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• Continue to advise parents to place their infants on their backs for sleeping, to prevent sudden infant death. A
• Educate parents about the value of supervised prone positioning (“tummy time”) during waking hours, which helps infants learn to raise their head, push up on their arms, and attain on-time milestones such as rolling over and unsupported sitting. A
• Tell parents that supervised abdominal positioning aids in preventing plagiocephaly and torticollis. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
As happens with many interventions, the Back-to-Sleep campaign1 to prevent sudden infant death syndrome (SIDS) has led to unintended consequences. The campaign’s primary recommendation—that infants be placed on their backs for sleeping instead of on their stomachs—has of course yielded tremendous benefits. The prevalence of SIDS among healthy infants has dropped to 0.57 children per 1000 live births, totaling 2200 deaths per year, compared with 1.2 children per 1000 births in 1997.2-4 However, as the incidence of SIDS began to decline, it became apparent that children were experiencing delayed gross motor movement coincident with placement in the supine sleeping position5-7—or, more accurately, because parents following the Back-to-Sleep recommendation also generally avoided placing their infants in the prone position when they were awake.7
These delays become apparent as early as 2 to 3 months of age and manifest as the inability of an infant to raise his or her head when placed in the prone position.8 Because of this finding, the American Academy of Pediatrics modified its original recommendation for healthy infants, in part stating, “A certain amount of tummy time while the infant is awake and observed is recommended for developmental reasons….”9
In this article, I address the 3 most common unintended consequences for infants perpetually placed in the supine position: developmental motor delays, plagiocephaly (flattening of the occiput) and brachycephaly (widening of the skull), and congenital muscular torticollis (CMT) (a head tilt to one side). Each of these outcomes is preventable with vigilance in the care of newborns.
Prevent developmental motor delays with “tummy time”
The need for prone positioning, or “tummy time,” while an infant is awake cannot be overestimated. Particularly for preterm infants, a delayed acquisition of the ability to lift and turn the head could result in upper airway compromise or rebreathing and, thus, asphyxia.10 Infants who sleep in the supine position and exhibit delayed motor development by age 6 months very often are also found to have had their awake prone positioning restricted.11 In one study, delays in gross motor skills persisted in some cases to 15 months of age, and fine motor skills were delayed in 6-month-old infants who had little prone positioning.11 Infants who sleep in the side or supine position roll over later than those who sleep in the prone position.5 The TABLE compares mean age differences for milestone achievements with varying sleep positions.
On multiple regression analyses, awake prone positioning has consistently emerged as the most significant predictor of early motor development.11 For babies regularly placed in the prone position, the average Peabody Development Motor Scales-2 locomotion score has been significantly higher than that of babies not placed in the prone position when tested at 6 and 18 months.12 For infants routinely sleeping supine, supervised “prone to play” during waking hours enables them to practice prone-related motor skills such as head control.13
Infants with prone experience have attained the milestone of crawling on the abdomen significantly earlier than those without prone experience, leading to a higher 6-month gross motor development quotient.14 For children with just over an hour of daily prone positioning, an advantage in motor skill development has revealed itself as early as 4 months of age.15,16 Somewhat reassuring is evidence from one study that all infants, whether sleeping prone or supine, achieve all milestones within the accepted normal age range as long as prone positioning is initiated.7
What you’ll need to do. Stress to parents the importance of tummy time, or prone to play, in enabling normal developmental progression. Encourage this practice even if parents report that their infant cries or otherwise appears not to tolerate the prone position.15 In general, sleeping in the supine position does not negatively impact motor development as long as there is awake time with supervised prone positioning.17
TABLE
Mean age (months) for milestone acquisition
| Milestone | Prone sleepers | Mixed/side sleepers | Supine sleepers | P value* (linear regression)† |
|---|---|---|---|---|
| Rolls prone to supine | 3.93 ± 1.2 | 4.48 ± 1.8 | 4.87 ± 1.33 | .002 (.02) |
| Rolls supine to prone | 4.9 ± 1.3 | 4.97 ± 1.9 | 5.0 ± 1.6 | .95 |
| Sits supported | 4.7 ± 1.3 | 5.02 ± 1.4 | 5.13 ± 0.9 | .003 (.03) |
| Sits unsupported | 5.13 ± 1.1 | 5.17 ± 1.2 | 5.17 ± 1.0 | .80 |
| Transfers object | 5.87 ± 1.2 | 5.99 ± 6.5 | 6.23 ± 1.1 | .11 |
| Creeps | 6.07 ± 1.9 | 6.49 ± 1.9 | 7.23 ± 1.6 | .0002 (.001) |
| Crawls | 7.83 ± 2.0 | 8.47 ± 2.1 | 8.6 ± 1.7 | .003 (.05) |
| Pulls to stand | 8.1 ± 1.6 | 8.7 ± 1.5 | 8.77 ± 1.6 | .01 (.04) |
| Walks alone | 12.1 ± 2.0 | 12.2 ± 2.0 | 12.2 ± 1.7 | .4 |
| *Represents P value for prone sleepers vs supine sleepers. †Multivariate regression analysis controlling for infant size, gender, ethnicity, presence of siblings, and maternal education. Source: Davis BE, Moon RY, Sachs HC, et al. Pediatrics. 1998.7 Reproduced with permission of American Academy of Pediatrics. | ||||
Plagiocephaly and brachycephaly: Vary position for feeding, sleeping
Plagiocephaly and brachycephaly may occur as a consequence of prolonged supine positioning. Indeed, the incidence of plagiocephaly has increased since 1992, due largely to widespread adoption of the supine sleeping position.18 Plagiocephaly and/or brachycephaly is also more likely to occur in the first 4 months of life in infants who are male, firstborn, or who exhibit limited head rotation or low activity levels.19 Feeding with a bottle only and with the child’s head persistently placed to one side can lead to plagiocephaly.20
Delayed achievement of motor milestones is also associated with plagiocephaly, and tummy time to facilitate motor skill development helps protect against the deformity.20 Varying the head position when laying the infant down for sleep is also protective.21 One systematic review has shown considerable evidence that molding therapy with a helmet may reduce skull asymmetry more effectively than repositioning therapy.22
What you’ll need to do. Ask parents about their infant’s activity level, and encourage tummy time to protect against plagiocephaly. Also advise parents who bottle feed to alternate the feeding position between left and right arms.
Torticollis: Assess neck function in weeks after birth
Not only do infants with CMT display a head tilt to one side, but they also often have rotation of the head to the opposite side with the chin appearing to jut out.23 This postural deformity—primarily resulting from unilateral shortening and fibrosis of the sternocleidomastoid muscle24—is detectable at birth or shortly thereafter. CMT occurs in 1 of every 300 live births.25 Torticollis discovered at birth is likely related to a constrained intrauterine position. In one study, 1 in 6 newborns were born with torticollis, and mothers reported that the infants had felt “stuck” in the same position for several weeks before birth.26 The consequent restricted neck range of motion puts infants at risk of developing cranial deformations that may be prevented by changing their sleeping positions.26
What you’ll need to do. Check for limited neck function in the early weeks after birth and recommend neck motion exercises, if necessary, to encourage full head turning to both sides.19 Both torticollis and plagiocephaly due to static supine positioning can be largely eliminated with early written instructions about the value of tummy time when a baby is awake and supervised and the value of changing sleep positions.12 If repositioning or other forms of physical therapy fail to resolve the condition, surgical correction may be necessary.27
- Newer evidence indicates that the rebreathing of exhaled gases in the face-down position and the inability of the infant to reflexively lift his or her head may play a role in sudden infant death syndrome.28
- Nearly 13% of infants are still placed prone for sleep, according to an estimate from the National Infant Sleep Survey.29
- Resources are available from Pathways Awareness (www.pathwaysawareness.org), a not-for-profit foundation, to educate parents (and healthcare professionals) about early detection and intervention of motor delays in children. (The author is a member of the foundation’s Physicians’ Roundtable.)
Acknowledgement
I would like to acknowledge the review and comments of John F. Sarwark, MD.
CORRESPONDENCE
Russell Robertson, MD, Rosalind Franklin University of Medicine and Science, 3333 Green Bay Road North, Chicago, IL 60064; [email protected]
1. Willinger M, Hoffman HJ, Hartford RB. Infant sleep position and risk for sudden infant death syndrome: report of a meeting held January 13 and 14, 1994, National Institutes of Health, Bethesda, MD. Pediatrics. 1994;93:814-819.
2. Hauck FR, Tanabe KO. International trends in sudden infant death syndrome: stabilization of rates requires further action. Pediatrics. 2008;122:660-666.
3. Willinger M, James LS, Catz C. Defining the sudden infant death syndrome (SIDS): deliberations of an expert panel convened by the National Institute of Child Health and Human Development. Pediatr Pathol. 1991;11:677-684.
4. Moon RY, Horne RS, Hauck FR. Sudden infant death syndrome. Lancet. 2007;370:1578-1587.
5. Jantz JW, Blosser CD, Fruechting LA. A motor milestone change noted with a change in sleep position. Arch Pediatr Adolesc Med. 1997;151:565-568.
6. Dwyer T, Ponsonby AL. Sudden infant death syndrome and prone sleeping position. Ann Epidemiol. 2009;19:245-249.
7. Davis BE, Moon RY, Sachs HC, et al. Effects of sleep position on infant motor development. Pediatrics. 1998;102:1135-1140.
8. Perniciaro J. Development, behavior, and mental health. In: Tschudy MM, Arcara KM, eds. The Harriet Lane Handbook. 19th ed. Philadelphia, PA: Mosby; 2011;228:229.-
9. Changing concepts on sudden infant death syndrome: implications for infant sleeping environment and sleep position. American Academy of Pediatrics. Task Force on Infant Sleep Position and Sudden Infant Death Syndrome. Pediatrics. 2000;105:650-656.
10. Lijowska AS, Reed NW, Chiodini BA, et al. Sequential arousal behaviour in infants in asphyxial sleep environments. J Appl Physiol. 1997;83:219-228.
11. Majnemer A, Barr RG. Influence of supine sleep positioning on early motor milestone acquisition. Dev Med Child Neurol. 2005;47:370-376.
12. Jennings JT, Sarbaugh BG, Payne NS. Conveying the message about optimal infant positions. Phys Occup Ther Pediatr. 2005;25:3-18.
13. Ratliff-Schaub K, Hunt CE, Crowell D, et al. Relationship between infant sleep position and motor development in preterm infants. J Dev Behav Pediatr. 2001;22:293-299.
14. Kuo YL, Liao HF, Chen PC, et al. The influence of wakeful prone positioning on motor development during the early life. J Dev Behav Pediatr. 2008;295:367-376.
15. Dudek-Shriber L, Zelazny S. The effects of prone positioning on the quality and acquisition of developmental milestones in four-month-old infants. Pediatr Phys Ther. 2007;19:48-55.
16. Salls JS, Silverman LN, Gatty CM. The relationship of infant sleep and play positioning to motor milestone achievement. Am J Occup Ther. 2002;56:577-580.
17. Fetters L, Huang HH. Motor development and sleep, play, and feeding positions in very-low-birthweight infants with and without white matter disease. Dev Med Child Neurol. 2007;49:807-813.
18. Persing J, James H, Swanson J, et al. Prevention and management of positional skull deformities in infants—American Academy of Pediatrics clinical report. Pediatrics. 2003;112:199-202.
19. Hutchison BL, Hutchison LA, Thompson JM, et al. Plagiocephaly and brachycephaly in the first two years of life: a prospective cohort study. Pediatrics. 2004;114:970-980.
20. van Vlimmeren LA, van der Graaf Y, Boere-Boonekamp MM, et al. Risk factors for deformational plagiocephaly at birth and at 7 weeks of age: a prospective cohort study. Pediatrics. 2007;119:e408-e418.
21. Hutchison BL, Thompson JM, Mitchell EA. Determinants of nonsynostotic plagiocephaly: a case-control study. Pediatrics. 2003;112:e316.-
22. Xia JJ, Kennedy KA, Teichgraeber JF, et al. Nonsurgical treatment of deformational plagiocephaly: a systematic review. Arch Pediatr Adolesc Med. 2008;162:719-727.
23. Cheng JCY. Clinical determinants of the outcome of manual stretching in the treatment of congenital muscular torticollis in infants. A prospective study of eight hundred and twenty one cases. J Bone Joint Surg. 2001;83:679-687.
24. Cheng JCY, Tang SP, Chen TMK. The clinical presentation and outcome of treatment of congenital muscular torticollis in infants. A study of 1086 cases. J Pediatr Surg. 2000;35:1091-1096.
25. Clarren SK, Smith DW, Hanson JW. Helmet treatment for plagiocephaly and congenital muscular torticollis. J Pediatr. 1979;94:43-46.
26. Stellwagen L, Hubbard E, Chambers C, et al. Torticollis, facial asymmetry and plagiocephaly in normal newborns. Arch Dis Child. 2008;93:827-831.
27. de Chalain TM, Park S. Torticollis associated with positional plagiocephaly: a growing epidemic. J Craniofac Surg. 2005;16:411-418.
28. Kinney HC, Thach BT. The sudden infant death syndrome. N Engl J Med. 2009;361:795-805.
29. National Infant Sleep Position. Available at: http://dccwww.bumc.bu.edu/ChimeNisp/Main_Nisp.asp. Accessed February 8, 2010.
• Continue to advise parents to place their infants on their backs for sleeping, to prevent sudden infant death. A
• Educate parents about the value of supervised prone positioning (“tummy time”) during waking hours, which helps infants learn to raise their head, push up on their arms, and attain on-time milestones such as rolling over and unsupported sitting. A
• Tell parents that supervised abdominal positioning aids in preventing plagiocephaly and torticollis. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
As happens with many interventions, the Back-to-Sleep campaign1 to prevent sudden infant death syndrome (SIDS) has led to unintended consequences. The campaign’s primary recommendation—that infants be placed on their backs for sleeping instead of on their stomachs—has of course yielded tremendous benefits. The prevalence of SIDS among healthy infants has dropped to 0.57 children per 1000 live births, totaling 2200 deaths per year, compared with 1.2 children per 1000 births in 1997.2-4 However, as the incidence of SIDS began to decline, it became apparent that children were experiencing delayed gross motor movement coincident with placement in the supine sleeping position5-7—or, more accurately, because parents following the Back-to-Sleep recommendation also generally avoided placing their infants in the prone position when they were awake.7
These delays become apparent as early as 2 to 3 months of age and manifest as the inability of an infant to raise his or her head when placed in the prone position.8 Because of this finding, the American Academy of Pediatrics modified its original recommendation for healthy infants, in part stating, “A certain amount of tummy time while the infant is awake and observed is recommended for developmental reasons….”9
In this article, I address the 3 most common unintended consequences for infants perpetually placed in the supine position: developmental motor delays, plagiocephaly (flattening of the occiput) and brachycephaly (widening of the skull), and congenital muscular torticollis (CMT) (a head tilt to one side). Each of these outcomes is preventable with vigilance in the care of newborns.
Prevent developmental motor delays with “tummy time”
The need for prone positioning, or “tummy time,” while an infant is awake cannot be overestimated. Particularly for preterm infants, a delayed acquisition of the ability to lift and turn the head could result in upper airway compromise or rebreathing and, thus, asphyxia.10 Infants who sleep in the supine position and exhibit delayed motor development by age 6 months very often are also found to have had their awake prone positioning restricted.11 In one study, delays in gross motor skills persisted in some cases to 15 months of age, and fine motor skills were delayed in 6-month-old infants who had little prone positioning.11 Infants who sleep in the side or supine position roll over later than those who sleep in the prone position.5 The TABLE compares mean age differences for milestone achievements with varying sleep positions.
On multiple regression analyses, awake prone positioning has consistently emerged as the most significant predictor of early motor development.11 For babies regularly placed in the prone position, the average Peabody Development Motor Scales-2 locomotion score has been significantly higher than that of babies not placed in the prone position when tested at 6 and 18 months.12 For infants routinely sleeping supine, supervised “prone to play” during waking hours enables them to practice prone-related motor skills such as head control.13
Infants with prone experience have attained the milestone of crawling on the abdomen significantly earlier than those without prone experience, leading to a higher 6-month gross motor development quotient.14 For children with just over an hour of daily prone positioning, an advantage in motor skill development has revealed itself as early as 4 months of age.15,16 Somewhat reassuring is evidence from one study that all infants, whether sleeping prone or supine, achieve all milestones within the accepted normal age range as long as prone positioning is initiated.7
What you’ll need to do. Stress to parents the importance of tummy time, or prone to play, in enabling normal developmental progression. Encourage this practice even if parents report that their infant cries or otherwise appears not to tolerate the prone position.15 In general, sleeping in the supine position does not negatively impact motor development as long as there is awake time with supervised prone positioning.17
TABLE
Mean age (months) for milestone acquisition
| Milestone | Prone sleepers | Mixed/side sleepers | Supine sleepers | P value* (linear regression)† |
|---|---|---|---|---|
| Rolls prone to supine | 3.93 ± 1.2 | 4.48 ± 1.8 | 4.87 ± 1.33 | .002 (.02) |
| Rolls supine to prone | 4.9 ± 1.3 | 4.97 ± 1.9 | 5.0 ± 1.6 | .95 |
| Sits supported | 4.7 ± 1.3 | 5.02 ± 1.4 | 5.13 ± 0.9 | .003 (.03) |
| Sits unsupported | 5.13 ± 1.1 | 5.17 ± 1.2 | 5.17 ± 1.0 | .80 |
| Transfers object | 5.87 ± 1.2 | 5.99 ± 6.5 | 6.23 ± 1.1 | .11 |
| Creeps | 6.07 ± 1.9 | 6.49 ± 1.9 | 7.23 ± 1.6 | .0002 (.001) |
| Crawls | 7.83 ± 2.0 | 8.47 ± 2.1 | 8.6 ± 1.7 | .003 (.05) |
| Pulls to stand | 8.1 ± 1.6 | 8.7 ± 1.5 | 8.77 ± 1.6 | .01 (.04) |
| Walks alone | 12.1 ± 2.0 | 12.2 ± 2.0 | 12.2 ± 1.7 | .4 |
| *Represents P value for prone sleepers vs supine sleepers. †Multivariate regression analysis controlling for infant size, gender, ethnicity, presence of siblings, and maternal education. Source: Davis BE, Moon RY, Sachs HC, et al. Pediatrics. 1998.7 Reproduced with permission of American Academy of Pediatrics. | ||||
Plagiocephaly and brachycephaly: Vary position for feeding, sleeping
Plagiocephaly and brachycephaly may occur as a consequence of prolonged supine positioning. Indeed, the incidence of plagiocephaly has increased since 1992, due largely to widespread adoption of the supine sleeping position.18 Plagiocephaly and/or brachycephaly is also more likely to occur in the first 4 months of life in infants who are male, firstborn, or who exhibit limited head rotation or low activity levels.19 Feeding with a bottle only and with the child’s head persistently placed to one side can lead to plagiocephaly.20
Delayed achievement of motor milestones is also associated with plagiocephaly, and tummy time to facilitate motor skill development helps protect against the deformity.20 Varying the head position when laying the infant down for sleep is also protective.21 One systematic review has shown considerable evidence that molding therapy with a helmet may reduce skull asymmetry more effectively than repositioning therapy.22
What you’ll need to do. Ask parents about their infant’s activity level, and encourage tummy time to protect against plagiocephaly. Also advise parents who bottle feed to alternate the feeding position between left and right arms.
Torticollis: Assess neck function in weeks after birth
Not only do infants with CMT display a head tilt to one side, but they also often have rotation of the head to the opposite side with the chin appearing to jut out.23 This postural deformity—primarily resulting from unilateral shortening and fibrosis of the sternocleidomastoid muscle24—is detectable at birth or shortly thereafter. CMT occurs in 1 of every 300 live births.25 Torticollis discovered at birth is likely related to a constrained intrauterine position. In one study, 1 in 6 newborns were born with torticollis, and mothers reported that the infants had felt “stuck” in the same position for several weeks before birth.26 The consequent restricted neck range of motion puts infants at risk of developing cranial deformations that may be prevented by changing their sleeping positions.26
What you’ll need to do. Check for limited neck function in the early weeks after birth and recommend neck motion exercises, if necessary, to encourage full head turning to both sides.19 Both torticollis and plagiocephaly due to static supine positioning can be largely eliminated with early written instructions about the value of tummy time when a baby is awake and supervised and the value of changing sleep positions.12 If repositioning or other forms of physical therapy fail to resolve the condition, surgical correction may be necessary.27
- Newer evidence indicates that the rebreathing of exhaled gases in the face-down position and the inability of the infant to reflexively lift his or her head may play a role in sudden infant death syndrome.28
- Nearly 13% of infants are still placed prone for sleep, according to an estimate from the National Infant Sleep Survey.29
- Resources are available from Pathways Awareness (www.pathwaysawareness.org), a not-for-profit foundation, to educate parents (and healthcare professionals) about early detection and intervention of motor delays in children. (The author is a member of the foundation’s Physicians’ Roundtable.)
Acknowledgement
I would like to acknowledge the review and comments of John F. Sarwark, MD.
CORRESPONDENCE
Russell Robertson, MD, Rosalind Franklin University of Medicine and Science, 3333 Green Bay Road North, Chicago, IL 60064; [email protected]
• Continue to advise parents to place their infants on their backs for sleeping, to prevent sudden infant death. A
• Educate parents about the value of supervised prone positioning (“tummy time”) during waking hours, which helps infants learn to raise their head, push up on their arms, and attain on-time milestones such as rolling over and unsupported sitting. A
• Tell parents that supervised abdominal positioning aids in preventing plagiocephaly and torticollis. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
As happens with many interventions, the Back-to-Sleep campaign1 to prevent sudden infant death syndrome (SIDS) has led to unintended consequences. The campaign’s primary recommendation—that infants be placed on their backs for sleeping instead of on their stomachs—has of course yielded tremendous benefits. The prevalence of SIDS among healthy infants has dropped to 0.57 children per 1000 live births, totaling 2200 deaths per year, compared with 1.2 children per 1000 births in 1997.2-4 However, as the incidence of SIDS began to decline, it became apparent that children were experiencing delayed gross motor movement coincident with placement in the supine sleeping position5-7—or, more accurately, because parents following the Back-to-Sleep recommendation also generally avoided placing their infants in the prone position when they were awake.7
These delays become apparent as early as 2 to 3 months of age and manifest as the inability of an infant to raise his or her head when placed in the prone position.8 Because of this finding, the American Academy of Pediatrics modified its original recommendation for healthy infants, in part stating, “A certain amount of tummy time while the infant is awake and observed is recommended for developmental reasons….”9
In this article, I address the 3 most common unintended consequences for infants perpetually placed in the supine position: developmental motor delays, plagiocephaly (flattening of the occiput) and brachycephaly (widening of the skull), and congenital muscular torticollis (CMT) (a head tilt to one side). Each of these outcomes is preventable with vigilance in the care of newborns.
Prevent developmental motor delays with “tummy time”
The need for prone positioning, or “tummy time,” while an infant is awake cannot be overestimated. Particularly for preterm infants, a delayed acquisition of the ability to lift and turn the head could result in upper airway compromise or rebreathing and, thus, asphyxia.10 Infants who sleep in the supine position and exhibit delayed motor development by age 6 months very often are also found to have had their awake prone positioning restricted.11 In one study, delays in gross motor skills persisted in some cases to 15 months of age, and fine motor skills were delayed in 6-month-old infants who had little prone positioning.11 Infants who sleep in the side or supine position roll over later than those who sleep in the prone position.5 The TABLE compares mean age differences for milestone achievements with varying sleep positions.
On multiple regression analyses, awake prone positioning has consistently emerged as the most significant predictor of early motor development.11 For babies regularly placed in the prone position, the average Peabody Development Motor Scales-2 locomotion score has been significantly higher than that of babies not placed in the prone position when tested at 6 and 18 months.12 For infants routinely sleeping supine, supervised “prone to play” during waking hours enables them to practice prone-related motor skills such as head control.13
Infants with prone experience have attained the milestone of crawling on the abdomen significantly earlier than those without prone experience, leading to a higher 6-month gross motor development quotient.14 For children with just over an hour of daily prone positioning, an advantage in motor skill development has revealed itself as early as 4 months of age.15,16 Somewhat reassuring is evidence from one study that all infants, whether sleeping prone or supine, achieve all milestones within the accepted normal age range as long as prone positioning is initiated.7
What you’ll need to do. Stress to parents the importance of tummy time, or prone to play, in enabling normal developmental progression. Encourage this practice even if parents report that their infant cries or otherwise appears not to tolerate the prone position.15 In general, sleeping in the supine position does not negatively impact motor development as long as there is awake time with supervised prone positioning.17
TABLE
Mean age (months) for milestone acquisition
| Milestone | Prone sleepers | Mixed/side sleepers | Supine sleepers | P value* (linear regression)† |
|---|---|---|---|---|
| Rolls prone to supine | 3.93 ± 1.2 | 4.48 ± 1.8 | 4.87 ± 1.33 | .002 (.02) |
| Rolls supine to prone | 4.9 ± 1.3 | 4.97 ± 1.9 | 5.0 ± 1.6 | .95 |
| Sits supported | 4.7 ± 1.3 | 5.02 ± 1.4 | 5.13 ± 0.9 | .003 (.03) |
| Sits unsupported | 5.13 ± 1.1 | 5.17 ± 1.2 | 5.17 ± 1.0 | .80 |
| Transfers object | 5.87 ± 1.2 | 5.99 ± 6.5 | 6.23 ± 1.1 | .11 |
| Creeps | 6.07 ± 1.9 | 6.49 ± 1.9 | 7.23 ± 1.6 | .0002 (.001) |
| Crawls | 7.83 ± 2.0 | 8.47 ± 2.1 | 8.6 ± 1.7 | .003 (.05) |
| Pulls to stand | 8.1 ± 1.6 | 8.7 ± 1.5 | 8.77 ± 1.6 | .01 (.04) |
| Walks alone | 12.1 ± 2.0 | 12.2 ± 2.0 | 12.2 ± 1.7 | .4 |
| *Represents P value for prone sleepers vs supine sleepers. †Multivariate regression analysis controlling for infant size, gender, ethnicity, presence of siblings, and maternal education. Source: Davis BE, Moon RY, Sachs HC, et al. Pediatrics. 1998.7 Reproduced with permission of American Academy of Pediatrics. | ||||
Plagiocephaly and brachycephaly: Vary position for feeding, sleeping
Plagiocephaly and brachycephaly may occur as a consequence of prolonged supine positioning. Indeed, the incidence of plagiocephaly has increased since 1992, due largely to widespread adoption of the supine sleeping position.18 Plagiocephaly and/or brachycephaly is also more likely to occur in the first 4 months of life in infants who are male, firstborn, or who exhibit limited head rotation or low activity levels.19 Feeding with a bottle only and with the child’s head persistently placed to one side can lead to plagiocephaly.20
Delayed achievement of motor milestones is also associated with plagiocephaly, and tummy time to facilitate motor skill development helps protect against the deformity.20 Varying the head position when laying the infant down for sleep is also protective.21 One systematic review has shown considerable evidence that molding therapy with a helmet may reduce skull asymmetry more effectively than repositioning therapy.22
What you’ll need to do. Ask parents about their infant’s activity level, and encourage tummy time to protect against plagiocephaly. Also advise parents who bottle feed to alternate the feeding position between left and right arms.
Torticollis: Assess neck function in weeks after birth
Not only do infants with CMT display a head tilt to one side, but they also often have rotation of the head to the opposite side with the chin appearing to jut out.23 This postural deformity—primarily resulting from unilateral shortening and fibrosis of the sternocleidomastoid muscle24—is detectable at birth or shortly thereafter. CMT occurs in 1 of every 300 live births.25 Torticollis discovered at birth is likely related to a constrained intrauterine position. In one study, 1 in 6 newborns were born with torticollis, and mothers reported that the infants had felt “stuck” in the same position for several weeks before birth.26 The consequent restricted neck range of motion puts infants at risk of developing cranial deformations that may be prevented by changing their sleeping positions.26
What you’ll need to do. Check for limited neck function in the early weeks after birth and recommend neck motion exercises, if necessary, to encourage full head turning to both sides.19 Both torticollis and plagiocephaly due to static supine positioning can be largely eliminated with early written instructions about the value of tummy time when a baby is awake and supervised and the value of changing sleep positions.12 If repositioning or other forms of physical therapy fail to resolve the condition, surgical correction may be necessary.27
- Newer evidence indicates that the rebreathing of exhaled gases in the face-down position and the inability of the infant to reflexively lift his or her head may play a role in sudden infant death syndrome.28
- Nearly 13% of infants are still placed prone for sleep, according to an estimate from the National Infant Sleep Survey.29
- Resources are available from Pathways Awareness (www.pathwaysawareness.org), a not-for-profit foundation, to educate parents (and healthcare professionals) about early detection and intervention of motor delays in children. (The author is a member of the foundation’s Physicians’ Roundtable.)
Acknowledgement
I would like to acknowledge the review and comments of John F. Sarwark, MD.
CORRESPONDENCE
Russell Robertson, MD, Rosalind Franklin University of Medicine and Science, 3333 Green Bay Road North, Chicago, IL 60064; [email protected]
1. Willinger M, Hoffman HJ, Hartford RB. Infant sleep position and risk for sudden infant death syndrome: report of a meeting held January 13 and 14, 1994, National Institutes of Health, Bethesda, MD. Pediatrics. 1994;93:814-819.
2. Hauck FR, Tanabe KO. International trends in sudden infant death syndrome: stabilization of rates requires further action. Pediatrics. 2008;122:660-666.
3. Willinger M, James LS, Catz C. Defining the sudden infant death syndrome (SIDS): deliberations of an expert panel convened by the National Institute of Child Health and Human Development. Pediatr Pathol. 1991;11:677-684.
4. Moon RY, Horne RS, Hauck FR. Sudden infant death syndrome. Lancet. 2007;370:1578-1587.
5. Jantz JW, Blosser CD, Fruechting LA. A motor milestone change noted with a change in sleep position. Arch Pediatr Adolesc Med. 1997;151:565-568.
6. Dwyer T, Ponsonby AL. Sudden infant death syndrome and prone sleeping position. Ann Epidemiol. 2009;19:245-249.
7. Davis BE, Moon RY, Sachs HC, et al. Effects of sleep position on infant motor development. Pediatrics. 1998;102:1135-1140.
8. Perniciaro J. Development, behavior, and mental health. In: Tschudy MM, Arcara KM, eds. The Harriet Lane Handbook. 19th ed. Philadelphia, PA: Mosby; 2011;228:229.-
9. Changing concepts on sudden infant death syndrome: implications for infant sleeping environment and sleep position. American Academy of Pediatrics. Task Force on Infant Sleep Position and Sudden Infant Death Syndrome. Pediatrics. 2000;105:650-656.
10. Lijowska AS, Reed NW, Chiodini BA, et al. Sequential arousal behaviour in infants in asphyxial sleep environments. J Appl Physiol. 1997;83:219-228.
11. Majnemer A, Barr RG. Influence of supine sleep positioning on early motor milestone acquisition. Dev Med Child Neurol. 2005;47:370-376.
12. Jennings JT, Sarbaugh BG, Payne NS. Conveying the message about optimal infant positions. Phys Occup Ther Pediatr. 2005;25:3-18.
13. Ratliff-Schaub K, Hunt CE, Crowell D, et al. Relationship between infant sleep position and motor development in preterm infants. J Dev Behav Pediatr. 2001;22:293-299.
14. Kuo YL, Liao HF, Chen PC, et al. The influence of wakeful prone positioning on motor development during the early life. J Dev Behav Pediatr. 2008;295:367-376.
15. Dudek-Shriber L, Zelazny S. The effects of prone positioning on the quality and acquisition of developmental milestones in four-month-old infants. Pediatr Phys Ther. 2007;19:48-55.
16. Salls JS, Silverman LN, Gatty CM. The relationship of infant sleep and play positioning to motor milestone achievement. Am J Occup Ther. 2002;56:577-580.
17. Fetters L, Huang HH. Motor development and sleep, play, and feeding positions in very-low-birthweight infants with and without white matter disease. Dev Med Child Neurol. 2007;49:807-813.
18. Persing J, James H, Swanson J, et al. Prevention and management of positional skull deformities in infants—American Academy of Pediatrics clinical report. Pediatrics. 2003;112:199-202.
19. Hutchison BL, Hutchison LA, Thompson JM, et al. Plagiocephaly and brachycephaly in the first two years of life: a prospective cohort study. Pediatrics. 2004;114:970-980.
20. van Vlimmeren LA, van der Graaf Y, Boere-Boonekamp MM, et al. Risk factors for deformational plagiocephaly at birth and at 7 weeks of age: a prospective cohort study. Pediatrics. 2007;119:e408-e418.
21. Hutchison BL, Thompson JM, Mitchell EA. Determinants of nonsynostotic plagiocephaly: a case-control study. Pediatrics. 2003;112:e316.-
22. Xia JJ, Kennedy KA, Teichgraeber JF, et al. Nonsurgical treatment of deformational plagiocephaly: a systematic review. Arch Pediatr Adolesc Med. 2008;162:719-727.
23. Cheng JCY. Clinical determinants of the outcome of manual stretching in the treatment of congenital muscular torticollis in infants. A prospective study of eight hundred and twenty one cases. J Bone Joint Surg. 2001;83:679-687.
24. Cheng JCY, Tang SP, Chen TMK. The clinical presentation and outcome of treatment of congenital muscular torticollis in infants. A study of 1086 cases. J Pediatr Surg. 2000;35:1091-1096.
25. Clarren SK, Smith DW, Hanson JW. Helmet treatment for plagiocephaly and congenital muscular torticollis. J Pediatr. 1979;94:43-46.
26. Stellwagen L, Hubbard E, Chambers C, et al. Torticollis, facial asymmetry and plagiocephaly in normal newborns. Arch Dis Child. 2008;93:827-831.
27. de Chalain TM, Park S. Torticollis associated with positional plagiocephaly: a growing epidemic. J Craniofac Surg. 2005;16:411-418.
28. Kinney HC, Thach BT. The sudden infant death syndrome. N Engl J Med. 2009;361:795-805.
29. National Infant Sleep Position. Available at: http://dccwww.bumc.bu.edu/ChimeNisp/Main_Nisp.asp. Accessed February 8, 2010.
1. Willinger M, Hoffman HJ, Hartford RB. Infant sleep position and risk for sudden infant death syndrome: report of a meeting held January 13 and 14, 1994, National Institutes of Health, Bethesda, MD. Pediatrics. 1994;93:814-819.
2. Hauck FR, Tanabe KO. International trends in sudden infant death syndrome: stabilization of rates requires further action. Pediatrics. 2008;122:660-666.
3. Willinger M, James LS, Catz C. Defining the sudden infant death syndrome (SIDS): deliberations of an expert panel convened by the National Institute of Child Health and Human Development. Pediatr Pathol. 1991;11:677-684.
4. Moon RY, Horne RS, Hauck FR. Sudden infant death syndrome. Lancet. 2007;370:1578-1587.
5. Jantz JW, Blosser CD, Fruechting LA. A motor milestone change noted with a change in sleep position. Arch Pediatr Adolesc Med. 1997;151:565-568.
6. Dwyer T, Ponsonby AL. Sudden infant death syndrome and prone sleeping position. Ann Epidemiol. 2009;19:245-249.
7. Davis BE, Moon RY, Sachs HC, et al. Effects of sleep position on infant motor development. Pediatrics. 1998;102:1135-1140.
8. Perniciaro J. Development, behavior, and mental health. In: Tschudy MM, Arcara KM, eds. The Harriet Lane Handbook. 19th ed. Philadelphia, PA: Mosby; 2011;228:229.-
9. Changing concepts on sudden infant death syndrome: implications for infant sleeping environment and sleep position. American Academy of Pediatrics. Task Force on Infant Sleep Position and Sudden Infant Death Syndrome. Pediatrics. 2000;105:650-656.
10. Lijowska AS, Reed NW, Chiodini BA, et al. Sequential arousal behaviour in infants in asphyxial sleep environments. J Appl Physiol. 1997;83:219-228.
11. Majnemer A, Barr RG. Influence of supine sleep positioning on early motor milestone acquisition. Dev Med Child Neurol. 2005;47:370-376.
12. Jennings JT, Sarbaugh BG, Payne NS. Conveying the message about optimal infant positions. Phys Occup Ther Pediatr. 2005;25:3-18.
13. Ratliff-Schaub K, Hunt CE, Crowell D, et al. Relationship between infant sleep position and motor development in preterm infants. J Dev Behav Pediatr. 2001;22:293-299.
14. Kuo YL, Liao HF, Chen PC, et al. The influence of wakeful prone positioning on motor development during the early life. J Dev Behav Pediatr. 2008;295:367-376.
15. Dudek-Shriber L, Zelazny S. The effects of prone positioning on the quality and acquisition of developmental milestones in four-month-old infants. Pediatr Phys Ther. 2007;19:48-55.
16. Salls JS, Silverman LN, Gatty CM. The relationship of infant sleep and play positioning to motor milestone achievement. Am J Occup Ther. 2002;56:577-580.
17. Fetters L, Huang HH. Motor development and sleep, play, and feeding positions in very-low-birthweight infants with and without white matter disease. Dev Med Child Neurol. 2007;49:807-813.
18. Persing J, James H, Swanson J, et al. Prevention and management of positional skull deformities in infants—American Academy of Pediatrics clinical report. Pediatrics. 2003;112:199-202.
19. Hutchison BL, Hutchison LA, Thompson JM, et al. Plagiocephaly and brachycephaly in the first two years of life: a prospective cohort study. Pediatrics. 2004;114:970-980.
20. van Vlimmeren LA, van der Graaf Y, Boere-Boonekamp MM, et al. Risk factors for deformational plagiocephaly at birth and at 7 weeks of age: a prospective cohort study. Pediatrics. 2007;119:e408-e418.
21. Hutchison BL, Thompson JM, Mitchell EA. Determinants of nonsynostotic plagiocephaly: a case-control study. Pediatrics. 2003;112:e316.-
22. Xia JJ, Kennedy KA, Teichgraeber JF, et al. Nonsurgical treatment of deformational plagiocephaly: a systematic review. Arch Pediatr Adolesc Med. 2008;162:719-727.
23. Cheng JCY. Clinical determinants of the outcome of manual stretching in the treatment of congenital muscular torticollis in infants. A prospective study of eight hundred and twenty one cases. J Bone Joint Surg. 2001;83:679-687.
24. Cheng JCY, Tang SP, Chen TMK. The clinical presentation and outcome of treatment of congenital muscular torticollis in infants. A study of 1086 cases. J Pediatr Surg. 2000;35:1091-1096.
25. Clarren SK, Smith DW, Hanson JW. Helmet treatment for plagiocephaly and congenital muscular torticollis. J Pediatr. 1979;94:43-46.
26. Stellwagen L, Hubbard E, Chambers C, et al. Torticollis, facial asymmetry and plagiocephaly in normal newborns. Arch Dis Child. 2008;93:827-831.
27. de Chalain TM, Park S. Torticollis associated with positional plagiocephaly: a growing epidemic. J Craniofac Surg. 2005;16:411-418.
28. Kinney HC, Thach BT. The sudden infant death syndrome. N Engl J Med. 2009;361:795-805.
29. National Infant Sleep Position. Available at: http://dccwww.bumc.bu.edu/ChimeNisp/Main_Nisp.asp. Accessed February 8, 2010.