A Solution to Infant Developmental Challenges

Problem statement

Adoption of “Back to Sleep” protocol has had widespread and unintended consequences for infants by possibly causing slower attainment of developmental milestones and an increase in skull deformities and/or torticollis. Motor delays, as well as head shape issues, require the infant to receive corrective intervention in the form of physical therapy and/or helmet therapy. These interventions although sometimes successful, may be too late in “fixing” misshapen skulls, asymmetric postures (torticollis) and/or delayed development, as they miss critical windows of neuronal maturation.

Tummy time, on the other hand, is brief, effective, inexpensive, and suitable for all infants and especially for infants with plagiocephaly and torticollis. Tummy time involves an adult supervising and interacting with an infant placed in a prone position while awake. The frequency prescribed is two to three times a day for about three to five minutes each time, with the duration of time gradually increasing as the infant gains more strength. The positive impact of tummy time occurs primarily between birth and six months of age, thus early parental education is crucial. Many post-partum parents in the past have not received complete and appropriate positioning information from health care providers, resulting in confusion and uncertainty with the practice of tummy time.

Purpose

The purpose of this capstone was to use a well-established, early point of contact between pediatricians and parents at well-baby visits. Educating pediatricians on early tummy time is essential to pass on information to parents about important tummy time requirements, starting at birth. Pediatricians need expertise in working with families to educate them on early positioning priorities that will have a positive impact on the development of the infant. They also need to develop knowledge regarding when to refer families for physical therapy services if the infant is unable to perform the tummy time protocol. Pediatricians have clear practice guidelines for SIDS prevention that are implemented early on when educating parents of infants. In the same vein tummy time education must be implemented to make wakeful prone positioning a part of the infant’s routine and possibly decrease future intolerance by infants, to the prone position.

Plan

This capstone project involved getting pediatricians’ feedback about their perceptions and knowledge content of tummy time. Parents were also surveyed to get additional perspective of the current practice of tummy time. Once the results of the survey were analyzed and the information from the literature review was considered, a decision was made to create an evidenced-based flyer. Using information from the literature search, a timeline for the progression of tummy time was constructed. The flyer also included correct alignment for tummy time and the progression of tummy time as gross motor milestones develop. Pediatricians will be able to distribute this flyer to parents of infants starting right at birth, following up at each well-baby visit to re-enforce the tummy time protocol. A PowerPoint presentation was also used to introduce the flyer and discuss relevant research to educate pediatricians.

Outcomes from the Literature Review and Surveys

1. The results of the surveys confirmed results from the literature review that pediatricians and parents are aware that tummy time is important but do not have the specific information (duration and alignment) to effectively practice tummy time.
2. As per the survey conducted for this capstone project, pediatricians are willing to spend some time on tummy time education during well-baby visits starting at birth and follow up with subsequent well-baby visits. Pediatricians are willing to discuss tummy time and hand parents a flyer with tummy time information.
3. It must be emphasized to the parents that tummy time must always be supervised especially in families with lower socio-economic status.
4. After attempting the tummy time protocol for 6 weeks, some infants may be unable to perform tummy time and will require intervention by a physical therapist, especially if there is also a concurrent head shaping issue.

Clinical Relevance

Tummy time done correctly gets the musculoskeletal, visual, social, cognitive and sensory systems working in synchrony to help promote motor milestone acquisition.

Declining levels of physical activity in children are partly responsible for rising rates of childhood obesity. Getting infants upright, moving through their environment by placing them in tummy time may be an important to increase overall activity levels in children.

Lastly, even though plagiocephaly and torticollis are considered cosmetic, they are associated with an increased incidence in otitis media, dental malocclusion, and visual field defects.18 Tummy time is an effective and non-invasive means to keep the infant off his/her head. Tummy time may yield considerable improvements in head shape especially if these issues are diagnosed early.

The flyer was put together keeping in mind specific demographic, environmental and behavioral variables found to be positively and negatively associated with tummy time. This project could assist future research regarding interventions to promote tummy time, enhance motor development, increase infant physical activity and contribute to future tummy time recommendations for parents and health care providers.

Practice Recommendations

• Recommendation 1: Pediatricians must provide early tummy time education along with SIDS prevention education, starting at birth.
• Recommendation 2: Pediatricians must follow up with tummy time education at each subsequent well-baby visit after birth until the infant is at least 4 months of age while emphasizing correct tummy time alignment.
• Recommendation 3: Pediatricians must refer infants to a physical therapist at or around 6 weeks of age IF the infant has difficulty performing tummy time for the durations recommended AND, especially if the infant also has head shaping and/or symmetry issues.