What is Tummy Time: is it necessary for newborns?

By Joyce Miller, BSc, DC, PhD,1 and Sharon Vallone, DC, FICCP2

1. Anglo-European College of Chiropractic, Bournemouth, UK
2. Private practice, Kidspace Adaptive Play and Wellness, South Windsor, Connecticut, USA
Corresponding author: jmiller@aecc.ac.uk

Chiropractic offices are receiving large numbers of infant patients into their practices. Consequently, new guidelines have been forthcoming to assist chiropractors in applying their best evidence practice to this age group.1,2 However, very little has been said in how we give advice, particularly in the important topic of prone play (“tummy time”) for the infant. It is not always recognized that research data must be translated into clinical practice in order for the practical applications to benefit the end user, the patient, and in this case the parent and the infant. Why would such a simple concept, such as an infant playing in prone position be an issue for discussion between the doctor and parents? It is because the simple messages have become convoluted, confusing and difficult to follow. It is perhaps time to go back to the beginning.

What is the postural problem?
Most new mothers report little, if any physician advice on daytime positioning, but 90% report receiving information on infant sleep positioning.3 In general, correct positioning of the neonate is very important for postural control for any infant at risk of developing fixed deformities, but little specific advice may be given by physicians, except for the “Back-To-Sleep” program.4

The long-term 1992 advice from the American Academy of Pediatrics recommending that caregivers always place a baby on his or her back for sleep at night has come through loud and clear.4

This advice has been frequently reiterated, “reaffirmed” (what the AAP does periodically to keep specific policies in the public eye) and often repeated that the supine positioning has had a positive reduction in SIDS (sudden infant death syndrome).5,6-10 This advice may or may not stand up to scrutiny and is a potential and necessary topic for extensive evidence based review.11 That review cannot be done in the context of this paper. Our role and responsibility is to provide resources for parents so that they may attempt to make informed decisions based on the available evidence.

Another effect from Back-To-Sleep, and the topic of this commentary, has been a common occurrence of misshapen heads in the pediatric population (Table 1).5

Table 1

Why does head shape change with supine sleep? Since most of the infant’s time is spent in sleep, if the head position doesn’t vary, the soft skull is likely to flatten from consistent, weight bearing positioning. The problem is that the more it flattens, the harder it is for the infant to change position. The more time passes in only one position, the flatter the malleable, weight bearing area becomes, losing the roundness of the cranium and resulting in head deformation, or what is termed “plagiocephaly” or misshapen skull. This can occur on the posterior aspect of the skull, which is termed “brachiocephaly”, or very commonly, unilaterally (only on one side) when an infant has preferred or restricted neck rotation.

Although head shape problems do decline with age, there are still a significant number that suffer from longer term problems. Research suggests that infants with positional plagiocephaly are at risk of a delay in motor milestones.12-17 Although many physicians term the cranial deformation “purely cosmetic,” it may be that cosmetic head deformity is merely a marker for the problem, not the real problem, which is more likely the lack of opportunity to play in prone position which supports development.17

Chiropractors will be very familiar with the problem of the infant who cannot rotate his or her cervical spine equally to both sides (due to vertebral fixation or muscular imbalance), thus causing a flatness on one side of the cranium (more commonly the right side).18 Once the infant has settled into this preferred posture, the more the head flattens, the more difficult it is to overcome gravity and the more staying to that side becomes a habit, profoundly preferred by the child. Parents may accept this as typical behaviour and the head shape may not even be noticed by them and it is often first pointed out by the doctor on the 8 week wellness exam. If the baby is not prescribed and administered treatment to allow him/her full range of motion of the cervical spine and is not given good instruction on the need for tummy time, the problem may persist. There is some evidence that chiropractic care is helpful to reduce the head deformity through improving the infant’s ability to rotate equally in both directions.18 The AAP recognized that infants were missing out on important health motor develop by 1996 and recommended to parents that they vary their infant’s head position in their sleep and give them some tummy time when awake, beginning at birth.6 Unfortunately, this advice was largely ignored.3

Despite that early warning about the need for tummy time, it has never really become common advice for health care professionals to disseminate. Parents have had to learn on their own of its many benefits and they sometimes have a fear of placing their baby on his/her front based on the 1992 information linking any position except supine with SIDS.4 Many parents did not realize that supine is the position for sleep, but that day-time position should be varied for the health of the child.

What is it important for parents to know and understand?
Environment makes a difference to baby’s development and babies need to move within their environment. The authors are proposing a guideline for parents to use in order to help them understand how much tummy time may help their babies adapt to their environment in a positive way and to prevent or help alleviate any positional head deformation caused by continuous supine positioning (Table 2).

Table 2

Remember that the time per day can be split into smaller time intervals throughout the day. Make it fun with toys and interaction, so that they gradually get used to it and learn to enjoy the time and the new point of view. It is key to remember that until or unless the AAP guidelines are reviewed and refuted with evidence based information, lay babies down to sleep on their back, do not lie babies prone on less than firm surfaces (not on pillows, comforters, pillow tops, etc) and always supervise the tummy time. Doing these things may lower the risk for both SIDS and developmental problems.

1. Hawk C. Schneider M. Ferrance RJ. Hewitt E. Van Loon M. Tanis L. Best practices recommendations for chiropractic care for infants, children and adolescents: results of a consensus panel. JMPT 2009; 32(8):639-647.

2. Hawk C. Shneider MJ. Vallone S. Hewitt EG. Best practices recommendations for chiropractic care of children: a consensus update. JMPT 2016; 39(3):158-168. Accessed August 21,2016:

3. Koren A. Reece SM. Kahn-D’angelo L. Medeiros D. Parental information and behaviors and provider practices related to tummy time and back to sleep. Journal of Pediatric Health Care 2009; 24 (4):222-229.

4. American Academy of Pediatrics Task Force on Infant Positioning and SIDS, Positioning and SIDS. Pediatrics 1992; 89:1120-1126.

5. Hutchison BL. Hutchison LA. Thompson JM. Mitchell EA. Plagiocephaly and brachycephaly in the first two years of life: a prospective cohort study. Pediatrics 2004.,114, 970–980.

6. American Academy of Paediatrics Task Force on Infant Positioning and SIDS. Positioning and sudden infant death syndrome (SIDS): update. Pediatrics 1996; 98: 1216 –1218.

7. American Academy of Pediatrics Task Force on Infant Sleep Position and Sudden Infant Death Syndrome Changing Concepts of Sudden Infant Death Syndrome: Implications for Infant Sleeping Environment and Sleep Position. Pediatrics March 2000; 105(3): 650-656. Accessed on August 21, 2016: http://pediatrics.aappublications.org/content/pediatrics/105/3/650.full.pdf.

8. The Changing Concept of Sudden Infant Death Syndrome: Diagnostic Coding Shifts, Controversies Regarding the Sleeping Environment, and New Variables to Consider in Reducing Risk. Pediatrics. 2005;116(5):1245–1255. Reaffirmed 2008. Accessed on August 21, 2016: http://pediatrics.aappublications.org/content/pediatrics/116/5/1245.full.pdf.

9. SIDS and Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping Environment: Task Force on Sudden Infant Death Syndrome. Policy Statement. Pediatrics Nov 2011;128(5): 1030-1039. Accessed on August 21, 2016: http://pediatrics.aappublications.org/content/pediatrics/128/5/1030.full.pdf.

10. AAP Publications Reaffirmed or Retired Pediatrics April 2015; 135(4): e1105-6. Accessed on August 21, 2016: http://pediatrics.aappublications.org/content/pediatrics/early/2015/03/25/peds.2015-0339.full.pdf.

11. Pelligra, R., Doman, G., and Leisman, G. (2005) A reassessment of the SIDS Back to Sleep Campaign. The Scientific World JOURNAL 2005, 5: 550-557. Accessed on August 21, 2016 at:

12. Jantz JW. Blosser CD. Fruechting LA. A motor milestone change noted with a change in sleep position. Arch Pediatr Adolesc Med 1997; 151: 565-68.

13. Argenta LC., David LR. Wilson JA. Bell, WO. An increase in infant cranial deformity with supine sleeping position. Journal of Craniofacial Surgery 1996; 7: 5-11.

14. Ayer A. Campbell A. Appelboom G. Hwang BY. McDowell M. Piazza M. Feldstein NA. Anderson RC. The sociopolitical history and physiological underpinnings of skull deformation. Neurosurg Focus 2010;29:E1.

15. Collett B. Breiger D. King D. Cunningham M. Speltz M.. Neurodevelopmental Implications of “Deformational Plagiocephaly.” Developmental and Behavioral Pediatrics 2005; 26(5): 379-389.

16. Davis BE. Moon RY. Sachs HC. Ottolini MC. Effects of sleep position on infant motor development. Pediatrics 1998; 102(5): 1135-1140.

17. Dudek-Shriber L. Zelazny S. The effects of prone positioning on the quality and acquisition of developmental milestones in four-month-old infants. Pediatric Physical Therapy 2007; 19 (1): 48-55.

18. Douglas NA et al., Chiropractic care for the cervical spine as a treatment for plagiocephaly: a cross-sectional study, accepted for publication, JCCP 2016.