Tummy Time

What’s all the Fuss About?

By Sheri Ireland-Berk, Physical Therapist

As far as a newborn baby is concerned, his only jobs in life are to look cute and breathe. In 1994 when the “Back to Sleep Campaign” was initiated in the United States to reduce the risk of Sudden Infant Death Syndrome (SIDS) we made his job a little bit easier by placing Baby on his back to sleep. Since that time, the number of infants dying of SIDS has dropped by more than half. This is a very good thing! We need to continue to place Baby on his back to sleep. We also need to help him make up for the twelve hours of tummy time that he used to get while sleeping on his stomach.
Why all the fuss about tummy time? A healthy newborn, when placed on his tummy, will begin to bob his tiny nose up and down on the surface until he can comfortably breathe. From that very moment, he is beginning to contract those little neck and shoulder muscles and strengthen them each and every time he changes position. He also becomes motivated to move and begins to develop important motor skills that will help him push up, roll over, sit up, crawl and pull up to stand. In addition, he develops sensory perception, problem solving skills, balance, visual and hearing perceptions, and social emotional skills on his tummy. Many pediatricians say that for the normal child, tummy time is critical for developing a normal-shaped head. Infants who spend much of their time on their backs are at risk for developing flat spots on the backs of their heads. Improper development of the skull can then result in facial asymmetries such as uneven eyes, ears, and facial bones.

When we place Baby on his back, he doesn’t have to do a thing. He becomes comfortable and accustomed to this position. We then reinforce this by placing him in the swing, or the bouncy seat, or the car carrier (usually one that moves from the car, to the shopping cart, to the stroller, and then to the kitchen counter without ever disturbing Baby) and Baby gets very little time to experience the much needed tummy time during the course of his average day. He often isn’t all that motivated to move around and experience his environment. I often ask parents how comfortable they feel when they are required to change their own sleeping position for any reason. I am a stomach sleeper and generally keep my head to the right during most of the night. When I attempt to sleep on my back or my side, I fuss and turn and eventually do what I can to end up back on my stomach in my favorite familiar position. An infant is not strong enough to adjust his position when he is not comfortable…so he cries. This may be the very reason that babies resist tummy time. They quickly understand that their caregiver wants to make them happy and will change their position if they fuss.

The evidence has shown repeatedly that infants who sleep on their backs are more likely to have some delays in development. Many of these children will eventually catch up as they begin to sit upright for feedings, grow out of car seats, and become motivated on their own to move. As a physical therapist, I see more and more clients each year that are slightly behind simply because of decreased tummy time and most of these children quickly catch up and have normal age appropriate motor experiences. However, if a child has even minor motor delay issues because of special needs such as low or high muscle tone, neurological deficits, motor processing disorders, or sensory issues; keeping them off of their tummies could prevent them from progressing toward their full motor potential. It then becomes very difficult to catch up for these losses. The neural pathways for movement that develop early on are critical and as the child ages the window of opportunity to develop these pathways becomes smaller and smaller. Since we cannot always identify these babies until we see these delays, it is important that all babies get tummy time.

So, how do we increase tummy time when Baby resists? Optimally, we do it early and often. The sooner we place Baby on his tummy, the more he will accommodate to and eventually enjoy this position. Unless babies are put on their tummies to play from the first days and weeks of life, they may not easily accept “tummy time”. A happy baby develops best! Placing Baby on his tummy and leaving the room or plugging in the I Pod so that we can’t hear him fuss seems counter-productive. Feelings of guilt and failure because we caved to their crying and fussing and placed them back in their place of comfort are also counter-productive. There are many creative opportunities to provide the much needed tummy time when Baby is awake. Some work immediately and others take time and perseverance. Often Baby simply associates tummy time with being “left out” as he lay facing the floor and all of the action is up overhead where he cannot experience it. In the end, it is wise to treat tummy time as an insurance policy so that Baby can reach his developmental potential.

Here are just a few ideas:

• Hold Baby on your chest while you are lying down flat. This counts as tummy time!
• Talk to Baby and give him opportunities to lift his head and interact with you. If he struggles to lift his head up initially, place your hand above his bottom and gently apply pressure down and toward his feet to move his center of gravity downward and decrease the amount of gravity pushing down on his head and neck.
• Put yourself at Baby’s level. If it is difficult for the caregiver to get on the floor, place Baby on the sofa or chair with his head facing out and have the adult sit on the floor face to face with Baby. (Never leave Baby unattended on a high surface). If Baby really fusses lying flat, place a towel or other item under the sofa cushion to prop Baby’s head up and move the center of gravity down toward his bottom.
• Place Baby on his tummy in the stroller and take him for a walk. Take the car seat out of the stroller and move the seat back to its flattest position. The vibration and movement of the stroller is often a nice distraction and can either entertain Baby or lull him to sleep. Once Baby is asleep, you can either supervise him in this position while he sleeps or flip him over to sleep on his back.
• Place Baby on his tummy on an exercise ball. A 65 cm ball is best but any size ball will do and is easy to find in most retail stores. The ball provides a less rigid surface for Baby to lift his head and push off of. Better still, if you have a floor length mirror, place Baby in front of the mirror on the ball and softly bounce or gently move the ball in all directions. Most babies enjoy watching themselves and delight in this feedback.
• Carry Baby facing down instead of the traditional cradle hold. Position Baby chest down along your forearm with his head toward your elbow and his bottom in your hand. Be sure to support his head if he has not yet developed good head control (usually by 3-4 months). Build up his tolerance to this position over time. This is especially helpful if Baby has reflux and resists any touch on his belly.
• Try using a ticking timer. This is often helpful for the older baby who cries immediately when he is placed on his tummy. Set a ticking timer for a few minutes and play and talk to Baby on his tummy until the bell rings. Keep your attitude happy and playful and don’t pick him up until it rings. Increase the time Baby spends on his tummy each day. Baby quickly learns to remain on his tummy until he hears the bell ring.
• Make a bolster roll out of a towel. Place the bolster under Baby’s chest and armpits with his arms over the bolster. Move the infant back and forth on the bolster. You can also use your leg as a bolster and place Baby over it. Boppies work great for this, as well.
• Join an infant massage class in your area. Occasionally an infant will experience negative sensory input when lying on his tummy. Infant massage provides a venue to learn another great way to improve a Baby’s tolerance to touch and physical contact while also helping improve digestion and bonding. Look for a group infant massage class where several babies are facing one another on their tummies socializing and the benefits are multiplied.

The current recommendation for tummy time is 30 minutes a day, all at once or broken up into several short segments. Engage Baby in tummy time when he is content and alert. Insisting on tummy time when Baby is already irritable or tired may cause him to negatively associate this tummy time with being unhappy If Baby begins to fuss, try to make tummy time more interesting by adding gentle movement or a change of toys. Rhythm and movement together are great for infant development, so turn on some music for tummy time. If you feel stressed and anticipate that Baby will be unhappy, he probably will, so find a time when you are relaxed and can practice patience and perseverance. I often recommend that Dad, Grandma, or another person the child is comfortable with introduce tummy time so that Mom can remain “The Comforter” until his tolerance to tummy time improves. If nothing seems to work, try again later when Baby is calm and willing.

*Infants should be holding up their heads and pushing up on their arms by the end of three months. Infants who are getting enough tummy time and are still delayed in reaching these milestones should be evaluated by their health care provider.

Sheri Ireland-Berk is a pediatric physical therapist who has enjoyed working with infants and children for over 20 years. She recently helped open BDI Playhouse Children’s Therapy newest location in Naperville where she also teaches infant massage classes and helps children realize their gross motor goals and recognize the possibilities for their future. BDI Playhouse provides Physical Therapy, Occupational Therapy, and Speech Therapy as well as social work, nutrition, sensory-motor groups, social skills groups, and infant massage. For questions about this article or questions related to these services, contact Sheri at Sberk@Bdiplayhouse.com or call 708-478-1820.