Parents of infants all know that they should be working on tummy time every day from an early age. However, most parents also experience difficulty consistently working on tummy time, since babies are often initially resistant to this position.
Below is a list of reasons why tummy time is so important, even if your child does not initially enjoy the position:
Strength: When a baby is placed on her stomach, she actively works against gravity to lift her head, arms, legs and trunk up from the ground. Activating the muscle groups that control these motions and control the motor skills that your child will learn in tummy time allows for important strengthening of these muscle groups that your baby won’t be able to achieve lying on her back.
Sensory development: Your child will experience different sensory input through the hands, stomach, and face when she is lying on her stomach, which is an integral part of her sensory development. When your baby is on her stomach her head is a different position than she experiences when on her back or sitting up, which helps further develop her vestibular system.
Motor skill acquisition: There are a lot of motor skills that your child will learn by spending time on her stomach. Rolling, pivoting, belly crawling, and creeping (crawling on hands and knees) are just a few of many important motor skills that your child will only learn by spending time on her stomach. Along with being able to explore her environment by learning these new skills, your baby will also create important pathways in the brain to develop her motor planning and coordination that impact development of later motor skills, such as standing and walking.
Head shape: Infants who spend a lot of time on their backs are at risk for developing areas of flattening along the back of the skull. It is recommended that babies sleep on their backs to decrease the risk of sudden infant death syndrome, and since babies spend a lot of time sleeping, they are also already spending a lot of time lying flat on the back. Spending time on the tummy when awake therefore allows for more time with pressure removed from the back of the head, and also helps to develop the neck muscles to be able to independently re-position the head more frequently while lying on the back.
It is important to remember that your child should only spend time on his or her stomach when awake and supervised. Many infants are initially resistant to tummy time because it is a new and challenging position at first. However, by starting with just a few minutes per day at a young age and gradually increasing your child’s amount of tummy time, your child’s tolerance for the position will also improve.
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When I tell people that I am a pediatric physical therapist I am often met with a blank, questioning stare. Why could children possibly need physical therapy? When most people think of physical therapy, they think of recovering from a back injury or shoulder surgery, or maybe they think of someone in a nursing home going through rehab after a stroke. However, children can often benefit from the services of a physical therapist as well, from newborns all the way through adolescents. Pediatric physical therapists focus on the gross motor development of children, and work to address any limitations that may impact that development.
Pediatric physical therapists therefore work with a wide range of diagnoses and conditions including:
Gross motor delay: Development of gross motor skills is an important piece of child development. Since these skills build on one another, a delay with one skill can lead to further delays or difficulty with later skills. Pediatric physical therapists can help your child develop the major gross motor milestones listed below, as well as many more!
Torticollis and plagiocephaly: Torticollis is a condition that occurs when there is asymmetrical muscle length and strength in a baby’s neck muscles, and therefore limits symmetrical neck motion. Plagiocephaly, or asymmetrical head shape, often occurs when a child has torticollis, as a result of frequent pressure being put on only one part of the head. A pediatric physical therapist can help to stretch and strengthen the child’s neck in order to promote symmetrical motion and head shape.
Balance and coordination disorders: Limitations in balance and coordination can have a significant impact on a child’s ability to develop motor skills, as well as to safely negotiate his or her natural environments. A pediatric physical therapist can treat these limitations to allow for improved functioning and safety.
Neurological disorders: A neurological disorder occurs when there is abnormal functioning of the body’s nerves, spinal cord, or brain. These are just a few of the disorders that a pediatric physical therapist can treat.
Orthopedic conditions: Children get hurt too! Even though children tend to be more resilient to injury then adults, children who suffer an injury or require surgery can also benefit from physical therapy services to help restore function to the musculoskeletal system.
Genetic disorders: Genetic mutations may result in impaired development and functioning in children, and can therefore be addressed through intervention with a pediatric physical therapist. While there is a wide range of genetic disorders and their resulting impact on child development, below are a few examples of genetic disorders where a pediatric physical therapist is typically a part of the child’s team of providers.
Gait abnormalities: The way a child’s lower extremity bones and muscles develop have a large impact on the child’s gait mechanics. Abnormalities with gait, such as toe-walking, can be addressed by a pediatric physical therapist.
Many more! If you are unsure of whether your child may benefit from the services of a pediatric physical therapist, speak with your pediatrician or reach out to a pediatric physical therapist near you.
As a pediatric physical therapist in the outpatient setting, about 10-25% of my patients are diagnosed with Torticollis. Torticollis is the tightening of one muscle in the neck called the Sternocladeomastoid, or SCM for short. The SCM is the muscle that controls ipsilateral sidebend and contralateral head rotation. This muscle, located on either side of the neck, works to tuck the chin down. When one side works independently, it will work to turn the head to the opposite side and tilt the head towards the direction of the muscle. Torticollis is a serious medical condition, and left untreated, can result in many impairments. I will go over some of the most frequent and serious below.
Possible Results of Untreated Torticollis:
Plagiocephaly – This is the most common consequence of untreated Torticollis. Plagiocephaly is the mishapening of the bones on the skull, usually resulting in a large flat spot on one side of the back of the head and facial assymetries. Early diagnosis and conservative treatment can be successful in decreasing the severity of the Plagiocephaly. However, late diagnosis must be treated by a helmet or craniofacial surgery.
Cervical spine contractures into the preferred head rotation and sidebend – These contractures can become ossified over time, significantly impacting functional mobility and ability to interact with peers. Once a contracture is ossified, surgery is required to lengthen the muscle, followed by several sessions of physical therapy to regain full cervical spine range of motion.
Limited shoulder mobility – Decreased active movement into non-preferred rotation and sidebend can also result in shoulder elevation. This in turn impacts the child’s ability for upper extremity weight-bearing and reaching toward midline with hand.
Cervical Scoliosis – Persistent head tilt in the absence of shoulder elevation can result in a lateral shift of the cervical spine, which leads to cervical scoliosis.
A majority of the babies I see in the clinic are those diagnosed with torticollis and plagiocephaly. These babies are often accompanied by bewildered first-time parents with worried looks, scared by those big diagnostic words. The first questions they ask are “could I have prevented this?” and “will he need a corrective helmet?”
What is plagiocephaly and what causes it?
Since the beginning of the “Back to Sleep” program in the 1990s, which kept babies off their tummies to prevent Sudden Infant Death Syndrome, many babies started to develop flat spots on the back of their heads. Plagiocephaly and brachycephaly are two terms used to describe the abnormal head shape, depending on the degree of distortion and location of the flatness. While most parents think they were partially responsible for the flat spot developing in their newborn, an infant’s head is extremely malleable before it reaches cranial maturity. Any prolonged external force leads to some skull shape changes. Plagiocephaly and brachycephaly can be associated with many conditions, from prematurity and twin births, to torticollis (asymmetrically tight neck muscle), to developmental delay. Often times, the asymmetries are resolved with simple repositioning and stretching exercises to encourage the child to look to both sides, physical therapy, as well as nap and play time on the tummy, all with supervision of course.
How do plagiocephaly helmets work and what’s the best time to get one?
Plagiocephaly helmets are cranial orthoses made out of a hard plastic shell with foam lining, custom made to each child, and designed to keep pressure off the flat spots to help the head naturally round itself out. They are meant to be worn for 8-12 weeks for at least 23 hours a day, during sleep and play. Certain hospitals, orthotics companies, and plastic surgeon’s offices design their own version of the helmets, but the concept is still the same.
The earlier a child with torticollis and plagiocephaly starts a repositioning and physical therapy program, the less likely he will need a skull reshaping orthosis. As physical therapists, we usually recommend a helmet evaluation if 1) A baby has been repositioned off his flat spot and participating in physical therapy for 1-2 months without any significant changes noted to his head shape, 2) A baby has spent 1-2 months sitting independently with good head control and playing easily in tummy time, and moderate to severe plagiocephaly is still present, or 3) A baby is over 6 months of age and facial asymmetries are still obvious. Usually, helmets are not expected to be effective for kids over 18 months. What facial asymmetries do we look for as an indication of moderate to severe cranial change? A smaller chin on the affected side, a smaller ear or an ear that’s shifted forward, and a smaller or droopy eye on one side are examples. Of course, every baby develops differently and other factors may be taken into consideration, such as if his abnormal head shape is keeping him from achieving gross motor milestones (rolling, head control, etc).
Do helmets actually help? Aren’t all of our heads a little bit asymmetrical? What happens if my child doesn’t get one?
In its early years, the infant helmet received a bit of scrutiny. The biggest push-back from some insurance companies and doctors against cranial helmets is that asymmetrical head shape in babies appears to be a cosmetic complaint that hardly justifies a costly and bulky orthosis. Parents and practitioners alike question the association between deformational plagiocephaly and long-term functional delay in kids. There has been research over the last two decades on whether helmets alone prevent long-term asymmetries, if cranial asymmetries lead to other medical issues, or if neurodevelopmental delays occur in school-aged children with plagiocephaly. While the literature is still young and long-term research is still in the works, untreated cranial asymmetries have been linked to visual defects, ear infections, middle ear malfunction, jaw bone changes, developmental delay, learning difficulties, and other psychomotor delays.
In a brand new study out of the Netherlands this month, researchers found that helmet therapy alone yields similar results to natural cranial growth. The study, however, focused only on babies with mild plagiocephaly, not torticollis, prematurity, or other associated conditions. Babies with severe plagiocephaly were also not included in the study, which limited the population to a very specific, underrepresented, group in pediatric clinics. Interestingly enough, the study found that by the time their child was 2 years old, parent satisfaction was much higher and parent anxiety was slightly lower in the group who received helmets. Even in this study suggesting the ineffectiveness of helmets, the authors referenced other studies that discussed the long-term implications of letting deformational plagiocephaly go untreated. These included researchers from different fields, such as neurology, child development, physical therapy, orthotics and prosthetics, and plastic surgery. Overall, developmental experts agree, long term consequences of untreated plagiocephaly are multi-faceted and future research is imperative.
Because physical therapists like us have no association with helmet companies, doctors’ offices, or orthotists, our recommendations are purely based on the child and family’s needs. What I always tell anxious parents trying to make this decision of whether or not to try the cranial orthosis helmet with their child is this:
Helmets are not right for every baby with cranial asymmetry. The results you can get out of a helmet depends on the fit, consistency of wear, and the baby’s growth. The most effective time period to make the most changes to a baby’s head is short. Don’t let a medical professional bully you into making a decision you aren’t comfortable with. At the same time, take on a wider perspective when trying to make this decision. Have we done all the necessary exercises and reposition changes? Have we taken into consideration medical advice from all the different health professionals involved in your baby’s care? Did the helmet evaluation (with measurements done by machines for precision) reveal moderate to severe cranial changes? Are you worried about side effects or costly interventions that might be needed down the road? These are great questions to talk out with your pediatrician or physical therapist.
In my clinical experience, I have never had a parent regret the decision they made, whether it was to seek out a helmet evaluation or to forgo helmet therapy. Though often it was a hard decision to make, we were able to work through the questions together to determine the best course of action for their precious little one’s all-important noggin.
Do you still have questions or have experience you want to share? Please let us know!
Kordestani R, Patel S, Bard D. Neurodevelopmental Delays in Children with Deformational Plagiocephaly. Plastic and Reconstructive Surgery 2006;117:1. Available from: www.plasreconsurg.org. [accessed 15 April 2014]
Stevens, P. Beyond Cosmetic Concerns – Functional Deficits Associated with Deformational Plagiocephaly. April 2012. The O&P EDGE. Available from: http://www.oandp.com/articles/2012-04_02.asp [accessed 15 April 2014]
Van Wikl RM, van Vlimmeren LA, Groothuis-Oudshoorn CGM. Helmet therapy in infants with positional skull deformation: randomized controlled trial. BMJ 2014;348:g2741. Available from: http://www.bmj.com. [accessed 12 May 2014]
https://secureservercdn.net/184.108.40.206/fnf.6b5.myftpupload.com/wp-content/uploads/2014/05/133910422.jpg?time=1611229024338507Judy Wang, PT, DPThttps://secureservercdn.net/220.127.116.11/fnf.6b5.myftpupload.com/wp-content/uploads/2016/05/nspt_2-color-logo_noclaims.pngJudy Wang, PT, DPT2014-05-20 13:46:492015-01-13 17:27:49Babies, Misshapen Heads, and Plagiocephaly Helmets: a Physical Therapist Perspective