What SIDS is NOT!

I had the distinct opportunity to attend the Collaborative Improvement and Innovation (COIN) meeting for the Safe Sleep initiative in Alabama this week and met some motivated leaders in the field who are passionate about making a difference in the arena of protecting infant life.  This initiative will be collaborating with the Safe to Sleep campaign through the National Institute of Health.  Encompassing 13 states, the five areas of focus for COIN are 1) Safe Sleep 2) Perinatal Regionalization 3) Smoking Cessation 4) Interconception Care and 5) Elective Deliveries before 39 weeks.  All five focus areas have a single goal: lowering the infant mortality rate- saving babies' lives.

During the meeting, a common theme resounded.  The second leading cause of death in children under the age of 18 years old is sleep related deaths.  The first leading cause is attributed to vehicle accidents.  Astonished?  I am, too!  What that means is in the state of Alabama the second leading killer of children is PREVENTABLE!  In order to break this down, I feel it is first essential to explain and over explain what SIDS is not so that people realize they can prevent infant death....they can save babies' lives. 

SIDS is the unexplained death of an infant under one year old diagnosed after autopsy, death scene investigation and child/family medical history review.  If the cause of death remains unclear or unknown it is labeled SIDS.  I bring this up again because many people think of any infant death as SIDS and that there was "nothing that could prevent it". If it is a true SIDS case and all of the requirements are met, then yes, you can't prevent it when you don't know happened.  The actual SIDS rate is very low.  However, if the death was preventable, IT IS NOT SIDS!

What is preventable?  Sleep related deaths.  And because they are preventable, they are NOT SIDS.  A sleep related death is when a baby suffocates laying in an adult bed.  A sleep related death is when a baby is trapped under another child and smothered during sleep.  A sleep related death is when a baby is left to sleep in a car seat, his or her head falls forward and cuts off the airway causing the baby to stop breathing.  A sleep related death is when a baby slips between the crib and the mattress because it is not properly fitted and becomes trapped.  A sleep related death is when a baby is smothered by pillows, blankets and stuffed animals in the crib.  It is gruesome, it is gory, but it is absolutely necessary for all of you to understand you can prevent sleep related deaths.  And it is also essential to understand that we are not fighting SIDS here, we are fighting accidental deaths. 

I firmly believe people have it in their minds that sudden infant death has us all clutched in its grasp with no recourse.  It is simply not true.  We must, MUST understand the distinction between SIDS and a sleep related death if we are ever going to move forward in lowering the infant mortality rate.  What you know can save your baby's life. 

It is a grave injustice for parents to be given a SIDS diagnosis for the death of their infant when in fact it was a sleep related death.  This only puts future children at risk for an accident of the same kind.  Being told "there was nothing you could have done, it was SIDS" when it was actually an accidental suffocation, entrapment or parent overlay will do nothing to help those parents.  We have a responsibility as a medical community to be honest and upfront so parents can not only protect their own children, but also become advocates for other parents as well in safe sleep practices for infants. 

Safe sleep means:
1) An infant should have their own sleeping environment with a firm sleep surface (crib, play yard) where they sleep alone
2) Nothing soft or plush should be put in the baby's sleeping area like heavy, thick blankets, pillows or stuffed animals
3) A baby should not sleep in an adult bed, on the couch or in a recliner due to the risk of suffocation
4) A baby should not sleep in a car seat, swing or bouncer due to the risk of closing off the airway

Be safe out there and know that you can protect your baby's life! 

Plagiocephaly and Craniosynostosis

I'd like to share a case study of an infant I have been seeing for ~5 months.  He was first referred to me in the clinic for flattening of the back of the skull (positional plagiocephaly) at 4 months old.  We started on a stretching program to stretch his neck muscles that were tightened (torticollis) and a positioning program to correct the flattened area of the skull.  He made a full recovery from the tightened neck muscles and his head rounded out to within a few millimeters difference from left side to right side.  A few months later, he returned for developmental delay due to a weak trunk and not sitting.  Through the course of treatment, his mother, pediatrician and myself noted a protrusion on his forehead that was becoming more prominent.  After a trip to Vanderbilt to consult with a cranio-facial surgeon, he was diagnosed with single suture craniosynostosis.  There exists in the skull a series of sutures that are open at birth to allow an infant to pass through the birth canal.  These "soft spots" remain open through the first year to accommodate the growing brain and fully fuse by adulthood.  If any one of these sutures closes prematurely, it is termed craniosynastosis.

After some research, it became evident that although craniosynostosis is rare (reports stating 1 in 2000 to 1 in 4000) it is important for parents and physical therapists alike to be aware of it when it comes to plagiocephaly (misshapen head).  It is therefore encouraged for pediatric physical therapists to check whether the soft spots are still open with each baby with a diagnosis of plagiocephaly.  This is especially true with babies with a diagnosis of brachycephaly- a type of plagiocephaly.  Fusion of the metopic suture (the suture on the forehead) causes a triangular shaped head with a narrow forehead and wide back of the head which is also the cranial shape with brachycehpaly.  In my travels across the country, I have spoken with many PT's and orthotists alike who say "It is more difficult to treat a baby with brachycephaly with a cranial remolding helmet," with some claiming very little success with this head shape type.  Perhaps it is actually a single suture craniosynostosis of the forehead suture (metopic) rather than a failure of the helmet in these cases. 

Every tool we can put in our case is a benefit to a child.  If you have a story you would like to share on this topic, I'd like to open it for discussion.   

Press Release

The National Institute of Health is pleased to announce the launch of the Safe to Sleep Campaign which enhances the previous Back to Sleep Campaign of 1994.  This campaign is different from the original program in that it expands the focus from only Sudden Infant Death Syndrome (SIDS) to all sleep-related, sudden unexpected infant deaths.  As part of the initiative, the NIH has announced Safe to Sleep Champions in the states with the highest numbers of SIDS and other sleep-related deaths to promote the new campaign.

Stephanie Pruitt, Pediatric Physical Therapist and author of The Truth About Tummy Time: A Parent’s Guide to SIDS, the Back to Sleep Program, Car Seats and More has been named a Safe to Sleep Champion by the National Institute of Health as a spokesperson for the North Alabama region.  Pruitt, along with 35 other Champions in the states of Alaska, Arkansas, Delaware, District of Columbia, Georgia, Iowa, Kansas, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Montana, North Carolina, Oklahoma, South Carolina, South Dakota, Tennessee, West Virginia and Wyoming will be promoting the Safe to Sleep Campaign in various media outlets throughout the month of October, National SIDS Awareness month, to spread the word about the new campaign.

“What you know could save your baby’s life”, Pruitt says stressing that a safe sleep environment can determine your baby’s survival.  “Although the SIDS rate has declined in recent years, the rates of other sleep-related deaths like suffocation, accidental strangulation and entrapment have increased making this program so important for parents and caregivers of infants up to one year old.” 

The main message of the new campaign is a safe sleeping environment.  This includes a separate sleep environment for the infant (like a crib, bassinet or play yard) with a firm mattress that fits the bed snugly.  Infants should not be placed to sleep in an adult bed due to the risk of overlay, entrapment or suffocation.  All soft, loose items like stuffed animals, thick, heavy blankets or pillows should not be placed in the sleeping area as they pose a risk of suffocation.   The American Academy of Pediatrics recommends placing the baby on the back to sleep for every sleep in a safe sleeping environment. 

For more information on the Safe to Sleep campaign, visit www.nichd.nih.gov/SIDS

For more information on The Truth About Tummy Time A Parent’s Guide to SIDS, the Back to Sleep Program, Car Seats and More visit www.abouttummytime.com  

New AAP Recommendations for Safe Sleep

It is with great pleasure that I am posting the new American Academy Recommendation for infant sleeping.  The policy statement released in October 2011 is now making its rounds in the medical community with the NICHD launching the Safe to Sleep campaign in the near future.  I am almost moved to tears to read in the opening paragraph of the policy statement, "The AAP, therefore is expanding its recommendations from focusing only on SIDS to focusing on a safe sleep environment that can reduce the risk of all sleep-related infant deaths, including SIDS."  Also in that opening paragraph is, ""...other causes of sudden unexpected infant death that occur during sleep, including suffocation and asphyxia, and entrapment...have increased in incidence, particularly since the AAP published its last statement in 2005".  I am SO excited to hear about the newly expanded campaign as it makes all the effort of educating about safe sleep for the last several years worth it!  

The following are the new recommendations:

1) (not surprisingly) Back to sleep for every sleep
    - Once an infant can roll from back to stomach and stomach to back, the infant can be allowed to remain in the sleep position that he or she assumes.

2) Use a firm sleeping surface- a firm crib mattress, covered by a fitted sheet
    - infants should not be placed for sleep on beds because of the risk of entrapment and suffocation
    - portable bed rails should not be used because of the risk of entrapment and strangulation
    - Sitting devices, such as car seats, strollers, swings, infant carriers and infant slings are not recommended for routine sleep

3) Room-sharing without bed sharing is recommended
    - infant crib, portable crib, or bassinet should be placed in the parents' bedroom.  This arrangement reduces the risk of SIDS and removes the possibility of suffocation, strangulation, and entrapment that might occur when the infant is sleeping in the adults' bed.
    -devices promoted to make bed sharing "safe" (co-sleepers) are not recommended

4) Keep soft objects and loose bedding out of the crib to reduce the risk of SIDS, suffocation, entrapment and strangulation

5) Pregnant women should receive regular prenatal care

6) Avoid smoke exposure during pregnancy and after birth
    - Smoking in the infant's environment is a major risk factor for SIDS

7) Avoid alcohol and illicit drug use during pregnancy and after birth

8) Breastfeeding is recommended

9) Consider offering a pacifier at nap time and bedtime

10) Avoid overheating

11) Infants should be immunized in accordance with recommendations by the AAP and the CDC

12) Avoid commercial devices marketed to reduce the risk of SIDS

13) Do not use home cardiorespiratory monitors as a strategy to reduce the risk of SIDS

14) Supervised, awake tummy time is recommended to facilitate development and to minimize development of positional plagiocephaly   :)

The list goes on for a total of 18 recommendations.  For a complete view of the policy statement click here. 

Why you Must Treat Torticollis even with a Helmet!

Since the last post "Cranial Remolding Helmets: To Be or Not to Be", my inbox is flooded with people asking for more information on why it is important to treat torticollis even when a baby has a cranial remolding helmet.  Just to reiterate, the cranial remolding helmet is treating the flat spot on the head and ONLY the flat spot on the head (plagiocephaly).  The subsequent shortened neck muscle(s) are still shortened and need to be addressed with a stretching and positioning program to ensure equal range of motion on both sides of the neck as well as balanced muscle development.  The helmet is not designed to treat the neck or it would have a component that extends beyond the head to the neck as well. 

Here is an analogy:  If you were in a car accident sustaining injuries of a broken arm and a severe muscle strain in your back, would you not treat your back because you had a cast on your arm?  The same applies for the difference between plagiocephaly (head flattening) and torticollis (shortened neck muscles).  Because the two conditions coexist 80-90% of the time, they must each be treated in conjunction. 

In a nutshell, you must treat the torticollis even if your baby has a helmet.  For more information and research backing this claim, refer to the reference section of the book The Truth About Tummy Time.  If changes are not made in the pattern of caring for your baby, the shortened neck muscles will not magically resolve on their own.

Cranial Remolding Helmets: To Be or Not to Be?

It is common for parents to have many questions about cranial remolding helmets or orthotics.  Here is what you need to know about them:

What is the helmet and what does it do? There are several different types (helmets, headbands) that all have the same goal of remolding the shape of your baby's head.  The type used on your baby will be determined by the orthotist or cranial remolding center you go to for treatment.  The theory is that the brain grows in the path of least resistance.  The helmet or headband works by maintaining the high points or rounded areas of the skull allowing the flattened areas to round out as the brain continues to grow.  Optimally, the helmet is fit by nine months old and is worn anywhere from two to nine months depending on the severity of the head deformity.  The baby wears the helmet 23 hours a day and you must return to the orthotist or cranial remolding center for adjustments on a regular basis.  Insurance does not always cover this treatment with the average costs of head remolding orthotics ~$3000. 

Is there another option for treating a misshapen head? The short answer is yes!  Conservative measures are very successful when a positioning program is put in place right away.  This can mean from day one after birth to prevent head deformity in the first place or as soon as a flat spot is detected.  A positioning program is clinically proven to work and involves changing the position of your baby every time you put him or her down.  This means sometimes on the back, sometimes on the stomach, sometimes on the right side and sometimes on the left side.  The variety of positions ensures equal forces on the head to allow a rounded head appearance as well as developing equal muscle strength on all sides.  Head movement also develops the balance system itself.  Another must is limiting the time your baby spends in carseats, swings and bouncers as all of these items contribute to flattening of the skull.  These apparatuses are ok for brief periods to ensure not only a rounded head shape, but also developmental milestone acquisition. 

Who should get a cranial remolding orthotic? In my experience, there are two groups who could benefit from a helmet for the treatment of a misshapen head (plagiocephaly).  The first group are infants with a diagnosis of hydrocephalus or similar internal disease process that effects the shape of the head.  With hydrocephalus, once the spinal fluid is properly regulated and shunted off the brain, the head may have an abnormal appearance.  Where conservative methods could also work depending on severity, a helmet or headband would assist in the process of reshaping. 

The second group is if the parents/caregivers do not have ample time to institute a positioning program.  There is no judgement passed here, it is reality as we know it today in our busy world with both parents working, single parenthood, etc.  And the daycare is not always willing, able or allowed to assist in the positioning program.  A baby who spends the majority of his or her time confined in a carseat, bouncer or swing or flat on his or her back for whatever reason with little opportunity for floor/play time could benefit from a helmet or headband to ensure optimal rounding of the head if flattening exists.  Be aware that people rarely go to an orthotist or a cranial remolding center to inquire about a hemlet without walking out of there with one--often regardless of how minimal or severe the case.  So be prepared and stand your ground if you have reservations. 

Look for upcoming posts on why treating a misshapen head is so vitally important to your child.  In the meantime, I am happy to answer any questions you may have.  Good luck out there! 

Book Review

I am happy to share a book review from Australia by Whatson4.com.au: (http://www.whatson4littleones.com.au/review-parenting-support.asp)

"When I first began reading this book, I thought it may have been too scientific and not "easy reading" which is all I can cope with these days (new mother!).  But I found it so informative, I couldn't put it down!  I found the author's personal experiences portrayed in the book to be really honest, without being scary and gave some good advice on finding the right balance between following the SIDS recommendations and incorporating tummy time in your baby's day.  There are some sections that were more scientific and statistical which would make it a very valuable resource for a health professional and a great resource to have as part of a library." 

~Anna, mother to 1

Guest Post- Tummy Time and Infant Development

"Thank you, Stephanie, for the opportunity to write a guest post for your blog.  We share a passion to teach parents and others about the importance of infants being on their tummies. 

Many facets of human development are dependent on infants being in the prone position.  One important, yet often overlooked, facet is sensory development.  We all learn in preschool about our senses.  Those senses are the way we learn about our world and our place in it! 

Hearing

Our sense of hearing has two components, 1) the structure of the ear receiving sound appropriately and sending those signals to the brain and, 2) processing of those signals once received in the brain (commonly called auditory processing).  Both are stimulated for an infant by being on their tummy.  Foundational reflexes that are available ONLY in the prone position are developed during infancy.  Development of bi-aural hearing (using both ears simultaneously) is done on the stomach. 

Feeling

If an infant is not overdressed and is on their tummy moving and exploring their world, the opportunities for “tactile stimulation” are almost limitless.  They spend time flexing their fingers or seemingly “scratching” the floor, the blanket, the sofa and anything else they can reach.  Rolling around on the floor or in the grass gives a whole-body experience to our sense of feeling.  This also stimulates our sense of balance—which relates directly back to hearing and auditory processing.  If you have seen the popular movie “A Christmas Story”, you may remember when the younger brother has been almost mummified in winter clothing as he walks to school.  On his way, he falls into the snow and cannot move.  He can’t feel a thing, and thus he can’t move!  We can’t move what we can’t feel.  (Just try to walk after sitting on your foot too long!)  Allowing our children to have their arms/legs/feet/hands bare as much as possible while prone is one of the best ways to encourage their mobility and their interaction with their world.

Seeing

Babies are born not seeing very well.  Their vision is not yet developed---and they do that developing best----you guessed it----on their bellies.  They can begin to understand the images around them within a very short distance—and it is easiest for them when it is “finite”.  In other words, it is easier for them to see the short distance to the ground from their belly, than it would be for them to be on their back and try to see an object above their heads.  It would be very easy to lose focus on an object in the vast expanse over their heads when supine---the ground gives a definite endpoint.

Children in populations where tummy time doesn’t happen, don’t develop the ability to focus or “converge” their eyes on a single object.  The ability to converge their vision is the foundation for depth perception. 

Parents sometimes think the senses just automatically develop, but nothing could be farther from the truth.  Time in the prone position has far-reaching effects that last a lifetime---starting today!

Guestpost written by Donna Bateman, a Neurodevelopmental Specialist and the mother of eight children.  Mrs. Bateman knows the importance of tummy time and understands the negative consequences throughout the developing years if this step to development is denied.  You can read more about her and her practice (Parents With Purpose) at http://www.parentswithpurpose.com/ ."

Co-Sleeping vs. Bed Sharing

While giving a presentation at a local hospital yesterday, the coordinator asked me if I followed the research of Dr. McKenna on infants and sleeping.  Evidently, there are a couple of Dr. McKenna's but the one she was referring to was James McKenna who often writes about the sleeping debate.  After scrolling through a few of his blogs, I was entertained to find that he separates out the terms co-sleeping and bed sharing.  Unfortunately, most others use these terms interchangeably.  So to clarify,  in the last entry entitled, "Co-sleeping, is it safe?"  I am referring to a baby sleeping in the same bed with adults or other children.  Room sharing is another topic all together and is recommended by not on the AAP but many others.  Room sharing is where the baby sleeps in the same room as the parents but in a separate sleeping environment- a crib or bassinet, etc. 
Hope this clears everything up! 

Co-sleeping, is it safe?

According to research, one of the greatest risk factors for infant death is co-sleeping, yet, it is still a common occurrence either intentionally or unintentionally.  I say unintentionally because we have all experienced the terror of accidentally falling asleep while nursing our baby in the wee hours of the morning then waking in a panic afraid we have smothered him or her.  Co-sleeping is especially dangerous if an infant shares a sleeping environment with other children.  The Center for Disease Control released some statistics in 2003 then updated them in 2008 stating that infants who died of "SIDS" were 5.4 times more likely to have shared a bed with other children*.  I put SIDS in quotes because I believe a more appropriate diagnosis would be smothering or entrapment in the case of co-sleeping since the cause is known.  Dr. Andrea Minyard,  Medical Examiner in Florida explained that 2/3 of the 41 infant deaths she examined were accidental asphyxiations.  She determined "These infants die because they are accidentally smothered by their parents or other children who sleep with them or because they are placed on dangerous overstuffed sofas or heavily blanketed beds."**

More recently, I attended a seminar to hear Lisa Carter, RN speak.  Lisa is the Regional Perinatal Director in Alabama who is undergoing an investigation with the other regional directors in Alabama reviewing the infant deaths in our state from 2010 to 2011.  She stated that 50-75% of cases were sleep related deaths.  1) Co-sleeping in an adult bed 2) Co-sleeping on a sofa or recliner 3) Infants sleeping in swings unattended 4) Lying on the stomach on an adult bed 5) Sleeping on U-shaped pillows (like a Boppy) She was very specific when she stressed, "These were all preventable deaths!

The bottom line is, an infant is safest in a his or her own sleeping environment on a firm mattress.  To answer the question, "Is co-sleeping safe?"  No, it is not.  And for all of you mothers who nurse your baby throughout the night, I recommend nursing the baby in a place other than your bed so you are less likely to fall into a deep sleep in the comfort of your own mattress.  Personally, I had a firm twin bed in the nursery where I would nurse with a lamp on to remind me I was nursing and not safe to fall into a deep sleep. 


*NIH/NICHD "Bed Sharing with Siblings, Soft Bedding, Increased SIDS risk and Frequently Asked Questions about Bed Sharing" NIH/NICHD News Release, May 5, 2003. Updated September 16, 2008.
**Hargrove, T., Bowman, L. Many Babies Die from Suffocation, not SIDS, Study Shows. Scripps Howard News Service, December 16, 2007. 

SIDS Shift in Thinking....Finally!

It is very refreshing to read the latest study that now has swept through the medical community regarding SIDS and sleeping environments. 568 SIDS deaths in the San Diego SIDS/Sudden Unexplained Death in Childhood Research Project from 1991 through 2008 were reviewed concluding that multiple risk factors are responsible for the remaining ~2,500 SIDS death each year, not just back sleeping. FINALLY!

The article explains that a safe sleeping environment is paramount. Just to review, a safe sleeping environment is one in which a baby sleeps alone in a crib with a properly fitted, firm crib mattress devoid of soft, plush items such as stuffed animals or thick, heavy blankets. Included in the term "safe sleeping environment" includes not smoking around the baby or in the room where the baby sleeps.

It goes on to pinpoint prematurely as a risk factor for "SIDS" as well. Prematurely is on the rise with an increase in 9% since 2000. A baby born premature is at risk for complications. This makes prematurity/low birth weight the second leading cause of infant mortality in the United States.  It is perplexing why a premature infant with complications leading to mortality is sometimes labeled as "SIDS". Shouldn't this be labeled "complications with prematurely" since the cause of death is known? Remember that by definition, SIDS is an "unknown" cause of death. Just FYI, the number one cause of infant mortality is congenital defects with heart defects leading the pack. Sudden Infant Death Syndrome is the third.

It is not in my professional repertoire to say, "I told you so!" so instead, I will refer you to the book The Truth About Tummy Time: A Parent's Guide to SIDS, the Back to Sleep program, Car Seats and more. I am just thrilled that we are heading in the right direction in protecting our youngest and most precious members. 

SIDS, Daycares and Back to Sleep

With two thirds of children younger than 12 months old being cared for in a child care setting in the United States, it is important to be aware of what position your child is spending most of the day in.  Does he spend hours a day on his back in a bouncer, swing or car seat?  Or is he given the opportunity to move around and play in the safety of a crib or play yard?  These are the questions I encourage you to ask every day when you drop your infant off and pick him up from a secondary caregiver. 

One retrospective study done in 2000, not only gained a lot of media attention, but started its own widespread panic surrounding daycares.  Unfortunately, law suits were cast resulting in some daycares fearful of positioning infants in their care.  The study consisted of 11 states reporting with 1916 SIDS cases analyzed.  It found that 20.4% of what was diagnosed as SIDS occurred in a daycare setting citing an “unaccustomed” sleeping position as the culprit.  Rather than encourage everyone to get infants accustomed to different positions from birth, the AAP decided it was best to further discourage any position but on the back.  Of course, the AAP is referring to the sleeping baby, but what people hear most is “only place your baby on the back” translating to “never put your baby on his side or stomach”.  The whole “while sleeping” part is often left out of the equation. 

If babies are given the opportunity to explore side lying, lying on the stomach and lying on the back equally from the beginning (birth) during waking hours, there should be no “unaccustomed” position.  Unfortunately, I hear from the parents of my patients that the only position their baby is in for long hours a day is on the back, especially if he isn’t the only infant being cared for at the daycare.  One could only assume it is easier to keep all the infants contained if there are multiple babies in one room. 

If you are not the primary caregiver of your child, I encourage you to have this conversation with the one who cares for you infant during the day.   Think variety of positions.  If the caregiver needs to put your child in a contained situation to care for the other infants, ask them to place him or her in a crib or play yard so they are not confined and can easily move around an explore in an safe situation.  Cribs and play yards are so much better for development, exploration and movement because the baby is given the opportunity to use his muscles, build his skills and mature his brain.  Car seats, swings and bouncers restrict movement and discourage muscle movement and exploration.  They also encourage a favored head position and propagate flat spots on the head.  Substituting the crib or play yard is a very reasonable request that even the busiest day care worker should be able to comply with.  Even if they are not comfortable placing your child in any position but on the back, at least your child can move around during the day and explore the positions he is capable of on his own. 

Good luck out there! 

Tips for Getting Baby Used to Tummy Time

Here are some tips to get your baby used to lying on his or her stomach:

1) Start early.  You can safely place your baby on the stomach as early as the first day after uncomplicated birth.  Babies are equipped with reflexes that assist them to lift and rotate their head from side to side. 

2) Lay on your back and place baby on your chest.  He/she will take comfort in being close to you and hearing the sounds of your body he/she was used to during pregnancy.

3) Lay baby over your legs on his/her stomach.  You can rock your legs to soothe baby and you can add a gentle back massage. 

4) Carry baby in your arms facing out with your forearm across his/her stomach and chest.  Baby will rest his/her head on your arm.  This is a great position to help relieve gas

5) Prop baby up on his or her arms while on the floor on a thin blanket or sheet.  Place something stimulating to look at so baby will lift his/her head.  Remember, some tummy time is better than no tummy time at all. 

6) Don't forget about allowing baby to play in side lying.  This will help the muscles of the front and the back work together and get stronger so when baby is on his/her stomach, it is easier to lift his/her head. 

7) Play airplane with baby.  Lay on the floor on your back, bend your knees up and place baby on your shins.  Baby can see your face and become accustomed to the sensation of lying on the stomach at the same time.  (This position is also a great ab work out for you!)

8) Most importantly, carry your baby on your shoulder instead of in a car seat.  Even being upright against your body allows for muscle strength to be built up all the way around and improves head control, trunk control and balance at the same time. 

They are little for so brief a period!  Hold them as much as you can in this very fast, fleeting first year.  You'll be glad you did. 

The Tummy Time Debate

So, where did this recent tummy time debate start in the first place?  Prior to the Back to Sleep campaign in 1992, various researchers investigated the benefits and drawbacks of sleeping on the stomach.  In one study done in 1983 by Hashimoto, T. et al¹, there was evidence to suggest that newborn infants had significantly more quiet sleep on the stomach than on the back with breathing more regular while on the stomach.  Further, sleep apnea was less when infants slept on their stomach as well as pulse rate higher.  Another study done in 1987 by Masterson J., et al², looked at the energy expenditure of low birth weight neonates summarizing that “when low birth weight infants are changed from the supine (back) to the prone (stomach) position, energy expenditure decreases, time spent in quiet sleep increases, and time spent awake decreases.”  The conclusion was that low birth weight infants’ position of choice was on the stomach. 

After the Back to Sleep campaign, there seemed to be a shift in the number of studies that were out to prove that stomach sleeping was harmful.  In 2001, Horne, RS., et al3³ studied the arousal from sleep in term infants concluding that arousal thresholds were higher when infants slept on the stomach at 2 to 3 weeks and 2 to 3 months, but not at 5 to 6 months.  This was considered an “impairment” by the researchers stating this “provides an important insight into its role as a risk factor for sudden infant death syndrome.”   Sleeping soundly was considered a benefit by researchers just a few years before, but was now considered an impairment. 

In 2009, Ammari A., et al⁴, took a look at what I would consider the most important factor in this debate-the actual cardiorespiratory and metabolic activity going on in the infant (or the breathing, heart activity and energy expenditure) while asleep.  This group studied low birth weight infants who are considered at higher risk for complications than term, healthy weight infants.  Sleeping on the stomach “exhibited many physiological differences from sleeping supine (back)”.  These included less energy expenditure and less heat loss which influenced cardiorespiratory activity.  It was concluded that infants who slept on their stomachs consumed less oxygen and produced less carbon dioxide as well as had a higher respiratory quotient. 

What does all this scientific stuff mean?  To me, it means that infants tend to sleep more soundly on their stomachs likely due to the positive effects on the cardiorespiratory system.  I do not see sleeping soundly as a negative thing for infants.  I do see the concern for arousal level by the opposing side IF the baby was in an unsafe sleeping environment.   With all the research I have done on this topic, the primary concern is the baby’s reaction to adverse conditions while sleeping like a stuffed animal falling over the face causing him or her to breathe poorly oxygenated air.  The argument is if the baby is on his or her back, he or she is not sleeping as soundly and is aroused easier to change position to find a better source of oxygen.  Again, the counterpoint stresses the importance of a safe sleeping environment because a baby does not have the muscle strength to do anything about something blocking the face in any position for the first few months. 

Ultimately, the decision is undoubtedly yours.  Your comfort level will determine how you proceed in this long-standing debate.  Have questions or comments?  Email me:  Stephanie@abouttummytime.com

1.      Hashimoto, T, et al, “Postural effects on behavioral states of newborn infants- a sleep polygraphic study” Brain Development 1983; 5(3):286-91

2.      Masterson, J, et al, “Prone and supine positioning effects on energy expenditure and behavior of low birth weight neonates.” Pediatrics 1987 Nov; 80(5):689-92

3.      Horne, RS, et al, “The prone sleeping position impairs arousability in term infants” J Pediatrics June; 138(6):811-6.

4.      Ammari, A, et al, “Effects of body position on thermal, cardiorespiratory and metabolic activity in low birth weight infants” Early Human Development  2009 Aug; 85(8):497-501. Epub 2009 May 5

Is it ok for babies to sleep on their stomachs?

Should a baby sleep on his or her stomach? Parents and interviewers alike have asked me this question in reference to a baby who rolls him or herself onto the stomach while sleeping at night. Parents tell me they are “so worried” about this occurring, they will wake up many times a night and check on their baby for fear he or she has rolled over. This concern was reiterated in an interview on the "Baby and Toddler Instructions" interview I had with Blythe Lipman who expressed callers were asking this question of her on a regular basis.


My answer? If a baby can roll onto his or her stomach from the back without help, then yes, he or she can sleep there. I say this with confidence because if a baby has the muscle strength to get into that position, he or she has the muscle strength to get out of that position. The primary concern then becomes the safe sleeping environment. Just to remind you, a safe sleeping environment is alone in a crib or play yard with a mattress designed to fit in it, devoid of soft, plush items, or thick, heavy blankets.


Many babies actually prefer to sleep on their stomachs! So, go back to bed and relax. You will need as much sleep as you can get in these early years!

When Do I remove the head support from the Car seat?

Many parents ask me when it is ok to remove the head support from the infant car seat. Equally as many leave the head support in long after the child has outgrown it with the comment, “I never knew when to take it out.” Not to worry, you are not alone!

The head support in a car seat is designed to support the infant’s head during the first few months of life before he or she has adequate muscle control to hold his or her head up in midline. This is also the most important time to protect the baby’s head while he or she is being held so it doesn’t whip suddenly in any one direction. Once the baby has good control of the neck muscles and can hold his or her head up while being held on your shoulder or while the baby is held sitting, it is time to remove the head support from the car seat. Depending on how much opportunity the baby is given to develop those muscles, this can be anywhere from 3 to 5 months of age.

It is important to remove the head support in the car seat to allow the baby to continue to develop strength in the neck and upper back muscles unrestricted. It is also necessary to allow the baby to freely turn his or her head from side to side reducing the risk of flattened spots on the head.

(Speaking of car seats, it also important to make sure the straps are in the right spot so not to squish the baby into a favored head position- leaning to one side all the time. The strap slot should be at the middle of the back of the shoulder for proper fit. You will be amazed how the baby appears longer when the straps are put in the right place!)

Is My Child Developmentally Delayed?

This is a question I am asked by many parents when they bring their children in to see me for physical therapy services.  It is important to look at many factors to make this determination, for instance, underlying medical issues, prematurity, personality and size of the child and most importantly opportunity for movement unhindered. 

                To take each in turn, there are many medical reasons that can contribute to a developmental delay.  Rather than listing them all, it would suffice to say that certain patterns will begin to emerge to indicate a problem.  A parent will notice multiple areas that are “not quite right” across the spectrum of fine motor, gross motor, feeding, sleeping, etc. that occur over time as the child develops in the first year.  Most children who I treat with the diagnosis cerebral palsy receive the actual diagnosis anywhere from 8 months of age to 18 months of age.  It follows an observance by the doctor and the parents of multiple issues with the child.  Prematurity is technically considered a medical condition which also influences when a child will develop certain skills.  We establish an adjusted age on evaluation.  What this means is if your child was born 8 weeks premature, you could possibly see a 2 month delay in skill acquisition up to about three years old.  By three years, children are typically all doing about the same thing. 

                Personality and size play a huge role in how fast a child develops.  In my experience, the smaller and lighter an infant is, the easier it is for him or her to progress through skills.  In contrast, the heavier and bigger an infant is, a slower progression is more often observed.  This is just physics.  It is more difficult to lift a heavy head with weak muscles than it is a light one.  It is more difficult to roll a heavy body than a light one.  (No, you don’t need to put your baby on a diet!  It is simply genetics.)  On topic with personality, a very curious, active baby will likely develop faster than a baby with a laid back personality.  My second son is a perfect example.  He was very content to just sit and observe as an infant.  There was nothing he needed bad enough to move for.  We nick named him “The Rock” because wherever you placed him would be where he remained until you moved him again.  He eventually did everything he was supposed to, he just took his sweet time about it.  To this day, he is a more laid back individual who doesn’t really get ruffled about much in life. 

                The most important factor that you as the parent can directly influence is how much opportunity for movement your child receives.  It stands to reason that the more opportunity a child receives to explore the use of his or her muscles, the faster he or she will develop.  Conversely, the less opportunity the child has for movement, the slower he or she is likely to develop.  For example, a mother has been bringing her infant son in for treatment of developmental delay for a few months now.  He was six months old when I first evaluated him, in the higher percentile of weight and height- a big baby boy- with a laid back personality and who spent most of his time confined in a car seat, bouncer or high chair in a day care setting.  With this combination of size, personality and limited opportunity for movement, it was no surprise he was not moving.  I was not alarmed, nor did I detect any medical reason for the delay, but it was much more difficult to explain to the mother who was panicked that he wasn’t doing the things other children his age were doing.  Even though I have been encouraging her endlessly to give him opportunity for movement and to get him out of the car seat, she consistently tells me she doesn’t have time to work with him on his exercises because she never sees him (he is in day care and she works 40-50 hours a week) and brings him in for every treatment strapped in his car seat.  (Just a side note here, there comes a point when you have to boldly and blatantly say to a mother, “Leave the car seat in the car and carry your baby around!”)  The simple act of actually carrying your baby gives him much opportunity to use his muscles, his balance, his eyes and many other systems in the body.  So, if you are like this mother who does not have enough hours in the day to get it all done, just carry your baby around on your hip.  This will help. 

                In conclusion, I must remind you all that medical professionals look for patterns over time and for skills to be mastered in certain ranges of time.  With the advent of car seats and bouncers, etc. this range of skill acquisition is slowly ebbing towards later months for accomplishment.  Observe your baby for personality and size; observe yourself and how much you are carrying your baby in your arms as opposed to pushing a stroller or carrying a car seat.  Take a look at how much opportunity for movement your baby gets during the day.  All of these factors, medical, prematurity, personality, size and opportunity for movement will more accurately answer the question, “Is my baby developmentally delayed?” 

The SIDS Devil's Advocte

A reporter recently played the devil’s advocate in a phone interview with me a few weeks ago.  He brought up a really good point which I had thought of myself while writing the book.  He asked, “If all of these problems (torticollis, plagiocephaly and developmental delay) are treatable, what’s the big deal with keeping babies on their back to reduce SIDS?”  Excellent point, my friend!  I fully agree with keeping infants alive and safe at all times above all else.  To fully answer this question, we have to take a look at a few different angles.

First, let’s look at the numbers.  There are approximately 4.1 million babies born in the United States every year.  Of those 4.1 million, 6.7 infant deaths occur for every 1,000 live births.  The leading cause of infant death is congenital abnormalities with heart defects being the most common of that category accounting for approximately 5,500 each year.  The second leading cause of death is preterm birth/low birth weight accounting for approximately 4,600 each year.  A diagnosis of SIDS is the third leading “cause” of death accounting for approximately 2,000 each year.  Breaking that down to something tangible, of the 4.1 million babies born every year, 2,000 receive a diagnosis of SIDS.  That is 0.5 in every 1,000. 

To remind you, a diagnosis of SIDS is given after a complete autopsy, death scene investigation and a complete review of the baby’s and family’s medical history.  When a cause CANNOT be determined, the term SIDS is used to say in essence, “We cannot find a cause of death.”  It can be any number of things that caused the death but for whatever reason, the review process did not reveal a known cause.  As new medical advances are made every day, the number of things that remain “unknown” is diminishing.  It is not necessarily that the rate of SIDS is “declining”, rather we are better able to identify the cause of infant death and more accurately diagnose it.  Therefore, SIDS is not necessarily a disease process like cancer, it is what cannot be determined or is unknown.  (Yes, I get very frustrated when people use SIDS and suffocation interchangeably.  They are NOT the same thing!)

Torticollis and plagiocephaly are occurring at a rate of 1 in 300 infants according the latest available statistics.  This rise has been directly related by many experts to the Back to Sleep campaign that began with the primary intention of reducing the rate of SIDS.  The biggest benefit of the Back to Sleep campaign was to streamline the requirements of a SIDS diagnosis.  The AAP itself compared the “decline” in the SIDS rate with the coinciding rise in other infant diagnoses saying that a more accurate classification was being made where a SIDS diagnosis was used in years past. 

If left untreated, torticollis may lead to scoliosis, vision problems, balance issues and TMJ/orthodontic issues to name a few as the child grows.  Forty percent of children with untreated plagiocephaly have been shown to require physical therapy, occupational therapy, speech therapy and/or special education once they reach school age.  What this translates to is a potential lifelong medical intervention need.  Yes, these diagnoses are treatable and many recover fully with intervention by a medical professional, sometimes requiring orthotics or surgery.  The treatment process lasts anywhere from a few months to a year.  But, these diagnoses are also preventable!  Isn’t prevention the best medicine? 

So, “If all of these problems are treatable, what’s the big deal?”  The big deal is we are seeing a negative impact on an entire generation of infants because of a fear of something that occurs 0.5 in 1000 infants.  One in 300 infants are being negatively affected to be precise.  Doesn’t it make more sense to follow a few simple rules for a safe sleeping environment than to confine a baby on his or her back day in and day out in the name of “preventing SIDS”?  Yes, we can prevent the negative impact of the Back to Sleep/fear of SIDS era and keep babies alive at the same time! 

Bumper Pads and infant Safety

Bumper pads are now getting the bad rap that tummy time did a few years ago, although I am not as upset about people never using bumper pads again since that has no effect on the development of a child! A recent article was published in national parenting magazine covering the story of the Chicago City Council who banned the sale of bumper pads citing their danger to infants during sleep. I find this a knee jerk reaction to fear. Of course, I am completely for anything that can protect children, but overreactions to bits of information can prove to be equally dangerous. Such is the case with the Back to Sleep program of the 90’s and early 2000’s. People have become so afraid of placing their baby on the stomach that a good percentage never do!

Bumper pads have become increasingly plush in recent years as has everything to do with caring for infants- car seats, bouncers, toys- although plush, soft things are very dangerous to infants because of the risk for suffocation. The history for placing a bumper pad in the crib goes back to keeping the draft off of a sleeping baby following the belief that a baby could “catch its death”. They are also useful in keeping the baby's arms and legs from getting caught between the slats of the crib.

As a mother and as a pediatric physical therapist, I have to draw on my experience when giving a recommendation about bumper pads. If you place an infant, unable to roll over or even hold the head in midline for lack of strength, in the center of a crib, he or she will likely be unmoved when you return to check on him or her. We are talking about a newborn up to 2 months. It is the exact time when regulating body temperature is still new to the system making it important to keep dramatic temperature changes from happening in the room, hence the bumper pad. Once the baby starts to wiggle around, move and change position during sleep, it is probably best to remove the bumper pad from the crib. This is for suffocation safety as well as for preservation of the bumper pad. For me, my boys would start to pull the bumper pad off the crib and play with it, lift it up to look underneath it, tear the little ties off of the pad that attached it to the bed.

My professional opinion in a nutshell? For infants who are not moving around at all, bumper pads are probably not a big threat if securely attached to the crib with the baby placed in the center of the crib. Go for the thinner variety, avoid the thick, plush types. For infants who are moving around during sleep, remove the bumper pads. And as always, keep all loose, soft, plush items out of the crib at all times including stuffed animals, thick, heavy blankets and all forms of soft mattress covers like foam and egg shell mattresses.

Tummy Time and Crawling Milestone

I field many questions about milestones in my profession, but the one I get most often is about crawling. I love the crawling milestone (if someone can actually love a milestone that is!) It is the single most beneficial skill, in my opinion. Let's break it down a bit. When a baby crawls on all fours, she is weight bearing on her arms and legs, strengthening the hip and shoulder joints. She is shifting her weight between four limbs to move forward, sideways, and sometimes backwards. This requires a great deal of motor planning. Her hands are gripping the floor reinforcing the arches of the hands which will later be essential in handwriting and fine motor skills. Turning her head from side to side in the all fours position is developing the vestibular/balance sense and also the various aspects of vision. The most important piece of crawling is the actual development of the brain by the movement of the body. The corpus callosum is a thick band of nerve fibers that divides the cerebrum into left and right hemispheres. It connects the left and right sides of the brain allowing for communication between both sides transferring motor, sensory, and cognitive information between the brain hemispheres. The reciprocal movement of crawling reinforces the development of this vital part of the brain due to the use of the left and right sides of the brain cooperatively to move the left and right side of the body in a coordinated fashion.

In my practice, I have noticed a correlation between babies who never crawled and those who have difficulty with reading and handwriting once school age. This stands to reason because the corpus callosum is required in reading and writing to follow a sentence across the page from left to right utilizing both sides of the brain. These children also tend to have balance and coordination issues as well.

Why is tummy time important here? Without tummy time, a child may not develop the extensor strength or the reflexes to assume the all fours crawling position. The Symmetrical Tonic Neck reflex is what gets a child up into the crawling position and is developed from the prone or stomach lying position. Again, it is difficult to develop a balanced, coordinated body while neglecting an entire muscle group, the extensors of the neck and back.

Last thing to remember: It is NEVER too late to crawl! :)

SIDS vs. Suffocation

With the latest theory on SIDS, it is a bit difficult to determine the difference between SIDS and suffocation. For starters, SIDS is the unexplained death of an infant under a year old. This diagnosis can only be given if the cause of death is still unknown after a complete autopsy, investigation of the death scene/circumstances of death and a review of the baby’s and family’s medical history. Suffocation on the other hand is the inadequate intake of oxygen and exhalation of carbon dioxide as in the case where the airway is obstructed or in the case of smothering.

The latest theory on SIDS, published in February 2010, indicates the possibility of babies having a maldeveloped brainstem that has less receptor binding to a chemical messenger called serotonin. What this means in layman’s terms is if the baby is not getting a good source of oxygen, whatever the reason, serotonin will sound an alarm in the baby’s brain so he or she will move to find a better source of oxygen.
It is this theory that is driving the latest trend in the talk about bumper pads. Some products are even being advertised as “may help reduce the risk of SIDS” mainly due to the fact that they allow increased air flow through the crib. The same line of thinking is true with the conversation about ceiling fans and “may reduce the risk of SIDS” because ceiling fans circulate the air in the room.

Be aware that suffocation and SIDS are not the same thing. The recommendation about not having plush items in the crib like stuffed animals and thick blankets is indicating the risk of suffocation. Even if a baby has a normal binding of serotonin, an unsafe sleeping situation is a risk for sudden death. The baby may get the alarm that the oxygen source is less than optimal, but if he or she cannot move out from underneath whatever is on top of him or her, the result could be the same.

Be safe out there!