Vol. 17 Issue 23
The Value of Tummy Time
Helping babies change positions can prevent plagiocephaly and torticollis
I recently got a call from a new mom in need of therapy for her son. This call would normally have not struck me differently, but in my new role as mother I could empathize and feel this mother's fear that her child needed help.
"My baby has torticollis and the doctor said he needs therapy." I heard the sadness in her voice, her fear of the unknown. I was so happy to tell her that yes, I can helpand yes, you can also help your baby get better faster!
After seeing her son, I found he not only had torticollis but also that his head was becoming misshapen, causing positional deformational plagiocephaly. My first question to all moms of infants is how much tummy time are they doing. Her response was, "Oh, we don't really do much of thatI guess I should start?" Tummy time is where our treatment suggestions began.
Why Tummy Time?
The concept of tummy time has emerged because Sudden Infant Death Syndrome (SIDS) has caused a fear of putting children down in any position other than on their backs. Tummy time is needed to remind us of the value of play in a variety of positions.
In 1992 the American Academy of Pediatrics recommended that babies be positioned on their backs for sleeping to decrease the incidence of Sudden Infant Death Syndrome. Since the Back to Sleep campaign, there has been a significant decrease in the amount of SIDS-related deaths. But the Back to Sleep recommendation, as well as infants spending more time in infant carriers and less time on their bellies, has caused an increased incidence of babies with positional head deformities, known as plagiocephaly.
Plagiocephaly is the misshaping of the head due to molding and weight bearing forces occurring pre- and post-natally on the soft skull of infants. In 1992, the incidence of plagiocephaly in a healthy child was one in 300; in 1999 (seven years after the Back to Sleep recommendation) the incidence was one in 60 healthy infants.
Flattened Head Syndrome/ Plagiocephaly
Plagiocephaly occurs in about 20 percent of infants to varying degrees. In many births, skull asymmetry is common from pressure in the uterus and birth canal, but it usually resolves spontaneously.
When increased abnormal forces remain on the soft skull, greater changes in head shape occur, causing this positional deformity. These abnormal forces occur when an infant repeatedly holds its head in one position at rest, has a lack of tummy time (prone positioning), and excessive positioning on its back.
With the advent of so many positioning devices for infants, many babies are positioned in car seats, bouncers, swings and other devices for prolonged hours throughout the day in addition to sleeping on their backs as required. All these positions put increased weight-bearing forces on the back of the head and can cause deformation.
Initially, lying on the belly (prone) is a difficult position for infants. Their neck and back muscles are not strong enough, making head lifting or moving difficult. Often, infants are resistant to tummy time and parents want their babies happy, so they avoid belly lying. Limited tummy time promotes a viscious cycle of decreased strength and control in prone and a greater dislike of the position, in turn leading to greater time weight bearing on the back of the head. If an infant has an average of less than 15 minutes a day of prone positioning before six months of age, the infant often will qualify for early-intervention services.
Signs and Symptoms
Infants who hold their heads to one side often have a condition of neck muscle tightness and imbalance called torticollis. Torticollis is a neck dysfunction often seen in infants presenting as a consistent head tilt in most positions. The asymmetrical weight bearing on one side of the head from the tilt can lead to an increased incidence of plagiocephaly.
Plagiocephaly is when the head becomes more of a parallelogram shape with one side of the forehead coming forward and flattening of the rear side behind the opposite ear. Brachycephaly is another form of positional deformity that describes the flattening of the back portion of the head, causing a broadening of the frontal view and elevation of the top of the head. This is more common in children who remain in a back-lying position for extended positions.
Pediatricians monitor for these skull changes. A quick way to identify a plagiocephaly is to look down at the top of a child's head (a bird's eye view) and if the ears are not aligned there may be a plagiocephaly. Brachycephaly can be visually noted from a side view with a marked flattening of the back of the skull. Torticollis can be identified if a child holds his head tilted to one side a majority of the time and appears to have limited neck motion in the other direction.
Both plagiocephaly and torticollis respond very well to conservative treatments of stretching, changes in positioning and developmental activities. Treatment is more effective when symptoms are addressed early on, starting by four months of age. Treatment has been shown to be less effective after one year of age; therefore, it is best to identify and treat problems early. If further intervention was required, often an orthotic helmet would be recommended for cranial remodeling. Fortunately, once plagiocephaly improves, there is rarely any regression.
Changes in positioning during activities and rest periods are an important component of plagiocephaly and torticollis treatment. Offering a variety of positions is key to any infant's development. For example:
Alternating the ends of the crib and changing table in which the child is placed.
Specialized cushions or wedges to help with head positioning and decrease pressure on the back of the skull.
Position in side lying, especially on the opposite side of the flattened area.
Parents can use pads, rolled towels or cushions to position the head out of a relaxed tilt. (Parents should be careful with towels or blankets in the crib or when child is not supervised).
Alter the position of car seat if the child tends to always look out the window to one side.
Decrease use of car seat for all-around convenient positioning.
Limit lengths of time child is positioned in bouncers and swings.
Tummy Time Tips
Many infants with plagiocephaly spend a lot of time lying on their backs or in a carrier seat and that is a large cause of skull deformation. These infants do not develop necessary neck and back extension control and have a poor tolerance to the prone position.
A research study demonstrated that six-month-olds who did not spend waking time on their bellies had lower gross-motor developmental scores than infants who did regularly spend waking time on their bellies. Their greatest limitations were in prone and sitting skills.
Therefore, it is very important to encourage regular periods of prone activity ("tummy time") for a minimum of 30 minutes a day. This can even be done in five-minute sessions five to six times a day.
The child may initially be irritable, so starting with short sessions and as strength and tolerance improve, increasing time in prone may be more successful.
If the child has difficulty tolerating the prone position, a "boppy" pillow or rolled receiving blanket under the child's chest may help with tolerance and control.
Try toys to increase children's interest while on their belly: mirrors, musical and light toys, and even just a parent or sibling interacting in front.
Doing tummy time in busy areas of the house may help retain the baby's interest.
Often parents are most comfortable handling and carrying their baby a certain way; for example, always feeding the baby with the right arm or carrying on the left hip. Being in the same position all the time encourages the neck tightness of torticollis and weight bearing on one side of the head in plagiocephaly.
Change the hip or side on which the baby is carried. Carry the child so his head turns away from side of flatness.
Use baby slings or carriers that require increased head control and less weight bearing on the skull.
Alter position for bottle or breast feedings to encourage a more neutral head position.
Stand to the side opposite of tightness while changing diapers or interacting with baby.
For overall development, it is important to encourage a baby to move and explore mobility without constant support of positioning devices.
Place toys to side where motion is most limited.
Vary the toys and location of toys.
Encourage bringing head, body and hands to the middle.
Play games that require visual tracking of toys or people in all directions (up and down, side to side and diagonally).
Side-lying activities help decrease pressure on certain areas of the skull and help children develop better overall control of their bodies.
Rolling helps the child develop control and movement out of one regular position.
Play in supported sitting is helpful to facilitate the child's motor development and decrease weight-bearing forces on the head.
Weight shifting or tilting child side to side in supported sitting and other positions can help develop head righting and strengthen the neck muscles. Try sitting your child on your thigh while supported and rock side to side.
The baby was an eight-week-old boy referred for physical therapy with a diagnosis of torticollis. He was born through a full-term pregnancy, prolonged labor with a Cesearean-section delivery and weighed 6 pounds, 11 ounces.
He presented with right congenital torticollis and a moderate deformational plagiocephaly. His head was positioned with right rotation and right lateral flexion. Lateral cervical flexion to the left was 25 degrees passive and active to midline. Cervical rotation to the left was 70 degrees passively and 50 degrees actively. He momentarily brought his head to midline in supine, visually tracked an item to the left 30 percent of the time.
He had poor tolerance to prone and mom noted she did not put him in prone at all; he was unable to lift his head in prone or turn his head to clear his face. His gross-motor developmental scores were in the 10th percentile on the Alberta Infant Motor Scales (AIMS). He had no reflux; hearing and vision tests were normal.
His physical therapy plan of care was treatment twice a week (once with mom and once with grandma since both were caregivers) for four weeks. Treatment focused on instructing the family on a home program of cervical stretching, active cervical range of motion, positioning and handling changes and a tummy time routine. Physical therapy sessions included passive and active cervical range of motion, soft-tissue mobilization, facilitation in prone, supported sit, side lying and head-righting activities.
He was seen for eight physical therapy sessions twice a week for four weeks and then once a week for two weeks. At 13 weeks of age, he was discharged with full passive and active cervical range of motion, no palpable muscle tightness, improved head shape, ability to maintain head in midline in sit, supine and prone, active lateral head righting, visual tracking, tolerating prone for five-minute periods and lifting head in a prone prop. His gross-motor skills were in the 40th to 50th percentile on the AIMS.
He was discharged to a home program that continued to encourage prone positioning, in which the family was instructed to place him in prone position every time he was put down on the floor to increase his tolerance. It was also recommended to use an infant chair that promotes sitting without pressure on the back of the head. Early diagnosis and treatment helped him move along quickly and happily.
The Back to Sleep campaign has been a great success. The recommendation is to put your baby to sleep on its back. This does not mean to avoid putting children on their stomachs, but to supervise them while they are there. Children are meant to move and learn in all positions. Prone is a wonderful position for your child to learn and develop strength.
Kelly, K., Littlefield, T., Pomatto, J., Ripley, C., Beals, S., & Joganic, E. (1999). Importance of early recognition and treatment of deformational plagiocephaly with orthotic cranioplasty. Cleft Palate-Craniofacial Journal, 36, 127-130.
Littlefield, T., Reiff, J., & Rekate, H. (2001). Diagnosis and management of deformational plagiocephaly. BNI Quarterly, 17(4), 1-8.
Monson, R., Deitz, J., & Kartin, D. (2003). The relationship between awake positioning and motor performance among infants who slept supine. Pediatric Physical Therapy, 15(4), 196-203.
Persing, J., James, H., Swanson, J., & Kattwinkel, J. (2003). Prevention and management of positional skull deformities in infants. Pediatrics, 112(1), 199-202.
Joanne Bundonis is a senior physical therapist at 1st Cerebral Palsy of New Jersey in Belleville, NJ. She has authored home study courses for www.ptcourses.com