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The Defense of Tummy Time

Just yesterday, as most days, a colleague at Kids Unlimited posted an excerpt talking about the importance of tummy time. Some responses offered an alternative article written on the RIE/Janet Lansbury blog highlighting the case against tummy time. I would like to directly respond to this article. There is much of RIE, Resources for Infant Educarers, I love and respect and use on a daily basis with my patients, clients and children. However, I do not agree with their beliefs on tummy time.

Tummy Time Tips

Move Play Grow is three years old and I now have a “preschooler” on my hands. I’ve learned so much from the over 450 babies and families I’ve taught in that time and I want to take this moment to thank you all, to share some great photos of my happy babies in tummy time, and of course to offer some tips to help the next generation of happy tummy timers! See you in class!

To Sit…Or Not to Sit: Developing Functional Sitting Skills in Babies

A celebrated developmental milestone is when a 6-month-old baby (give or take a few weeks) can sit up independently. But, what does that mean? The reference books say independent sitting is when a baby is placed in sitting on the floor and can remain there without help from caregivers, other supportive props or gear, or the use of their own hands for balance. But, is this independent sit functional for baby and why does it matter?

The Importance of Tummy Time

Wendi was recently featured as an expert guest on ParentSavers.com, talking about the importance of tummy time! The podcast is a total of 30 minutes with the feature interview taking place after the initial discussion about an application called Alert ID. Click on the link below to listen! We would love any and all comments! Stay tuned for a video of a Tummy to Play Everyday class from Parent Savers, which streamed live at the Your Natural Baby Fair 2013!

Is My Baby’s Head Normal?

Today, many more babies have flat spots on their heads than 20 years ago. In fact, it is now common to see babies out in public wearing orthotic helmets and to hear stories about their courses of physical therapy. Diagnosis of positional plagiocephaly/brachycephaly and often-concurrent torticollis, two mostly preventable conditions, is on the rise. What can we as parents, caregivers, and medical practitioners do to reduce the risk of these diagnoses?

Buy This: Multi-Purpose Items

Buy this: items that serve more than one purpose. As discussed earlier, infant positioning and alignment are important but often overlooked. One item that accomplishes all these criteria is a U-shaped head support pillow that cradles baby’s head in car seat, keeping it in midline. Car seats often have infant inserts, but they rarely keep baby’s head from falling to the side. These pillows, when used correctly, successfully do so most of the time.
This pillow also serves as a great prop for tummy time for younger babies up to 5 months. It lifts baby’s chest slightly, not overextending her back, helping her weight to shift backwards towards pelvis. It hugs her chest to prevent rolling to the side. It provides a barrier to keep elbows in line with or in front of shoulders.
I love finding truly useful, multipurpose items that are reasonably priced. The infant head support pillow fits these criteria beautifully.

Buy This….Not That: Tummy Time

This December will be dedicated to offering ideas on the great and not-so-great gifts for infants birth to 12 months! Check back often!

We start with my favorite find for our 3rd child, wishing of course we had found it for #s 1 and 2! It’s the Lily Pad playmat by Nook. It is portable, washable and is PERFECT for tummy time! The cushion is made of breathable air cells, so there is always good air flow around your baby’s precious nose and mouth no matter what his head position. It is firm enough for baby to push into and work to pick his head up, YET cushy enough to soften the inevitable head bob face plant, even when placed directly on hardwood floor!

Enjoy this find and Happy Tummy Time!

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Just as there are products out there that truly help our babies discover new ways to move, become aware of what their bodies can do, and encourage active development of pathways to increase the body-brain connection, there are also products that do all this hard work for them.

Product manufacturers create new items every year that make the hard work of developing seemingly easier and more fun, but often with unintended consequences. We don’t want our babies to be passive participants in the hard work of creating foundations for their own independence.

The Wingbo, pictured here, is an example of a product that seems to solve the problem of tummy time blues. However, the swing carriage is plastic and is the same every time you put your baby in it, offering no variety, the very hallmark of movement and movement development. Though it adds the element of whole body movement through space that your baby otherwise would not get, it does not encourage absolutely essential components of being on the tummy, which are:
1) getting active elongation/stretching of the hip flexors (hips are encouraged to be flexed),
2) active connection of the upper body and lower body through lateral weight shifting (upper body is wedged in a hard plastic container inhibiting active abdominal contraction), and
3) free exploration of movement on all planes of motion: front/back, side to side, and rotation (movement from legs and swing is primarily frontal).

All of these essential items are accomplished by simply placing baby down on a play mat surface, holding baby across your chest or lap on their tummy, or carrying them in a tummy down position.

So, please consider saving your money with this product and opt for a great playmat where your baby can do her own independent exploration of movement. If you have this product, no need to stop using it, but please have your baby enjoy it in small doses!432193_537511226260461_9834930_n

Tracking Tummy Time to Prevent Plagiocephaly and Torticollis

The importance of tummy time play cannot be overstated. Since the introduction of “Back to Sleep” in 1994, many published studies have cited an increase in medical diagnoses such as plagiocephaly, brachycephaly and torticollis*(see below for descriptions) and developmental delay of gross motor milestones. Though this program successfully cut in half the rate of Sudden Infant Death Syndrome (SIDS), the rise of other mostly-preventable diagnoses illustrate some of the unintended consequences of “Back to Sleep.”

Many parents are anxious or even fearful about the tummy down position because of its connection to SIDS. Just because an infant is awake, that anxiety does not dissipate, so parents often avoid placing their infants on their tummies from the start. In addition, parents are not aware of the importance of tummy time when babies are awake, so there is little reason for them to even try.

Tummy time is important for many reasons. Babies are often positioned in utero in asymmetrical positions, and many stay in the same position for most of pregnancy. These asymmetries do not disappear overnight after babies are born. They need to be worked out with babies’ spontaneous movements against the floor and gravity. Babies need to have plenty of time to move freely on the floor, to be out of containers such as car seats, infant seats, swings, and strollers. The position of choice when putting an awake baby down should be tummy down. Newborn babies do not have the strength to lift their heads for sustained periods of time. They rest their head on the floor with their cheek in contact and their neck turned 90 degrees. As long as they position themselves looking both directions, gravity and the floor provide a long, low-load stretch on the SCM and other muscles implicated in torticollis. Tummy time also eliminates any pressure on the back of the head, preventing flatness or allowing any flat spots to round out.

Parents should look at their baby from head to toe after birth to look for any asymmetries in baby’s preference for turning his head or flexing his body one direction or another. Parents can also take pictures of head shape over time to ensure that any flat spots round out. Keeping a photo diary or a log of activity over time helps parents to determine patterns that either exacerbate or alleviate any asymmetries present at birth.

I looked at a few different smart phone applications that would help me do just this after my son was born. I settled on iBabyLog, which is a great tool to track nursing, diapering, sleeping, and activity schedules (many other categories are also available for tracking). I can customize my comments, take photos, and easily look at patterns over time to track progress. For example, when putting my newborn son down for sleep, I make sure that he looks to the left one time and then to the right the other. When working on awake tummy time, I also track the time he looks left versus right. With the ability to track and summarize positions and alignment over the day and the week, it is easy for parents to notice any asymmetries that are present. And, at this very young age, parents have the power to fix asymmetries early with great results.

Using iBabyLog or other tracking tools to document positions during sleep and awake times can help parents to be more aware of their baby’s alignment. Proper alignment is a crucial foundation to symmetrical movement, which is essential for baby to properly achieve motor milestones. By being aware and tracking some of the foundation elements of movement, parents can intervene early and prevent medical problems in alignment and movement from ever occurring.

*      Plagiocephaly is a misshapen head secondary to abnormal and asymmetrical forces placed upon the skull as an infant’s head is growing. It causes a diagonal asymmetry with flatness on the back of one side of the head and protrusion of the opposite forward side. It affects the shape of face, position of eyes and ears, and shape and symmetry of joints of the jaw and cervical spine. Since “Back to Sleep” began, the incidence of plagiocephaly has increased from 1 in 300 to 1 in 15. Though many pediatricians state that misshapen heads are merely a cosmetic issue, there are two very important joints that articulate with and are affected by skull shape: the jaw (TMJ) and the upper cervical vertebrae (OA). Atypical alignment in any joint, but especially those that require simultaneous action of two sides, increases abnormal wear and tear, leading to premature joint breakdown, arthritis and pain. Though this is a well-known and accepted medical phenomenon, because the first “Back to Sleep” babies are only 18 years old, long-term consequences of this specific malalignment due to misshapen heads have not yet been documented in medical literature.

*      Torticollis is a shortening of the sternocleidomastoid (SCM) muscle on one side of the neck. Other neck muscles can be involved as well, but this muscle is most often implicated because of its long ropelike and very superficial location. When this muscle is short/contracted, your baby will have a head tilt to the same side, rotate to the opposite side, and prefer to extend head backwards rather than tuck his chin. Babies often avoid turning their head in the other direction and cannot achieve midline orientation of the head. Torticollis can be congenital, most often due to position in utero, or acquired, often due to asymmetrical head shape and positioning, such as with plagiocephaly. These two diagnoses frequently present together.

*      Brachycephaly is a flatness on the back of the head that is more symmetrical from left to right, but causes protrusions laterally on both sides, making the face and head wider than otherwise would be. It reduces the space for the cerebellum to grow and decreases the distance between the back of the head and spinal cord, possibly placing the spinal cord at greater risk for injury with any head injury. It also changes the orientation of jaw and cervical spine joints. Brachycephaly is due to constant pressure on the back of the head from sleeping and positioning in infant “containers” such as car seats, infant seats, strollers, and swings.

Tummy Time, Part II: Newborn to Four Weeks

The tummy down position for newborns looks awkward to adults. Babies have their little tushies in the air like a beetle, their legs tucked underneath them, and all their weight pushed forward on their upper chest and face. To most of us, that position looks like torture. To others, it may remind them of the yoga “child’s pose” that is meant to relax and center us, bringing our spirit back to a state of equilibrium. This position is actually exactly what a newborn infant needs to help calm and give them the opportunity to learn how to self-soothe. When newborns are on their tummy, the floor provides support to counteract the ballistic movements that are typical and can disorganize babies’ states of consciousness. Their arms are tucked underneath them with their hands conveniently close to their faces and mouths. Newborns frequently get their hands to their mouths when in this position. However, when on their back, they do not have the motor control to easily reach their hands to their mouths. The floor provides that support.

Full term, healthy newborns can turn their head each way and effectively clear their airway when awake and placed on a firm surface, so there is no need to be concerned about suffocation when baby is in this position. They drag their faces, including cheeks, lips, and chin across the floor, which provides rich sensory information to those parts of the face. Again, conveniently, these are the parts that are essential for feeding; the extra sensory information provided by the floor causes more frequent firing of neurons in this part of the brain, and strengthens the pathways that are needed to reinforce successful feeding.

In regards to vision, newborn infants see best 8-12 inches from their face. When on their tummy, parent and caregiver faces and voices (the best toy around) can easily be positioned in that precise spot so you can marvel, talk to and bond with your baby where they see you best. It also gives the parent an opportunity to lie down: Something all new parents need to do!  Also, if babies’ hand happens to move a bit away from their face, they can visually regard it and start learning about self-discovery: Wow, that is MY hand!

You can also start working on the coordinated connection/integration of auditory and visual information with behavioral/motor responses. By positioning yourself on the opposite side of way baby is facing and softly calling to your baby, they will first hear and then listen, locating your voice and the hearing sound of their name, responding with motor movements to try and turn their head the other direction in order to SEE the source of what they heard. This simple game helps to connect sensory information with motor output AND ends with an amazing gift to both you and the baby: They get to see your smiling face! Added bonuses are that they 1) crossed midline in the process, which strengthens the integration of right and left sides of the brain, and 2) practiced looking both directions, increasing mobility, length, and strength of joints and muscles on both sides of the body. It truly is amazing how a simple game can positively affect so many systems and contribute to their development and maturity.

One of the best ways to ensure that your baby likes tummy time is to start at birth. If your baby is still not tolerating this position well after consistently practicing throughout the day for a couple of weeks (such as short times after each diaper change), there are many ways to modify the tummy-down experience to make it easier and more successful. Try chest to chest tummy time, lap soothe tummy time, and tummy down carrying. If you are still struggling to help your baby enjoy this time, live workshops and individual consultations are available in the San Diego area and online video consultations are available for those further away!

A recent search for online videos of infants on their tummies highlighted a misconception that many parents have. Despite the very calm, happy babies that were on the floor on their tummies for minutes at a time, parent’s voice-overs indicated they thought they were torturing their babies, that they were doing this merely to follow doctors’ orders to force their babies to “workout.” Rather than interpreting what your feelings would be in this position, take the time to read your babies’ expressions. This position is one that calms and nurtures our newborns’ immature systems; it provides rich sensory and motor experiences that no other position provides; and it allows the opportunity for babies to build foundations in these domains that will positively contribute to development for the weeks, months and years ahead. Enjoy this position with your baby; it is one of the easiest and least expensive ways to support your babies’ development.

Tummy Time, Part I: Why are we talking about this?

The “Back to Sleep” program, introduced by the American Academy of Pediatrics after comprehensive research from multiple continents, was one of the most successful public relations campaigns. From 1994 to 2006, the frequency of babies placed on their backs to sleep increased six-fold while at the same time the SIDS rate was reduced by 50%. However, there have been many unintended consequences. Before the back to sleep program, infants had a combined awake and asleep time on their tummies of at least 18 hours per day. We are lucky these days if infants experience even 30 minutes per day. That is a lot of time lost in a position that is imperative for proper development in many domains and body systems. Research has repeatedly shown that a lack of tummy time contributes to gross motor delays such as lifting head up/head control, rolling over, pushing up and crawling. However, tummy time is imperative not only for gross motor development, but for the foundation skills required for fine motor, oral motor, body awareness, vision, and self-soothing skills. This series will address the importance of tummy time from birth to seven months, provide benchmarks for each stage and the developmental importance of tummy time for many domains and body systems.

A parent’s anxiety about tummy time can negatively affect how their infant perceives and experiences this important position. SIDS is a scary thing, but parents feel they have a strong, effective tool to help combat the likelihood of it happening to their child: by placing their infant on their back to sleep. Unfortunately, even if a parent understands that it is during sleep time that the back position is important, it is difficult to turn off that anxiety about the tummy time position even during awake hours.  In turn, when a baby fusses or cries while on his tummy, parents swoop in to rescue them versus calmly trying to modify the situation to truly figure out why the baby is upset. Babies have great instincts and they figure it out quickly that the tummy is a position that should cause anxiety. Thus, many babies do not tolerate it well.

There is much parents can do to help babies develop happy routines on their tummies. The easiest way to start is at birth when a baby is used to being “smashed.” A full term baby’s house is very small before birth when she is most often supported in a “fetal position” by the uterine walls. After birth, the floor can also provide that kind of comfort barrier. Because it is more difficult for babies to remain in a flexed position on their back, often nurses and families choose to swaddle to contain them as if still in utero and to support them before their muscles really have had a chance to first stretch out and then learn to move efficiently and with control against gravity.  The tummy down position after birth is comforting. If it is repeated frequently and consistently everyday, trying it first whenever you place your baby down, it remains a very comfortable position and a place where your baby can happily learn to move, play and grow.

For a photo essay and general description of what to expect the tummy position to look like from newborn to seven months, see blog post, Madeline’s Tummy Time Journey: Birth to Seven Months. Future blog posts will also describe this journey in greater detail to explain why your baby’s posture and movement changes as she matures. Stay tuned!

Madeline’s Tummy Time Journey: Birth to Seven-Months

This series of photos and captions follows one baby girl, Madeline, from six days old to seven months in order to illustrate the typical progression and development of posture and movement skills while on the tummy. Disclaimer: Rather than choosing to use infant seats and other containers, Madeline was placed on her tummy first every time she was put down on the floor. She practiced tummy time regularly and usually enjoyed more than 60 minutes per day from birth and more than 90 minutes per day after three months of age.

At six days old, baby Madeline shows appropriate physiologic flexion and is supported by the floor happily in tummy time! The floor helps to prevent startles and providers her the opportunity to see her hand and get it to her mouth to start learning self-soothing skills. The floor serves as a soothing confinement, similar to the sensory experience of being in the womb. Though she occasional works to lift her head away from the surface, she is content to relax into the surface.
At 27 days old, baby Madeline’s legs are more extended at her hips and knees, allowing her pelvis to drop and weight to shift backwards a bit. Her arms at the shoulder and elbow are also stretched out more, allowing them to come away from her body, though her elbows are still behind her shoulders. She can lift her head higher, but total clearance from the floor as she rotates side to side is not a regular occurrence. VISION is a key driver to help “right” the head so her eyes approach the horizon. This natural drive to reach the visual horizon is essential for development of head control.
At six weeks, Madeline is more disorganized in her postures and movements than when she was birth to four weeks because she has had sufficient time for flexor muscles to relax and stretch out, but not enough time to develop active, controlled contractions against gravity. Head lifting while on tummy is typically unilateral so that her head is slightly rotated one way or the other rather than controlled in the middle. Babies can lift head to 45 degrees briefly, but there is still a lot of head bobbing.
At eight weeks, Madeline’s pelvis continues to drop because hip flexors are stretched out more and head lifting is easier because of 1) increased mobility in cervical/neck and thoracic spine; 2) increased strength in extensor muscles against gravity; and 3) a strong desire to lift head because of vision and vestibular/inner ear righting reactions that work to maintain eyes on the horizon and nose on the vertical. Postures are still asymmetrical, elbows tend to be behind shoulders, and there is inconsistent weight bearing through the arms.
At eleven weeks, Madeline demonstrates more extension in the spine and, finally, the ability to get the elbows in front of the shoulders for more effective weight bearing on the arms. Babies at this age to three months should hold their head steadily at 90 degrees, maintain midline position and rotate each direction.
At 14 weeks, Madeline can easily hold her head up to 90 degrees with elbows in front of shoulders. She shows great symmetry between left and right sides on tummy and all other positions. By this age, babies should spend at least 90 minutes per day on their tummies.
At four months, Madeline is starting to play with the swimming position where head and all limbs are extended off the floor. She will alternate between swimming and bearing weight, which is important to develop co-activation and symmetry between the front and back muscles.
At five months, Madeline is far more proficient moving around on her tummy, pivoting, shifting, turning, and dragging or pushing herself around. She controls lateral weight shifts because there is now symmetry between the flexor muscles and the extensor muscles of the body. Madeline is showing elongation on the left weight bearing side and shortening on the right non-weight bearing side. Those side tummy rolls say it all. 🙂
At six months, Madeline is performing a straight-arm plank, challenging herself to discover what her body can do! She moves easily around on her tummy, rolling, scooting, and pivoting independently. She sits independently when placed and is working on the transition from floor into sitting as well as the transition to hands and knees and rocking back and forth…getting ready to crawl! At this point, tummy time is usually a position for transition rather than the end product because she is independent balancing in upright positions. She has more access to her environment, people, and toys when sitting, where both her hands are free to explore and manipulate objects.
At seven months, Madeline shows us ultimate control of her body while on her tummy. She has shifted her weight over her right side, balancing without falling while reaching her left hand across her body. Movement like this requires precise balance and control of muscles on the front, back, right and left, all working in coordination with one another. Her body is active from her head to her toe. At this time, Madeline is capable of getting onto hands and knees and transitioning from her tummy to sitting by herself.

 

Practicing best practice

It has already been 4 weeks since Baby #2 arrived!  We have gone from the newborn “shock” and calm from leaving the comfy, cozy womb to truly being more awake, alert, and aware.  I have also had 4 weeks of working to practice what we preach in our Tummy to Play Everyday Classes.  I am a second time mom and now work to manage (aka juggle) a 3 year old, a newborn, a household chores/errands, and, oh yes, trying to “sleep when baby sleeps”!

I think that I now have a unique opportunity to blog about the reality of implementing much of what is presented in our classes . . .  when life happens.  So, here it goes . . .

  • Start Tummy Time Day 1:  Check!  Have done it every day.  One of our favorites is tummy to tummy.  It is so peaceful to watch a little one sleep but I sure would love some too!  We have managed to do true tummy time on the floor one time each day.  He is not always happy and begins to fuss after a while.  BUT, I do change his position or modify something before picking him up (ie. Put him on his side, eye level smile, sing, pat his back, etc.).  It definitely helps for a short time.
  • Leave the Carseat in the Car: I have ventured in to the doctor and the grocery store using the Sleepy Wrap only.  I find it much easier to go “car seat free” in public when with just the baby.  It is much easier to chase after the older one because “his listening ears weren’t turned on” while pushing a stroller vs. having a newborn in a carrier.  The car seat does stay in the car when we come home – a tremendous change from Baby #1.
  • Container Culture:  Hello, my name is Rachel and I use a container with my baby!!  My first son really only wanted to be held or be in a carrier – which became quite exhausting!  With Baby #2, we have more variety: held in arms or a carrier or being in the Co sleeper, pack and play, and the bouncy seat.  This baby still has yet to enjoy the swing.  The bouncy seat has been so useful for short periods of time for mommy to grab a shower, a peaceful meal, and also gives him a different view of the world!
  • Making Movements Meaningful:  Another tip that has been difficult to implement ALL the time: meaning all diaper changes, all transfers between caregivers, etc.   Yet, I find myself doing it more automatically than 4 weeks ago and definitely more automatically than with Baby # 1.
  • Symmetry:  Wow!  This has been the toughest one!  I am a physical therapist that works with children, have had one baby already, and still find it difficult and awkward to switch to my right side when carrying, bottle feeding, etc.  I didn’t realize just how difficult it would be.
  • Bonding: I love this part!!  My favorite times are our tummy to tummy play and snuggles, when baby is fast sleep in the carrier making cute baby sleepy noises; talking to baby about what he is doing, what I am doing, what we are doing together; making faces and imitating sounds; and kissing every sweet baby part on that lil monkey (cheeks, fingers, belly, toes . . you know).

I will continue work daily to practice what I preach and love the knowledge that I have gained by doing these Tummy to Play Classes.   Let’s continue on this journey together as our children move, play, and grow!

Rachel

Disclaimer
The content on this website is based on Wendi’s personal and professional experience and general research. It is not meant for individual medical diagnosis or treatment. If you are concerned about your child, please consult with your primary physician and/or therapist.