Since the National Institutes of Health initiated in 1994 its "Back to Sleep Program," which encourages parents to place their healthy children on their backs during sleep to prevent sudden infant death syndrome (SIDS), the incidence of SIDS has been cut by half. But this gain is not without its consequences.



The negative ramifications of having a child spend much of its time supine are mainly delays in motor skills.



About a year after some Kansas pediatricians implemented new American Academy of Pediatrics (AAP) sleep guidelines that were influenced by the Back to Sleep Program, they noticed particular motor skills problems in many 4-month well-baby check-ups (Arch Pediatr Adolesc Med. 1997;151(6):565-8). The pediatric group then retrospectively examined 350 records and found that babies who slept supine or on their side were less likely to be able to roll over at 4 months. They suggested that "normal" age ranges for certain milestones may need to be changed depending on the baby's sleep position.



Several subsequent studies confirmed these findings, including a U.K. study of more than 10,000 infants that found babies who slept prone had better motor skills at six months than those who slept on their backs (Pediatrics. 1998;101:5-12).



Of interest are studies that have found that spending a significant amount of time prone while awake is just as important as prone time asleep in terms of motor function development.



In "The Truth About Tummy Time: A Parent's Guide to SIDS, the Back to Sleep Program, Car Seats and More," Stephanie J. Pruitt, PT, outlines the important physical milestones associated with child development and associates them with giving the child plenty of prone time while asleep and awake.



What I like about Pruitt's book is that she doesn't resort to scare tactics. Everything comes back to how it influences physical development.



"An infant first develops head control, then trunk control, and so on by lying on the stomach," she writes. "There must be muscle balance between the flexor and extensor muscles for a baby to develop well-rounded strength."



The key, according to Pruitt, is movement, and the modern notion of keeping a baby confined in a car seat, or bouncer, or a swing for long periods of time could stunt proper physiological development.



Her interest in pediatric physical development began at her first baby's 4-month check-up. Pruitt's pediatrician informed her that her son's head was flat on one side from sleeping on it.



Pruitt said she couldn't believe it because no one had advised her to rotate the baby's position during sleep. also, one of the maxims she often heard was not to disturb your baby once he is asleep. The flat spot eventually rounded out after Pruitt began to rotate her son's head at night.



She was then motivated to go back to school and focus her physical therapy work on children.



When her second son was born prematurely, she noted that the nurses in the NICU would place him onto his stomach when he was upset. She questioned this because of her understanding of SIDS, but also because of the increased fragility of a premature baby. The nurses told her that babies don't struggle as much to breathe when they are lying on their stomachs.



Again, this is a nugget of wisdom that no one had bothered to tell her, and one she wouldn't have received from the nurses had she not asked.



This son, as well as her prematurely-born third son, had a "very unusual crawling pattern," Pruitt writes. They would sit on their right hip and propel themselves with their left foot and right arm. When they were old enough to understand instructions, she had them play a game where they would "crawl like a puppy" on all fours.



They would practice this "normal crawling pattern to ensure that [their brains] received the essential connections that crawling creates between the left and right brain."



Pruitt does a good job of outlining the processes of development and how each successive milestone relies on the previous ones. If the child does not learn to move its head while on its tummy, for example, the neck muscles will not develop properly, which could then impair or stunt other motor functions.



"Without head control, the child cannot get necessary stimulation from her sense of balance, resulting in low muscle tone and muscle weakness," she says.



"Movement is essential not only for development, but also to help prevent things like torticollis [abnormal shortening of of neck muscles], plagiocephaly [flattening of the skull], developmental delay, sensory processing disorder, and related conditions," she says.



She mentions that since the Back to Sleep Program's initiation, the incidence of torticollis has increased by 84% and plagiocephaly by 48% (Pruitt cites her sources).



Many of the developmental milestones can be missed by parents who are focused primarily on preventing SIDS, Pruitt says. And the information on SIDS can be very confusing.



The proposed causes of SIDS that Pruitt points out include sleep position, maldeveloped brainstem, lack of the neurotransmitter serotonin, heart contractility problems that may also be linked to serotonin, arrhythmias caused by problems with the bundle of His, congenital malformations, long QT syndrome, soft mattresses or other articles that can cause suffocation, and sharing a bed with parents.



Pruitt notes that among 14 recommendations by the AAP regarding preventing SIDS are a few that deal with head shape and car seats, but these get overshadowed by the Back to Sleep mantra, she said.



She also said that many deaths attributed to SIDS are actually cases of suffocation, which have been documented in several studies.



Where does all this lead? Pruitt encourages parents to be informed, and this book, I believe, is a good start.



She encourages parents to allow their children to learn "the old-fashioned" way, by being able to explore their environment without being confined, but using active toys rather than passive toys that have lots of lights and sounds.



"I often take the batteries out of toys in my clinic to teach children the value of being satisfied with the simple cause and effect of a toy without all the bells and whistles," she says. "The more engaged a child is in playing, the more developed his brain will become."



And the more he or she will reach important physical development milestones.



The book was published by Author House, Bloomington, Ind., in 2011.

