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Back to Sleep, Tummy to Play Written by: Daniel Cross As parents, we have been blessed with beautiful, precious, irreplaceable gifts; our children. And as parents, it is our job, our need, and our instinct to do everything that we can to protect them from harm. Unfortunately in some instances, our need and desire to protect our children leads to over protecting them and keeping them from natural, normal experiences that they need in order to learn and grow properly. One example of this is parents not allowing their infants to spend enough time on their stomachs for play, in fear of Sudden Infant Death Syndrome (SIDS). In the last 15 years, there’s been an increasing trend of muscle weaknessin young infants and toddlers due to lack of tummy time. In 1992, the American Academy of Pediatrics recommended that babies be positioned on their backs or sides to sleep in an effort to decrease the incidence of SIDS.In coalition with the AAP, the public health department created the “Back to Sleep” campaign to bring awarenessto the causesof SIDSand to educate parents about the dangers of infants sleeping on their stomachs. Since the “Back to Sleep” campaign began, there has been a decreasein the amount of SIDSrelated deaths. But the back to sleep recommendation, as well as infants spending more time in infant carriers, bouncy seats, swings and less time on their stomachs, has caused an increased incidence of babies with positional plagiocephaly, a condition where the head becomesan oblong shape with frontal displacement on one side of the forehead and flattening of the back of the skull on the other side, more commonly known as a flat spot. In 1992, the occurrence of plagiocephaly in a healthy infant was one in 300; in 1999 the occurrence was one in 60. Although the “Back to Sleep” campaign has helped prevent many casesof SIDS,it has unfortunately been a factor in the increase of some abnormalities in childhood development. In some cases,parents are taking the “Back to Sleep” mantra to an extreme by not placing their babies on their stomachs at all. This tactic has the potential to lead to a variety of other issues that can create difficulty for the children as they get older. A few of these issuesin addition to plagiocephaly, are the decreasein core body strength, delay in gross motor development and torticollis (tightening of one side of the neck). In many births, cranial asymmetry is common and usually resolves spontaneously. But after birth, if an increased amount of abnormal pressure or force remains on the soft skull, there is greater chance for change in the head shape to occur. Assessment of the child’s head shape and symmetry is also important becauseplagiocephaly is common in children with torticollis, which can effect prone (lying face down) skills, visual tracking skills1, midline development, balance, shoulder movement, use of upper body, protective extension2 and rib mobility. If plagiocephaly is left untreated, the child may require a shaping helmet to help realign the skull bones. Typically, these abnormal childhood developments can be avoided by allowing supervised infant tummy time from two to three months of age.


The importance of tummy time or prone play is greatly underestimated by many parents. When an infant is born, they are in a curled position called physiological flexion. This position is imperative for the infant’s development becauseit allows them to organize their body and develop a starting point of movement. This position also gives them some control over how much of the world they experience and it helps them avoid overstimulation. Two to three months of age is the most critical stage for tummy time becauseit’s when the body begins to elongate and the child becomesmore interactive with the world. Initially, most children do not like this position becauseit limits their interaction with the world, but it is important to encourage it. During tummy time, infants begin to develop neck muscles necessary to control their head, they increasetheir stomach strength needed for sitting and rolling, and increasetheir arm strength needed to control their hands and to reach for objects and people. The building blocks created at this stage pay great dividends at the four to five month stage when babies begin to coordinate their motions into actual patterns, begin to roll, and to sit with support. Children that do not spend enough time on their belly typically do not develop the necessary prone extension control 3 needed which results in poor tolerance to the prone position. Monson, et.al. a study conducted in 2003 demonstrated that six month olds who did not spend waking time in the prone position had lower gross motor development scores on the Alberta Infant Motor Scales4 than infants who did regularly spend waking time in the prone position. Their greatest limitations were in prone and sitting skills. Unfortunately, this tends to be a very common issue in infants. As a pediatric therapist, I typically see caseswhere at four months of age, the baby’s flat spot has not improved and the pediatrician has recommended pediatric therapy. In these instances, if the parent is actively involved and works with the child in addition to therapy, we begin to see improvement within the first month of intervention. So how do you encourage tummy time and make it more enjoyable and safe for your child?

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Help your baby get into a good routine. Families will know when the baby is most happy and this is the best time to introduce new skills and challenges. Remember that your young child is learning how to handle stress and new experiences and needs plenty of reassurance and love during times when new experiences are being presented.

Lying next to your infant, talking to them, rubbing their back and looking at their face will allow them to better handle the stress of a new experience.

Limit the time on the tummy at the beginning then build on the successas your child becomesstronger and more accustom to the position. This allows your child to experience successwithout pushing them into too much stress.

Place your baby on carpet with just a blanket to protect their face. Harder surfaceswill make it easier for them to push against and easier for them to raise their head and chest off the floor.


Have several short tummy time sessions throughout the day versus one long session. I recommend at least 30 minutes of tummy time per day, broken up into several smaller sessions.

Stick with it even when the first several tries end poorly. Practice does make perfect in this case.

Never leave your baby on their stomach unattended until they are consistently rolling off their belly on their own.

If you start to notice that your child is beginning to favor one side over the other and their head is beginning to tilt, here are some tips that will help prevent muscular tightness from occurring.

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Alternate the ends of the crib and the changing table in which you lay your baby.

Alter the position of the car seat if your baby tends to always look out the window to one side.

Stand to the opposite side of the tightness while changing diapers or interacting with your baby.

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Place the toys to the side where the motion is most limited.

Encourage side lying on the opposite side of tightness.

Change the hip or side in which you carry your baby. Alter their position for bottle or breast feedings to encourage a more neutral head position.

Use a cushion or foam piece to position your baby’s head in a neutral position while in a car seat or stroller.

Children are very adaptable creatures and are eager to learn, play and grow. It is important for you as a parent to educate yourself on typical childhood development so you are aware of abnormalities and are able to identify if your child is experiencing abnormal development. If at any time you have questions or concerns about your child’s development or feel that they are displaying uncharacteristic behaviors for their age, seek out advice from a pediatric health professional that has expertise in early childhood development or ask your pediatrician for a referral to a pediatric physical therapist. For more information on early childhood development, visit www.AStepAheadPT.com.

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The ability to track one’s eyes from left to right in an efficient manner Part of a child's developmental processand is used in order to protect them from a loss of balance The ability to lift and move their upper body while lying on the stomach An observational assessment scale that was constructed to measure gross motor maturation in infants from birth through independent walking


Back to Sleep, Tummy to Play