Time to revisit tummy time: A commentary on plagiocephaly and development

Abstract

Many centres report receiving more referrals for deformational plagiocephaly since implementation of the Back to Sleep campaign. This commentary combines clinical experience, local quality improvement data and existing literature to highlight three points to help prevent and manage plagiocephaly: (1) communicating ‘Back to Sleep, Tummy to Play’, (2) the importance of early detection and (3) plagiocephaly as a marker of developmental risk. We recommend: (1) equal emphasis on the messages of Back to Sleep and supervised Tummy to Play, to start this messaging early and reinforce at every opportunity; (2) examination of skull shape and neck range of motion as a routine component of the newborn assessment so that caregivers can implement positioning and handling suggestions immediately and (3) physiotherapy referral for babies who have torticollis, or who show persistent or worsening plagiocephaly despite positioning and handling interventions, for further assessment and management.

In the April 2016 edition of this journal (1), physiotherapist Susan Harris outlined the importance of recognizing markers of neurodevelopmental delay in a timely fashion, so early intervention might be offered to families. We agree that the recognition of markers of developmental delay is critical. With this commentary, we wish to extend the discussion beyond the routine use of standardized developmental assessments to emphasize that presence of deformational plagiocephaly may be an early and important marker of developmental risk.

The Back to Sleep campaign was introduced in the USA in 1992, and 1999 in Canada in an effort to reduce the occurrence of sudden infant death syndrome (SIDS). The campaign was well adopted, with US sources indicating that the percentage of infants placed on their back to sleep rose from 27% in 1994 to 74% in 2009, while the incidence of SIDS appeared to decrease (2).

An unintended consequence of this campaign was a rise in deformational plagiocephaly, evidenced by an increase in the number of referrals to physiotherapy, occupational therapy and craniofacial clinics for management of this condition (3). Plagiocephaly is characterized by the development of a flat spot, typically on the posterolateral aspect of an infant’s head. Flattening can range from mild (slight flattening) to severe (significant flattening accompanied by ipsilateral forehead bulging, asymmetry in ear/eye position and facial scoliosis) (4).

This trend of increasing referral rates has been observed within our paediatric physiotherapy department in Winnipeg, Manitoba. Prior to Back to Sleep implementation, we received approximately 50 referrals each year for torticollis and/or plagiocephaly. The annual referral rate has been steadily rising since 2002, reaching 200 referrals in 2011 and peaking at 307 in 2014. Continued high referral rates suggest further efforts are required to ensure that health care providers and parents understand key principles of plagiocephaly prevention and management. From our perspective, there are three main points for health care providers to be aware of to better prevent and manage plagiocephaly: (1) communicating ‘Back to Sleep, Tummy to Play’, (2) the importance of early detection and (3) plagiocephaly as a marker of developmental risk.

COMMUNICATING ‘BACK TO SLEEP, TUMMY TO PLAY’

Australia was among the first to implement a SIDS prevention campaign emphasizing Back to Sleep (5). They were also among the first to explore how SIDS prevention messaging affected the positions that caregivers placed their babies in for sleep AND play. Reassuringly, there was strong adoption of the Back to Sleep message; 84% of caregivers reported to never put their baby on their tummy for sleep (5). However, for nearly 40% of caregivers, this messaging also affected playtime positioning. Nearly half of this subgroup reported they never put their baby on their tummy to play (5). These results suggest an over-interpretation of the Back to Sleep guidelines: the message of ‘don’t put your baby on their tummy to sleep’ became ‘don’t put your baby on their tummy – ever’. This study is over 20 years old, but we hear the findings echoed within clinical encounters today.

From the inception of the Back to Sleep campaign, there have been accompanying efforts to encourage supervised tummy time for infants. However, information about tummy time is frequently included as a side bar to information on SIDS prevention, perpetuating the difficulties in messaging observed by Mildred et al. (5) two decades ago.

Our efforts to better communicate the importance of tummy time began in 2006 with the campaign ‘A Good Head Start’. This project included evidence-based information shared through posters and handouts distributed to Winnipeg paediatricians, community clinics, obstetricians, physiotherapy clinics and hospitals. This was expanded to Nursing Stations and rural health centres in Manitoba and Northwest Ontario in 2008. In 2012, ‘Tummy Time and More! Preventing and Treating Flat Heads in Babies’ was developed and distributed to Public Health Nurses and Well-baby group leaders. This teaching guide included numerous photos and facilitator notes. The intent of the resource was to: (1) encourage new parents to practice tummy time with their infants to prevent plagiocephaly and (2) increase awareness of plagiocephaly to promote earlier detection and intervention. Corresponding with our efforts, we are beginning to see a shift in our annual referral patterns toward earlier referral to physiotherapy (Figure 1).

Figure 1.

Percentage of referrals to physiotherapy for torticollis/plagiocephaly per age group

This year, we developed ‘Tummy Time for Newborns’ which was distributed through the above networks. This two-sided handout (available on request) uses simple language and line drawings to convey two messages: (1) Back to Sleep (page 1) reinforces current guidelines and discourages the use of car seats for sleep (when not in a vehicle), infant swings or other supine positioning equipment for sleep and (2) Tummy Time (page 2) offers 5 position/handling suggestions to promote tummy time in very young infants prior to development of head control. The use of a handout to convey information about tummy time is supported by the literature (6,7), and we attempted to further increase the impact of this handout through engaging a media specialist for conceptualization and formatting assistance. Finally, over the last decade, we have provided presentations through the above networks to reinforce the Tummy to Play component of the Back to Sleep campaign.

We suggest that paediatricians and primary care providers place equal emphasis on the messages of Back to Sleep and supervised Tummy to Play, and to start this messaging with parents early and reinforce it at every opportunity.

THE IMPORTANCE OF EARLY DETECTION

The Canadian Paediatric Society (CPS) recommends well-baby checks within the first week and at 2 and 4 months (8). The CPS practice point ‘Positional Plagiocephaly’ (9) recommends that ‘evaluation for craniosynostosis, congenital torticollis and cervical spine abnormalities should be part of the examination of a child with plagiocephaly’ (author’s emphasis). We believe there is opportunity to intervene before plagiocephaly is established.

A Finnish study in 2014 (10) used photographic cephalometric analysis and digital goniometry to measure the skull shape and cervical range of motion of 155 healthy newborns. At assessment, 7.7% had plagiocephaly, 3.9% had evidence of torticollis and 46.4% had cervical range of motion imbalances. Similarly, a Canadian group found nearly half of the 435 healthy term newborns they assessed had developed plagiocephaly by 7 to 12 weeks of age (11).

The Finnish study, led by Aarnivala et al., went on to randomize the newborns into two groups. In the control group, caregivers received standard sleep safety/SIDS prevention education. Caregivers in the intervention group received detailed instruction on infant positioning and handling, including: supervised tummy time, providing ‘a non-restrictive environment’ (i.e., a safe surface where the infant can move freely, and minimal time in infant positioning devices) and stretches or range of motion exercises if cervical imbalances existed. Reassessment at 3 months of age showed the prevalence of plagiocephaly in the intervention group was approximately half that in the control group (15% vs. 33%) (12).

Several risk factors for plagiocephaly have been identified (e.g., male sex, multiples etc.) which are described in more detail within the CPS practice point (9). However, recent literature describing a high prevalence of range of motion imbalances at birth and early development of plagiocephaly are noteworthy (10,11), especially when combined with data to support the effectiveness of early caregiver education on positioning and handling.

We suggest that examination of skull shape and neck range of motion should be a routine component of the newborn assessment so that parents can implement positioning and handling suggestions immediately.

PLAGIOCEPHALY AS A MARKER OF DEVELOPMENTAL RISK

This final point is where we converge with Dr. Harris (1) regarding early identification of potential markers of developmental delay. Several studies report an association between developmental delay and plagiocephaly (13,14). Collett et al. (15) have considered these associations since 2005, and we direct readers to their research for a more in-depth discussion of potential reasons for this association (14,15). In brief summary, their work suggests that delays in both cognitive and motor development can be associated with the presence of plagiocephaly, and that delays can persist up to 36 months of age (14). They emphasize two hypothesized (and potentially interacting) pathways for this (15): (1) environmental positioning as the primary driver for motor delays and simultaneously for plagiocephaly and (2) an underlying central nervous system dysfunction as a primary driver of motor and cognitive delays, with motor delays leading to limited mobility and plagiocephaly (15). The important message for health care providers is that plagiocephaly may be a ‘physical marker for developmental delay’.

Regular supervised tummy time for play and limited use of supine infant positioning devices can help prevent or lessen the severity of deformational plagiocephaly (12), while promoting developmental gains. If improvements are not realized with positioning and handling, or if plagiocephaly is associated with torticollis, a referral to physiotherapy is recommended for further assessment and management.

It is our hope that the three points within this commentary will resonate with health care providers, who can help us spread the Tummy Time message.