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!