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.

Gravity, Pressure and Plagiocephaly

When treating plagiocephaly, parents are instructed to keep their baby off of the flattened spot as much as possible to prevent worsening.  Often, parents translate this to keeping the baby upright as often as possible with no pressure on the head at all in hopes that this will round out the head shape.  One frequent question I field in my practice when dealing with babies who have plagiocephaly is, "If I just keep him off his head, it will round out?"  It would seem a logical solution, but in fact, allowing the baby to lay on the rounded area is actually more beneficial.  The brain grows in the path of least resistance, therefore, if you put pressure on the right side, the brain "moves" left.  The scenario I use for parents is this: think of a tennis ball in a water balloon.  If you put pressure on one side of the balloon, the ball shifts to the opposite side.  When the soft spot and sutures are still open, the head is very much the same way albeit not as pliable.  Therefore, placing the baby on the rounded part of the skull actually acts to shift the head to a more rounded position.  This is same concept of cranial remolding helmets.  These orthotics hold the high points (rounded parts) of the skull and take all pressure off of the flattened areas to encourage brain growth in the desired direction, simply put.  Conservatively, placing the baby's head on the rounded area follows the same concept.  

In addition, according to Wolf's law, bone will adapt to the load placed on it and actually make structural changes to become stronger the more load it is experiencing.  In essence, the skull gets stronger by having the baby lay on it.  This is important in protecting the brain making lying on a firm surface essential.  Prolonged lying on soft surfaces will thwart this process of strengthening of the bone.  

Once the soft spot and sutures of the skull close, the head shape will remain unchanged, for the most part.  Eighty percent of head growth occurs in the first year of life making this the perfect window of opportunity to ensure a nice rounded head for the future.  The best practice is to place your baby a variety of positions on a firm surface for a rounded skull and a strong skull.  If high points or rounded areas exist, think of the path of least resistance and encourage the baby to lay on those areas of the head.  

How to Prevent Head Flattening and Shortened Neck Muscles in Your Infant

I thought it most beneficial to post a simple check list of the most effective ways to prevent flat spots on the head or misshapen head (plagiocephaly) and shortened neck muscles (torticollis) in your infants. 

*Avoid prolonged use of car seats, bouncers, swings, and the like.

*Only use car seats in the CAR not as a place to sleep at home.

*Allow baby plenty of play time lying flat on the floor, crib, bassinet, play yard.

*Tummy Time, Tummy Time, Tummy Time!

* Carry your baby in your arms as often as possible.

*Make sure your baby is turning the head to both directions daily.

*Be safe!  DO NOT PUT soft, plush items in the baby's sleep area to reduce the risk of suffocation!

 

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.