The benefits of positioning babies on their stomachs
When I was learning how to be a paediatrician, tummy time wasn’t really a concept, but now it’s on the list of advice we give every parent of a young baby, and like other paediatric advice about ostensibly simple topics, it encompasses common sense, safety precautions, and the essential central role of parent-child interactions.
Tummy time has come to be a focus of paediatrician recommendations because of the importance of the Back to Sleep campaign (now the Safe to Sleep campaign), which has significantly driven down the incidence of sudden infant death syndrome. But as it became routine to put babies down on their backs, doctors noted an increase in positional plagiocephaly, babies with flat patches on their heads, sometimes on the back of the head, sometimes asymmetrically on one side or the other.
Amy Leung, a paediatric physiotherapist who is associated with the University of Queensland in Australia, studied the impact of positioning on the development of plagiocephaly in very young infants. The 2017 study found that it was a significant risk factor if parents were aware that babies between three and nine weeks old had “head preferences,” that is, that the baby was spending significantly more time with the head turned to one side.
The other risk for plagiocephaly had to do with a combination of measures that spoke to longer sleeping times and longer total amount of time the baby spent on his or her back.
Parents who do note a strong preference for head side in a young baby should take the baby to the doctor to check that nothing is wrong with the neck muscles or joints, Leung said. If everything is fine — and it usually is — and what you’re seeing is a preference, then there’s an opportunity to vary the baby’s positions and try to keep the preference from affecting the baby’s growth and development — and head shape.
Since babies have to be on their backs to sleep safely, this is about what babies do when they are awake. What parents need to do, Leung said, is “try to cut down the time they’re spending on their back when the baby’s awake.”
Putting babies on their sides while they’re awake is particularly good for head control, she said, while positioning them on their stomachs helps with motor development. Holding them upright is also good, she said, and overall, “the most important message is keep changing the position.”
Rocking and swinging may also help a baby enjoy different positions and appreciate movement. And for babies who do develop severe plagiocephaly, corrective helmets are often recommended, though there have been questions raised about how effective they are. If parents notice that side preference early on, it’s much better to try and prevent the problem from developing, Leung said.
Anne Zachry, chairwoman of the department of occupational therapy at the University of Tennessee Health Science Centre, first got interested in having babies spend time on their stomachs when she was working as an occupational therapist with school children who were referred because of their poor handwriting. She noted that many of them had weakness in their trunk muscles and trouble controlling their shoulders and arms.
She did an informal study, sending home questionnaires to parents, and found that “the majority of these kids having fine motor and handwriting issues did not have tummy time.” Most of them had skipped the crawling stage, she said.
“The biggest message is start tummy time as soon as you get home from the hospital,” Zachry said. One good way to start is to lie down on your back and put the baby on your stomach, or on your chest, “eye to eye,” she said.
In addition to the safe sleep recommendations, the other factor that has tended to reduce the time that babies spend on their stomachs, Zachry said, is the popularity of car seats that also function as baby carriers. In her 2013 book Retro Baby, published by the American Academy of Paediatrics, she argued for less gear and more interaction.
With her first child, “in the 1990s, I did not use a carrier,” she said. “I would carry him and put him in the car seat, we’d get to Target, I would take him out of the car seat ... " But by the time her younger children were born, carriers and car seats had evolved: “You leave them in the basket, they don’t get any trunk control, they don’t get a lot visual stimulation, they’re just lying there like a potato.”
Parents should not feel guilty about taking advantage sometimes of this baby gear, Zachry said, but it needs to be limited. She urged parents to limit time babies spend not only in carriers, but also in bouncer seats and swings, “15 to 20 minutes at a time,” she said.
"In tummy time, they’re using their neck and trunk and shoulder muscles, and also their hands,” Zachry said. “They start pushing themselves up to look around, working muscles that are foundational for fine motor skills, and getting a different perceptual experience,” as they look at the world from new perspectives.
Some babies complain about being on their stomachs at first. “The reason I believe most infants resist it is they have poor head control and it’s hard,” Zachry said. Some may be happier in that position on a parent’s chest or a parent’s lap, at least to start out.
And the most important thing you can do to help your baby enjoy tummy time is, not so surprisingly, to get down there on the floor yourself. Bring a toy, make some noise, read aloud, do something to make it interesting and interactive.
“Don’t put them on a blanket on the floor and go, ‘OK, it’s time for tummy time,’ and step away,” Zachry said. “Get down at their level with a small toy.”