Updated Edition of The Truth About Tummy Time

The 2021 Updated Edition of The Truth About Tummy Time is now available in paperback and ebook on Amazon.com and Goodreads.com.  Get your copy today!

The Science Behind Tummy Time

     

    Prone positioning, or being on the stomach, has gotten alot of attention lately with the rise of patients suffering from Acute Respiratory Distress Syndrome (ARDS) as a result of COVID-19.  Part of the treatment regime in hospitals is the use of prone positioning for 12-20 hours a day whether the patient is on a ventilator or not. Research and clinical experience have shown that starting this treatment piece early in the process is improving outcomes for COVID-19 patients.  Why is that?

    From a physiological standpoint, laying on the back increases the pressure in the chest cavity and compresses the lungs making ventilation more difficult.  It also allows fluid to accumulate in the posterior, or back part, of the lower lobes of the lungs.  Reciprocally, when laying on the stomach, the weight of the heart is shifted onto the rib cage and off of the lungs. The back part of the lungs has the greatest capacity making it important to off load the pressure on these areas to reduce the work of effective breathing.  Laying on the stomach allows gravity to assist with passive expansion of the lobes of the lungs that are in the back and has been shown to improve moving fluid off of those lobes and out of the body.  

    Enter in Severe Acute Respiratory Syndrome (SARS) COVID-19 which targets the lungs and wreaks havoc on the ability of your lung tissue to do its job of transferring oxygen to the body.  Simply put, the virus does this by collapsing the sacs in your lungs and causing them to fill with fluid.  

    We can draw parallels between this treatment method, now widely used during the pandemic and the advice I was given by a Neonatal Intensive Care Unit (NICU) nurse who was caring for my premature son during his hospital stay after birth.  She was the first to tell me that they routinely put premature babies on their stomach to reduce the work of breathing and improve oxygen saturation in the blood.  It turns out that the medical community has been using the prone positioning method as early as the 1970s to treat hypoxia (having low levels of oxygen in the blood) and improve gas exchange (getting oxygen in and carbon dioxide out).  One researcher started a clinical study in 1974 after observing patients with Cystic Fibrosis getting on all fours to catch their breath when they were struggling to breathe.  

    Back to physiology, the muscles of the back, including the muscles that control the ribs which are involved in breathing, are strengthened by laying on the stomach.  Babies who spend the vast majority of their time on their backs often have weak back muscles because they are not given the opportunity to use those muscles.  Use it or lose it!  Or in this case, use it or don't develop it in the first place.  

    Bottom line- tummy time is a good thing for many reasons!  Start early, continue often.  It will help us all breathe easier.  

Stop Rock -n- Play

In the pediatric wing of our clinic, we see may infants with torticollis and plagiocephaly as stated in the earlier blog, "It Won't Just Go Away!" In the last year or so, the numbers of babies with severe plagiocephaly (flattened or misshapen heads) is increasing and all share one common practice: these babies sleep in a Rock -n- Play instead of in a crib or bassinet. The pattern is so clear that it is time to speak out against this product.

When measuring plagiocephaly, we use digital calipers in our clinic to determine the cranial vault asymmetry, or difference from the right side to the left side of the skull. The "normal range" is a difference of less than 5 mm cranial differential with the protocol to monitor the head shape. Most babies who are referred to us have a cranial vault asymmetry on average of 9-10 mm asymmetry, moderate plagiocephaly, which requires intervention to correct. A conservative approach is used initially with a cranial remolding helmet a "last resort" once conservative measures have not produced the desired results by ~7 months old. The babies we are seeing who sleep in a Rock -n- play are arriving with an average of 12-13 mm cranial differential which is considered severe plagiocephaly. The report of sleeping in this device is consistent across the board with the more severe cases of head deformity seen clinically. These babies more often require cranial remolding helmets to correct the asymmetry because the initial plagiocephaly is so severe.

Most parents get angry and feel they have been duped once they learn that the Rock -n- Play is the cause of the severity of the baby's head shape because it is advertised as a "sleeper." Let me clarify by saying that not all babies who sleep in the Rock -n- Play end up with severe plagiocephaly, but the ones that we are seeing clinically with this diagnosis have a consistent pattern of sleeping in this device. By design, the Rock -n- play limits movement. The baby is strapped in a reclined position with two angled side seams where the baby rests the side of his or her head or rests the chin on the chest with the back of the head flat on the surface.  A body at rest in a reclined position will seek out stability, so in the Rock -n- play, it is one of these two positions. Infants do not have the muscle strength to move out of confined positions which is why it is so important to monitor what they are sleeping on and rotate them regularly.  Being strapped in a position prevents the baby from moving freely.

A baby's soft spots are open until 12 to 18 months of age so during that time, the head is molding and changing shape. The sutures are open allowing the plates of the skull to move as the brain grows. It is vital to have equal contact on all parts of the head while the soft spots and sutures are open to ensure a round head shape. After the sutures and soft spots close, the head shape can only be changed surgically. This is the only window of opportunity you will have to shape your baby's head! If a baby sleeps through the night, that is 7-8 hours of laying in the same position on the same side of the head which will cause head flattening and deformation. My recommendation is a flat surface to allow baby to easily roll the head back and forth, wiggle the body in a natural movement. Without resistance from the sleep surface, this is much easier to do and much more natural. A body needs movement even when asleep. This movement and rotation of the head will help ensure a rounded head appearance. If you want something small and convenient to place next to your bed, look for something like this: It is the best of both worlds, portable as well as a flat, firm surface with enough room to move around while asleep.

Many parents begin using a reclined sleeper (Rock -n- Play, swing, bouncer) because the baby has reflux. It is shown that a baby only needs to be inclined for 30 minutes to 1 hour after eating to reduce reflux so it is not necessary to keep the baby propped up all the time. Just as adults who experience reflux do not sleep sitting up, rather, wait for a period of time after eating before laying down. The same principle applies here for infants. If you feel the need to prop you baby up, put a wedge under the crib mattress to incline the surface so the baby is still free to move around during sleep, not confined or strapped in one spot all night long.

It is my mission to stop babies from sleeping in the Rock -n- Play as it is clinically proven to be a significant contributing factor in causing severe plagiocephaly. Please don't let your baby sleep in a Rock -n- Play. Send the manufacturers a message that this device should not be advertised as a sleeper!

It Won't Just Go Away!

In treating torticollis and plagiocephaly, I speak with a variety of parents who are referred by a variety of pediatricians.  One of the biggest misconceptions I hear is the phrase, "The doctor said she will outgrow it and we shouldn't worry about it."  This is not only false but can be detrimental to the development and growth of a child.  In my seventeen years of pediatric practice, I have never seen a problem just go away by ignoring it.  Usually, the problem gets worse and starts to affect different areas. Torticollis is a head tilt or favored head position often due to tight neck muscles. Plagiocephaly is a flattening of the skull in one or more areas.

Speaking specifically about torticollis, if it is ignored, as the child continues to grow it will likely get worse as bone typically grows before muscle.  The bone grows, the muscle gets tighter.  The resulting head tilt can cause issues with the jaw opening and closing which could lead to future TMJ issues.  A head tilt can also cause an altered sense of upright in the inner ear.  If the head is always tilted to one side, the brain resets this plane as horizontal so when the head is actually straight, it will give the sensation of leaning to the opposite side.  This is how habitual torticollis develops.  Along with the inner ear being altered, vision can be adversely affected for the same reasons.  Untreated torticollis can also lead to shoulder issues and the mechanics of the shoulder-neck complex can be compromised as the child grows.  The spine is at increased risk of scoliosis due to the compensation of the rest of the back for the head tilt.  All of these issues can contribute to developmental delay and abnormal movement patterns of a developing child.

Untreated moderate to severe plagiocephaly can lead to various issues as well.  A shifted forehead will affect vision.  Preferred head rotation with plagiocephaly can lead to opposite side neglect in a developing infant which would have significant ramifications on the development of motor milestones with underlying muscle imbalances.  A flattening of one side of the head can affect facial features as well leading again to TMJ issues.  Once the fontanel or soft spot closes, the head shape will remain largely unchanged through the life of the child making that window of opportunity as an infant so critical in obtaining a rounded head shape.  Shifted facial features or a flattening of one side of the head will make it difficult to wear glasses, properly fitted football, softball, baseball or motorcycle helmets increasing the risk of head injury during those activities.

The bottom line is this: if nothing changes with the way the infant is cared for, torticollis and plagiocephaly will not improve on their own.  Something must be different for issues to resolve.  If you are advised that a condition with your child will "just go away", dig further and seek treatment from a physical therapist with pediatric experience.  You will be glad you did!  

Pediatric Continuing Education- August Special!

For the month of August, enjoy a discount on the popular course Evaluating and Effectively Treating Torticollis and Plagiocephaly.  

Learn the important components of treating torticollis and plagiocephaly with the convenience of an online course.  

6.0 Contact Hours for the discounted price of $150!  

For more information and to register visit:

www.abouttummytime.com

Evaluating and Effectively Treating Torticollis and Plagiocephaly

The continuing education course Evaluating and Effectively Treating Torticollis and Plagiocephaly is now available as an online course.  Designed for Physical Therapists, Physical Therapy Assistants, Occupational Therapists, Occupational Therapy Assistants and Orthotists, learn the important components of treating these two diagnoses at your convenience.  

For more information, visit the newly redesigned website at www.abouttummytime.com 

NICU Babies at Risk for Plagiocephaly

Who is at risk for plagiocephaly or head flattening?  The answer is every baby regardless of whether they are born vaginally, via c-section, full term or premature.  It is very important to be aware that gravity starts acting on a baby at birth making him or her susceptible to flattening of the skull right away.  Changing a baby's head position throughout the day is essential to ensure a rounded skull appearance.  The variety not only helps head shape, but it also aids in the increasing the tensile strength of the bone.

Often times when babies are born prematurely, they can spend anywhere from a few days to several weeks in the neonatal intensive care unit (NICU) depending on how premature they are.  Along with the increased level of prematurity comes the amount of intervention, tubes, machines, etc. hooked up to the baby.  Most of the time, all of the equipment is placed on one side of the isolet or bed. Potentially, a baby can spend days with his or her head turned to the same side.  I see many premature patients in the clinic, especially twins, for plagiocephaly because of lengthy NICU stays.  It is the nature of the situation.  I am not sure how feasible it is to move the equipment from side to side of the isolet, but it definitely would be helpful in ensuring round head development in our tiniest babies.  And if moving the equipment is not an option, why not move the baby from the head of the bed to the foot of the bed with each diaper change so that his or her head is turned the opposite way on a regular basis.

Having two premature babies myself, I know how important it is to keep the baby calm, reducing the amount of activity to a minimum for oxygen saturation and heart rate, but a little long term planning would really benefit these babies once they get out of the NICU and move on with development.  Remember, it is always easier to prevent head flattening than it is to correct it.