) , torticollis ( n = 10 ) , prematurity ( n = 6 ) , and developmental delay ( n = 2 ) . Only two patients had true lambdoidal synostosis ; in each case , this was associated with synostosis of the posterior sagittal suture and was managed effectively with cranial reconstructive surgery . Thirty-five patients with deformational plagiocephaly had a dramatic improvement in their cranial contour with positional therapy alone ; 34 patients failed to improve and were treated with molding helmets . All but five children , each of whom was more than 6 months old at initial intervention ( P < .025 ) , developed a normal or nearly normal head shape with these measures . CONCLUSION The vast majority of children with posterior plagiocephaly do not have true synostosis and can be effectively managed by nonsurgical means . The impact of positional preference on the development of this process is discussed Background : R and omized controlled trials of treatment for deformational plagiocephaly and brachycephaly have been lacking in the literature Active counterpositioning and orthotic helmets are the two main nonsurgical management options for positional plagiocephaly . The purpose of this study was to compare these two management regimens . We included a r and om sample of infants referred between January 1 , 1998 and October 31 , 1999 to Middlemore Hospital and Auckl and Surgical Center , for management of positional plagiocephaly . Two-dimensional head tracings were taken for each infant , every 3 to 12 months . From these tracings , we obtained Cranial Index and Cranial Vault Asymmetry Index .  Seventy-nine infants were assessed during an average of 48.2 weeks . Five infants had normal head tracings , and were therefore excluded from the study . Of the 74 infants included in this study , 45 were managed with active counterpositioning , and 29 with orthotic helmets .  Average management time for active counterpositioning  was 63.7 weeks , and 21.9 weeks for orthotic helmet treatment . For infants managed with active counterpositioning , the average change in Cranial Vault Asymmetry Index was 1.9 % . In the orthotic group , average change in Cranial Vault Asymmetry Index was 1.8 % . Orthotic helmets have an outcome comparable to that of active counterpositioning  , although the management period is approximately three times shorter . Active counterpositioning generally had a slightly better outcome than orthotic management after the management period BACKGROUND AND PURPOSE : Orthotic helmets and active repositioning are the most common treatments for deformational plagiocephaly ( DP ) . Existing evidence is not sufficient to objective ly inform decisions between these options . A three-dimensional ( 3D ) , whole-head asymmetry analysis was used to rigorously compare outcomes of these 2 treatment methods . PATIENTS AND METHODS : Whole-head 3D surface scans of 70 infants with DP were captured before and after treatment by using stereophotogrammetric imaging technology . Helmeted ( n = 35 
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CONCLUSION Within the limits of this systematic review , repositioning education is effective in affording some degree of correction in virtually all infants with positional plagiocephaly or brachycephaly .
Most studies suggest that a molding helmet corrects asymmetry more rapidly and to a greater degree than repositioning education .
In a Class I study ,  repositioning education  was as effective as  repositioning education  in conjunction with a repositioning wrap/device .
Another Class I study demonstrated that a bedding pillow was superior to physical therapy for some infants .