What is Tummy Time : is it necessary for newborns?

By Joyce Miller, BSc, DC, PhD,1 and Sharon Vallone, DC, FICCP2

1. Anglo-European College of Chiropractic, Bournemouth, UK

Introduction
Chiropractic offices are receiving large numbers of infant Table 1. Prevalence of head
patients into their practices. Consequently, new guidelines shape deformity in infants
have been forthcoming to assist chiropractors in applying Age Percentage
their best evidence practice to this age group.1,2 However,
6 weeks 16%
very little has been said in how we give advice, particularly
in the important topic of prone play (“tummy time”) for the 4 months 19.7%
infant. It is not always recognized that research data must 8 months 9.2%
be translated into clinical practice in order for the practical 12 months 6.8%
applications to benefit the end user, the patient, and in this
24 months 3.3%
case the parent and the infant. Why would such a simple
concept, such as an infant playing in prone position be an
issue for discussion between the doctor and parents? It is most of the infant’s time is spent in sleep, if the head posi-
because the simple messages have become convoluted, con- tion doesn’t vary, the soft skull is likely to flatten from con-
fusing and difficult to follow. It is perhaps time to go back sistent, weight bearing positioning. The problem is that the
to the beginning. more it flattens, the harder it is for the infant to change po-
sition. The more time passes in only one position, the flat-
What is the postural problem? ter the malleable, weight bearing area becomes, losing the
Most new mothers report little, if any physician advice on roundness of the cranium and resulting in head deforma-
daytime positioning, but 90% report receiving information tion, or what is termed “plagiocephaly” or misshapen skull.
on infant sleep positioning.3 In general, correct positioning This can occur on the posterior aspect of the skull, which
of the neonate is very important for postural control for is termed “brachiocephaly”, or very commonly, unilaterally
any infant at risk of developing fixed deformities, but little (only on one side) when an infant has preferred or restricted
specific advice may be given by physicians, except for the neck rotation.
“Back-To-Sleep” program.4
Although head shape problems do decline with age, there
The long-term 1992 advice from the American Academy are still a significant number that suffer from longer term
of Pediatrics recommending that caregivers always place a problems. Research suggests that infants with positional
baby on his or her back for sleep at night has come through plagiocephaly are at risk of a delay in motor milestones.12-17
loud and clear.4 Although many physicians term the cranial deformation
“purely cosmetic,” it may be that cosmetic head deformity
This advice has been frequently reiterated, “reaffirmed” is merely a marker for the problem, not the real problem,
(what the AAP does periodically to keep specific policies which is more likely the lack of opportunity to play in prone
in the public eye) and often repeated that the supine posi- position which supports development.17
tioning has had a positive reduction in SIDS (sudden infant
death syndrome).5,6-10 This advice may or may not stand up Chiropractors will be very familiar with the problem of the
to scrutiny and is a potential and necessary topic for exten- infant who cannot rotate his or her cervical spine equally to
sive evidence based review.11 That review cannot be done both sides (due to vertebral fixation or muscular imbalance),
in the context of this paper. Our role and responsibility is to thus causing a flatness on one side of the cranium (more
provide resources for parents so that they may attempt to commonly the right side).18 Once the infant has settled into
make informed decisions based on the available evidence. this preferred posture, the more the head flattens, the more
difficult it is to overcome gravity and the more staying to
Another effect from Back-To-Sleep, and the topic of this that side becomes a habit, profoundly preferred by the
commentary, has been a common occurrence of misshapen child. Parents may accept this as typical behaviour and the
heads in the pediatric population (Table 1).5 head shape may not even be noticed by them and it is often
first pointed out by the doctor on the 8 week wellness exam.
Why does head shape change with supine sleep? Since If the baby is not prescribed and administered treatment to

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What is Tummy Time : is it necessary for Newborns?

allow him/her full range of motion of the cervical spine and References:
is not given good instruction on the need for tummy time, 1. Hawk C. Schneider M. Ferrance RJ. Hewitt E. Van Loon M. Tanis L. Best
practices recommendations for chiropractic care for infants, children and
the problem may persist. There is some evidence that chiro- adolescents: results of a consensus panel. JMPT 2009; 32(8):639-647.
practic care is helpful to reduce the head deformity through
2. Hawk C. Shneider MJ. Vallone S. Hewitt EG. Best practices recommen-
improving the infant’s ability to rotate equally in both di- dations for chiropractic care of children: a consensus update. JMPT 2016;
rections.18 The AAP recognized that infants were missing 39(3):158-168. Accessed August 21,2016:
out on important health motor develop by 1996 and recom- http://www.ncbi.nlm.nih.gov/pubmed/27040034 .
mended to parents that they vary their infant’s head posi- 3. Koren A. Reece SM. Kahn-D’angelo L. Medeiros D. Parental information
tion in their sleep and give them some tummy time when and behaviors and provider practices related to tummy time and back to
awake, beginning at birth.6 Unfortunately, this advice was sleep. Journal of Pediatric Health Care 2009; 24 (4):222-229.
largely ignored.3 4. American Academy of Pediatrics Task Force on Infant Positioning and
SIDS, Positioning and SIDS. Pediatrics 1992; 89:1120-1126.
Despite that early warning about the need for tummy time, 5. Hutchison BL. Hutchison LA. Thompson JM. Mitchell EA. Plagioceph-
it has never really become common advice for health care aly and brachycephaly in the first two years of life: a prospective cohort
professionals to disseminate. Parents have had to learn on study. Pediatrics 2004.,114, 970–980.
their own of its many benefits and they sometimes have a 6. American Academy of Paediatrics Task Force on Infant Positioning and
fear of placing their baby on his/her front based on the 1992 SIDS. Positioning and sudden infant death syndrome (SIDS): update. Pedi-
information linking any position except supine with SIDS.4 atrics 1996; 98: 1216 –1218.
Many parents did not realize that supine is the position for 7. American Academy of Pediatrics Task Force on Infant Sleep Position
sleep, but that day-time position should be varied for the and Sudden Infant Death Syndrome Changing Concepts of Sudden Infant
health of the child. Death Syndrome: Implications for Infant Sleeping Environment and Sleep
Position. Pediatrics March 2000; 105(3): 650-656. Accessed on August 21,
2016:
What is it important for parents to know and understand? http://pediatrics.aappublications.org/content/pediatrics/105/3/650.full.
Environment makes a difference to baby’s development pdf .
and babies need to move within their environment. The au- 8. The Changing Concept of Sudden Infant Death Syndrome: Diagnostic
thors are proposing a guideline for parents to use in order Coding Shifts, Controversies Regarding the Sleeping Environment, and
to help them understand how much tummy time may help New Variables to Consider in Reducing Risk. Pediatrics. 2005;116(5):1245–
1255. Reaffirmed 2008. Accessed on August 21, 2016:
their babies adapt to their environment in a positive way http://pediatrics.aappublications.org/content/pediatrics/116/5/1245.full.
and to prevent or help alleviate any positional head defor- pdf .
9. SIDS and Other Sleep-Related Infant Deaths: Expansion of Recommen-
dations for a Safe Infant Sleeping Environment: Task Force on Sudden In-
Table 2: Recommended fant Death Syndrome. Policy Statement. Pediatrics Nov 2011;128(5): 1030-
tummy time per day 1039. Accessed on August 21, 2016:
http://pediatrics.aappublications.org/content/pediatrics/128/5/1030.full.
Age Minutes/day pdf .
1 week 5 minutes/day 10. AAP Publications Reaffirmed or Retired Pediatrics April 2015; 135(4):
4 weeks 10 e1105-6. Accessed on August 21, 2016:
http://pediatrics.aappublications.org/content/pediatrics/ear -
8 weeks 20 ly/2015/03/25/peds.2015-0339.full.pdf .
12 weeks 45 11. Pelligra, R., Doman, G., and Leisman, G. (2005) A reassessment of the
16 weeks 80 minutes/day SIDS Back to Sleep Campaign. The Scientific World JOURNAL 2005, 5: 550-
557. Accessed on August 21, 2016 at:
h t t p s : / / w w w. i a h p. o r g / r e a s s e s s m e n t - s i d s - b a c k - s l e e p - c a m -
mation caused by continuous supine positioning (Table 2). paign-12232014/.
Remember that the time per day can be split into smaller 12. Jantz JW. Blosser CD. Fruechting LA. A motor milestone change noted
time intervals throughout the day. Make it fun with toys with a change in sleep position. Arch Pediatr Adolesc Med 1997; 151: 565-68.
and interaction, so that they gradually get used to it and 13. Argenta LC., David LR. Wilson JA. Bell, WO. An increase in infant cra-
learn to enjoy the time and the new point of view. It is key nial deformity with supine sleeping position. Journal of Craniofacial Surgery
to remember that until or unless the AAP guidelines are 1996; 7: 5-11.
reviewed and refuted with evidence based information, lay 14. Ayer A. Campbell A. Appelboom G. Hwang BY. McDowell M. Piazza
babies down to sleep on their back, do not lie babies prone M. Feldstein NA. Anderson RC. The sociopolitical history and physiologi-
cal underpinnings of skull deformation. Neurosurg Focus 2010;29:E1.
on less than firm surfaces (not on pillows, comforters, pil-
low tops, etc) and always supervise the tummy time. Doing 15. Collett B. Breiger D. King D. Cunningham M. Speltz M.. Neurodevelop-
these things may lower the risk for both SIDS and develop- mental Implications of “Deformational Plagiocephaly”. Developmental and
Behavioral Pediatrics 2005; 26(5): 379-389.
mental problems.

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 Joyce Miller, BSc, DC, PhD, and Sharon Vallone, DC, FICCP

16. Davis BE. Moon RY. Sachs HC. Ottolini MC. Effects of sleep position on infants. Pediatric Physical Therapy 2007; 19 (1): 48-55.
infant motor development. Pediatrics 1998; 102(5): 1135-1140.
18. Douglas NA et al., Chiropractic care for the cervical spine as a treat-
17. Dudek-Shriber L. Zelazny S. The effects of prone positioning on the ment for plagiocephaly: a cross-sectional study, accepted for publication,
quality and acquisition of developmental milestones in four-month-old JCCP 2016.

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