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Supine Infant Positioning— Yes, but There's More to It

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Supine Infant Positioning— Yes, but There's More to It Russell Robertson, MD Rosalind Franklin Supine infant positioning— University of Medicine and Science, Chicago, Ill Yes, but there’s more to it russell.robertson@ rosalindfranklin.edu The Back-to-Sleep campaign has helped reduce The author reported no potential conflict of interest the incidence of SIDS, but a neglect of prone relevant to this article. positioning during wakefulness has increased the risk of 3 complications. s happens with many interventions, the Back-to- PRactice Sleep campaign1 to prevent sudden infant death syn- RecommenDations drome (SIDS) has led to unintended consequences. › A Continue to advise parents The campaign’s primary recommendation—that infants be to place their infants on their placed on their backs for sleeping instead of on their stom- backs for sleeping, to prevent achs—has of course yielded tremendous benefits. The preva- sudden infant death. A lence of SIDS among healthy infants has dropped to 0.57 › Educate parents about children per 1000 live births, totaling 2200 deaths per year, the value of supervised compared with 1.2 children per 1000 births in 1997.2-4 How- prone positioning (“tummy ever, as the incidence of SIDS began to decline, it became ap- time”) during waking parent that children were experiencing delayed gross motor hours, which helps infants movement coincident with placement in the supine sleeping learn to raise their head, 5-7 push up on their arms, and position —or, more accurately, because parents following attain on-time milestones the Back-to-Sleep recommendation also generally avoided such as rolling over and placing their infants in the prone position when they were unsupported sitting. A awake.7 › Tell parents that super- These delays become apparent as early as 2 to 3 months vised abdominal positioning of age and manifest as the inability of an infant to raise his instant 8 aids in preventing plagio- or her head when placed in the prone position. Because poll cephaly and torticollis. B of this finding, the American Academy of Pediatrics modi- QUESTION fied its original recommendation for healthy infants, in part strength of recommendation (SOR) stating, “A certain amount of tummy time while the infant Do you advise new A Good-quality patient-oriented is awake and observed is recommended for developmental evidence parents to give their 9 B Inconsistent or limited-quality reasons. .” baby “tummy time”? patient-oriented evidence In this article, I address the 3 most common unintended C Consensus, usual practice, n Yes opinion, disease-oriented consequences for infants perpetually placed in the supine evidence, case series position: developmental motor delays, plagiocephaly (flat- n No tening 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 vigi- lance in the care of newborns. Go to jfponline.com and take our instant poll conTinued jfponline.com Vol 60, No 10 | OCToBeR 2011 | The JouRnal of Family PracTice 605 Prevent developmental gross motor development quotient.14 For chil- motor delays with “tummy time” dren with just over an hour of daily prone The need for prone positioning, or “tummy positioning, an advantage in motor skill devel- time,” while an infant is awake cannot be over- opment has revealed itself as early as 4 months estimated. Particularly for preterm infants, of age.15,16 Somewhat reassuring is evidence a delayed acquisition of the ability to lift and from one study that all infants, whether sleep- turn the head could result in upper airway ing prone or supine, achieve all milestones compromise or rebreathing and, thus, asphyx- within the accepted normal age range as long ia.10 Infants who sleep in the supine position as prone positioning is initiated.7 and exhibit delayed motor development by z What you’ll need to do. Stress to par- age 6 months very often are also found to have ents the importance of tummy time, or prone had their awake prone positioning restricted.11 to play, in enabling normal developmental In one study, delays in gross motor skills per- progression. Encourage this practice even if sisted in some cases to 15 months of age, and parents report that their infant cries or oth- fine motor skills were delayed in 6-month-old erwise appears not to tolerate the prone po- infants who had little prone positioning.11 In- sition.15 In general, sleeping in the supine fants who sleep in the side or supine position position does not negatively impact motor roll over later than those who sleep in the development as long as there is awake time prone position.5 TheTA BLe compares mean age with supervised prone positioning.17 educate parents differences for milestone achievements with about the value varying sleep positions. of placing their On multiple regression analyses, awake Plagiocephaly and brachycephaly: infant in the prone positioning has consistently emerged Vary position for feeding, sleeping prone position as the most significant predictor of early Plagiocephaly and brachycephaly may oc- for brief periods motor development.11 For babies regularly cur as a consequence of prolonged supine when awake. placed in the prone position, the average Pea- positioning. Indeed, the incidence of plagio- body Development Motor Scales-2 locomo- cephaly has increased since 1992, due largely tion score has been significantly higher than to widespread adoption of the supine sleep- that of babies not placed in the prone posi- ing position.18 Plagiocephaly and/or brachy- tion when tested at 6 and 18 months.12 For cephaly is also more likely to occur in the first infants routinely sleeping supine, supervised 4 months of life in infants who are male, first- “prone to play” during waking hours enables born, or who exhibit limited head rotation or them to practice prone-related motor skills low activity levels.19 Feeding with a bottle only such as head control.13 and with the child’s head persistently placed Infants with prone experience have at- to one side can lead to plagiocephaly.20 tained the milestone of crawling on the abdo- Delayed achievement of motor mile- men significantly earlier than those without stones is also associated with plagiocephaly, prone experience, leading to a higher 6-month and tummy time to facilitate motor skill de- Did you know? • 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 profes- sionals) about early detection and intervention of motor delays in children. (The author is a member of the foundation’s Physicians’ Roundtable.) 606 The JouRnal of Family PracTice | OcToBer 2011 | Vol 60, No 10 Supine Sleep poSitioning TABLe Mean age (months) for milestone acquisition P value* (linear milestone prone sleepers mixed/side sleepers Supine sleepers 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. advise parents who bottle feed to alternate the velopment helps protect against the defor- position for several weeks before birth.26 The feeding position mity.20 Varying the head position when laying consequent restricted neck range of motion to guard against the infant down for sleep is also protective.21 puts infants at risk of developing cranial de- plagiocephaly. One systematic review has shown consider- formations that may be prevented by chang- able evidence that molding therapy with a ing their sleeping positions.26 helmet may reduce skull asymmetry more ef- z What you’ll need to do. Check for fectively than repositioning therapy.22 limited neck function in the early weeks after z What you’ll need to do. Ask parents birth and recommend neck motion exercises, about their infant’s activity level, and encour- if necessary, to encourage full head turning to age tummy time to protect against plagio- both sides.19 Both torticollis and plagioceph- cephaly. Also advise parents who bottle feed aly due to static supine positioning can be to alternate the feeding position between left largely eliminated with early written instruc- and right arms. tions about the value of tummy time when a baby is awake and supervised and the value of changing sleep positions.12 If repositioning torticollis: assess neck function or other forms of physical therapy fail to re- in weeks after birth solve the condition, surgical correction may Not only do infants with CMT display a head be necessary.27 JFP tilt to one side, but they also often have rota- tion of the head to the opposite side with the coRResPonDence Russell Robertson, md, Rosalind franklin university of 23 chin appearing to jut out.
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