Supine and Prone Infant Positioning

8/13/2019 Supine and Prone Infant Positioning

1/11

Supine and Prone Infant Positioning: A Winning Combination

Martha Wilson Jones, RN, BSN

MARTHA J ONES has been the coordinator of the Neonatal Follow-Up Program at Childrens Hospital of The KingsDaughters in Norfolk, Virginia, for 13 years. She is cur-rently enrolled in the MSN program in the School of Nursing at Hampton University in Hampton, Virginia.

Abstract

Since 1992, the optimal sleeping position for infants inthe United States has been supine. This position hasbeen shown to greatly reduce the rate of Sudden InfantDeath Syndrome (Skadberg, Morild, & Markestad,1998). However, the supine position may lead to otherunintended consequences or complications. Througha review of literature, this article explores some of thecomplications associated with the Back to Sleep cam-paign in the U.S. and discusses educational strategies forperinatal educators.

Journal of Perinatal Education, 13 (1), 10e 20;infant, sleep, head molding, supine sleep position.

Prior to the 1990s, nearly all infants in the UnitedStates were placed for sleep in the prone or tummyposition (Willinger et al., 1998). In 1992, theAmerican Academy of Pediatrics (AAP) published a po-sition statement recommending that all infants beplaced in nonprone positioning for sleep with the in-tended purpose of decreasing the incidence of SuddenInfant Death Syndrome (SIDS). In 1996, the AAP posi-tion was amended to promote supine sleep as the pre-

ferred position. Although lateral-sleeping positionconfers a lower risk when compared to prone position-ing, it still has a higher risk when compared to supinesleeping position (AAP, 1996). Over the past 10 years,the AAP, U.S. Public Health Service, SIDS Alliance,and the Association of SIDS and Infant Mortality Pro-grams have provided much education to the generalpublic, including the well-known Back to Sleep cam-paign (AAP, 1996).

10 The Journal of Perinatal Education Winter 2004, Vol. 13, No. 1


2/11

Sometimes, as changes occur in medical practice, un-anticipated sequelae appear in other areas. Followingthe change to supine sleeping, pediatricians, pediatric

therapists, neurosurgeons, and plastic surgeons notedsome new trends in their various practice areas, as illus-trated in the case studies described below. Following thecase studies, this article will review the literature relat-ing to trends and the research supporting the supinesleep position, and will present an overview of informa-tion on the prevention of SIDS. Strategies will also beprovided for perinatal educators to use in the educationof their patients regarding the information presentedhere.

Case PresentationsBaby Girl A was born at a local hospital and thentransferred to a neonatal intensive care unit in Virginia.The birth was by cesarean section due to breechpresentation. Apgar scores were 3 at 1 minute and 8 at5 minutes. Her birth weight was 1,050 grams at 30weeks gestation, reecting intrauterine growth restric-tion that was thought to be the result of the motherspregnancy-induced hypertension. The infant had mildrespiratory distress requiring mechanical ventilationfor 1 day. She spent 5 days in the neonatal intensivecare unit where tube feedings were successfully estab-lished and her respiratory status remained stable. Shewas then transferred to a Level II step-down unit at an-other hospital to continue her convalescence before be-ing discharged to return home with her parents.

The infant presented to the neonatal follow-up clinicat 6 months of age. Physical examination revealed anobvious left torticollis. Her head position was tilted tothe left, and she was unable to fully rotate her head tothe right beyond approximately 30 ( from midline (seeFigure 1). She also had plagiocephaly (a form of abnor-mal postnatal head molding), with occiput attening

noted on the posterior left side of her skull. Whenobserving the infants head from a posterior-superior ori-entation, the examiner noted her forehead to be asym-metrical, with the right side of her forehead appearingattened when compared to the left. Her left ear ap-peared to be anterior to her right ear (see Figure 2).

History-taking indicated that the infants gross mo-tor milestones were markedly delayed at the 1-monthlevel, with her skills limited to being able to lift her

head in the prone position. She was unable to roll over,push up on her forearms or wrists, or reach for ob-jectsd skills that are normally attained by 3 e 5 monthsof age. Parents reported that her pediatrician had ad-vised them to put her to sleep on her side but had notspecically told them to alternate from one side to theother. Essentially, the infant had been sleeping on oneside since discharge from the hospital. Parents reportedthat the infant had experienced minimal prone play-time because she did not seem to like this position. Shewas sent for anterior/posterior view and lateral cervicalspine x-rays to rule out anatomic abnormalities. Areferral for physical therapy was made.

In another case, Baby Boy B was born at 36 weeksgestation by spontaneous vaginal delivery withoutcomplications. He did not require any special infantcare and spent 48 hours in a normal newborn nursery

prior to his being discharged home with his parents.His mother stated that from the time he was born herson seemed to prefer sleeping with his head turned tothe left side. At his 3-month-old well-baby checkup,the infants pediatrician noted some plagiocephaly andleft-sided toricollis and offered positioning suggestionsto the mother. At 5 months of age, the infant showedlittle progress. He was referred for physical therapy ata childrens hospital where a plastic surgeon prescribed

Figure 1 Baby Girl A e Torticollis with Head Tilt toLeft

The Journal of Perinatal Education Winter 2004, Vol. 13, No. 1 11


3/11

orthotic helmet therapy (discussed later in this article;see Figure 3). After 5 months of therapy, the infantneared the end of treatment, and the parents reportedbeing pleased with the success of the interventions. Theinfants mother noted that she would have benetedfrom information during her prepared childbirth classregarding positioning and associated problems that canresult.

The two cases described above are common storiesof unadvised sleep positioning and simultaneous abnor-mal head molding or positional plagiocephaly, ac-quired torticollis, and delayed acquisition of grossmotor milestones. All of these conditions will be dis-cussed in depth in this article.

Review of Literature

Physiology of Sleep Position and Respiration

Although substantial research has been done on thecause of SIDS, not any one factor has been determinedto be responsible. Multiple mechanisms may accountfor the reduction of SIDS secondary to the change insleep position. Jeffery, Megevand, and Page (1999) ex-amined the laryngeal protective reexes of infants asa possible explanation. Swallowing and arousal areessential in preventing laryngeal stimulation, and the

researchers found that a reduction of these airwayprotective responses occurred when the infant was inthe prone position.

Galland, Bolton, Taylor, Sayers, and Williams(2000) examined physiological responses of ventilationand arousal to mild asphyxia in prone and supinesleeping infants. Methods included an asphyxial test:placing a box over the head of the sleeping infants andchanging the gas mixture breathed by the infants for

5e 6 minutes. Study results showed that babies sleepingprone, when compared to supine, had poorer ventila-tory responses to mild asphyxia during sleep at 3

months of age ( p [ 0.050).Ishikawa, Isono, Aiba, Tanaka, and Nishino (2002)

examined passive pharyngeal collapsibility in supineand prone positioned infants and concluded that theprone position increases upper airway collapsibilitycontributing to SIDS. Waters and colleagues (1999)studied the brains of 29 SIDS victims and, in 79% of the cases, found signicant neuronal apoptosis, a formof cell death that can be triggered by hypoxemia. Theyposited that neuronal damage caused functional loss inkey brain regions and may have some implications forunderstanding the sequence of events that lead toSIDS. Regardless of mechanisms involved, this changein sleep position has signicantly decreased the inci-dence of SIDS, as illustrated by the following studies.

Sleep Position and Incidence of SIDS

Willinger and colleagues (1998) conducted telephoneinterviews with 1,000 parents of infants born between1992 and 1996 and living in 48 states. The objective

Figure 2 Baby Girl A e Plagiocephaly

(Photo by Melissa C. Rose, PT )

Figure 3 Baby Boy B e Orthotic Helmet Therapy




4/11

was to determine the typical sleep positions of the in-fants and changes that occurred after the recommenda-tion of supine sleeping. Results showed that the

prevalence of infants placed in the prone position forsleep declined by 66%. During the same window of time, the rate of SIDS declined approximately 38%.Skadberg, Morild, and Markestad (1998) used a popu-lation-based case reference study with the referencegroup consisting of 500 randomly selected infants toshow a 98% decrease in prone sleeping in a 3-year pe-riod from 1993 to 1995. During this timeframe, theSIDS rate decreased from 3.5 per 1,000 live births to0.2 per 1,000 live births, which equals an overall de-crease of 94%. Thus, supine positioning for sleep isclearly evidence-based and has saved the lives of manychildren.

Prior to the Back to Sleep campaign, infants whoslept in the prone position also tended to spend awaketime in the prone position. When an infant awakes inprone and becomes fussy or bored, it naturally learnsto push up on its forearms and lift its head to explorethe environment. Pushing up against gravity also hasthe added benet of strengthening the muscles used inother prone skills such as pushing up onto hands andknees, creeping, crawling, and rolling over. Infantswho sleep in a supine position are not in the appropri-ate position upon awakening to achieve these skillsspontaneously. Without adequate prone time, the anti-gravity motor patterns may be underdeveloped. Whenthe infant is then placed in prone, it is an uncomfort-

able position and the infant will often fuss and cry.The parents response is to then say that their infantdoes not like this position, and therefore they may notprovide prone time during the day.

Although tummy time is also included in the Backto Sleep educational materials, it is often forgotten. Inaddition, parents are often so fearful of SIDS that theyare often reluctant to provide prone time, even whenthe infant is awake. Mildred, Beard, Dallwitz, and

Unwin (1995) found a signicant association betweenthe knowledge of SIDS and fears connected with proneplay positioning. In a self-administered questionnaire,

93% of the parents reported that their knowledge of SIDS inuenced the sleep position they chose for theirinfants. Eighty-four percent of these parents reportedthat they never placed their infant in a prone positionfor sleep, and 26% reported never placing their infantin a prone position for play. These results demon-strated a signicant association ( p [ 0.002) betweenthe knowledge of SIDS and the avoidance of the proneposition for play.

The nding in Mildred and colleagues (1995) re-search was corroborated later in a study by Davis,Moon, Sachs, and Ottolini (1998). Despite receivingcounseling regarding prone play, 26% of the parents inthis study did not provide prone playtime for their in-fants.

Fears of SIDS appear to overpower the informationgiven to parents regarding the importance of supervisedprone play. The following trends discussed below havebeen noted in association with the change to supinesleeping position and subsequent lack of proneplaytime.

Gross Motor Milestone Delays

The rst trend noted following the change to supinesleep positioning involves delays in acquisition of earlygross motor milestones. Physicians and therapists com-monly use motor milestones to evaluate normal devel-opmental progress in infants and children. Parents arealso generally very aware and concerned if their infantsdo not seem to achieve these milestones appropriately. Jantz, Blosser, and Fruechting (1997) noted somechanges in the motor milestones of infants in their pri-vate pediatric practice. They conducted a retroactivechart review in order to evaluate these changes in mo-

tor milestones observed at well-child checkups. Thestudy included 343 full-term infants who were seen fornormal newborn care, and the screening tool used wasthe Denver Developmental Test e Revised. Resultsshowed that infants who slept supine or in a side-lyingposition were less likely to roll over at the 4-monthcheckup than those who slept in the prone position.

A second pediatric practice group, Davis and col-leagues (1998), suspected that they were also nding

Supine positioning for sleep is clearly evidence-based

and has saved the lives of many children.



5/11

differences in the rate of milestone acquisition betweenprone- and supine-sleeping infants. A prospective,practice-based study was conducted with a sample of

351 healthy term infants in which parents were askedto keep a sleep position log for the rst 6 months of the infants life. Results showed a signicant differencein age for attainment of many early motor milestonesd including rolling, sitting, creeping, crawling, andpulling to stand d with the prone sleepers acquiring themilestones earlier than those sleeping supine ( p [ 0.05).Infants achieved all milestones within the normal agerange, which was dened by using range parametersadapted from the Denver Developmental Test. In-formation was culled from the parents logs, making itmore subjective than standardized testing due to theresults being limited by the accuracy of the parents re-sponses. The researchers concluded that it was signi-cant to reassure parents that, although milestones maybe on the low end of normal, the infants will eventuallyattain the milestones.

Occupational therapists Salls, Silverman, and Gatty(2002) also reported some changes in gross motor mile-stone achievements in their pediatric practice. These re-searchers conducted a descriptive developmental pilotstudy in which they compared a 1998 sample of infantsto the Denver II, a screening tool that was initiallystandardized in 1988 (Frankenburg, Dodds, Archer,Shapiro, & Bresnick, 1992). Sixty-six infants were in-cluded in the study and were examined at 2, 4, and 6months of age. Motor milestones examined were headcontrol, rolling prone to supine, tripod sitting, creep-ing, crawling, and pulling to stand. Parents were alsoasked to give estimates of awake-time in prone. Resultsshowed signicant differences in average milestoneachievement at 2 months of age when compared to the1988 normative population. However, infants who had15 minutes or more of prone time during the day hadstatistically similar pass-fail results when compared to

normative populations. This suggests that prone posi-tioning for play, even in small amounts, may relate tofaster achievement of developmental milestones. Nosignicant differences occurred between the groups at4 and 6 months, but the researchers suggested that us-ing a more sensitive instrument than the Denver II mayprovide more denitive results in future studies.

Dewey, Fleming, and Golding (1998) performeda prospective study using 12,208 infants delivered be-

fore, during, and after the Back to Sleep campaign inthe United Kingdom and followed these infants to 18months of age. The researchers found that, althoughinfants sleeping supine scored lower on gross motormilestones at 6 months of age, the difference resolvedby 18 months of age.

Although the difference in milestone acquisition be-tween supine and prone sleepers has been shown to re-solve over time, it still has some impact on the parentsand infants. Parental anxiety associated with the per-ceived delays in milestones may occur. In the absenceof other neurological ndings, parents can be assuredthat delays are transient and will resolve over time. Forthe infant who may miss learning and exploring experi-ences accrued during prone play, it is possible that theeffects may be more lasting. Thus, supervised proneplaytime should be stressed in all prenatal and dis-charge education, along with supine sleeping.

Shoulder Retraction

Shoulder external rotation and retraction with scapularadduction has been seen more frequently since thechange in sleep position (Hunter & Malloy, 2002;Montfort & Case-Smith, 1997). In developmentalclinics, this is commonly referred to as high guardpositioning and is caused when the infants arms con-sistently rest in external rotation in supine positioning(Monfort & Case-Smith, 1997). Essentially, some in-

fants get stuck in this position, which can affecthand-to-mouth activities, ne motor skills that involvehand midline play and reaching, and gross motor activ-ities that require forearm propping (Hunter & Malloy,2002). Although many infants who experience this areable to resolve it on their own, others may requirephysical therapy. Providing prone playtime as well asfacilitating midline hand skills will help prevent thiscondition.

Prone positioning for play, even in small amounts,

may relate to faster achievement of developmental

milestones.




6/11

Positional Torticollis

Positional or acquired torticollis is caused by a contrac-ture or tightening of the sternocleidomastoid muscleand includes lateral exion to the affected side androtation to the opposite side (Ratliffe, 1998). This isagain a diagnosis seen more commonly in infants whosleep in the supine position (Golden, Beals, Littleeld,& Pomatto, 1999). Positional torticollis is caused whenthe infants head is maintained primarily in one posi-tion. This may occur if the infant has a preference forhead position to one side or if parents consistentlyplace the infant in the same position. This conditioncan occur alone, but it is also associated with posi-tional plagiocephaly, which will be discussed in the

next section.With tortocollis, the infant is unable to turn his headaway from the affected area, which over time maycause mild facial asymmetry, range restriction of theneck, delayed development of postural control, and al-teration in visual gaze to one side (Emery, 1997;Hylton, 1997). Physical therapy involving stretching ordeep neck massage may be indicated. Prior to physicaltherapy, it is important to obtain cervical x-rays to ruleout structural abnormalities. Surgical release of thesternocleidomastoid muscle is done only as a last resortif other therapy fails. Botox injections are a newform of treatment being utilized by some practitionersto release the tight neck muscles (Luther, 2002).

Positional Plagiocephaly or Plagiocephalywithout Synostosis

Synostosis refers to the fusing of the lambdoid cranialsuture (craniosynostosis), resulting in head molding orplagiocephaly. In positional plagiocephaly, the suture isnot fused and the asymmetry or head molding iscaused by pressure exerted by the position of the headin one position for a period of time. Boere-Boonekamp

and van der Linden-Kuiper (2001) examined the posi-tional preference of 7,609 infants and followed up onthose with cranial asymmetry after 2 years of age.Infants sleeping in the supine position were found tobe among the group of infants having a higher risk of asymmetries, restricted range of motion, and atteningof the skull at 2 e 3 years of age. Positional preferencewas dened as the condition in which the infant, insupine position, shows head rotation to either the right

or the left side for approximately three quarters of thetime in observation (Boere-Boonekamp & van derLinden-Kuiper, 2001, p. 340).

Peitsch, Keefer, LaBrie, and Mulliken (2002) studiedearly signs of cranial attening in infants and potentialrisk factors. They found that the incidence of cranialattening was 13% in singletons and 56% in twins.Risk factors identied were assisted vaginal delivery,prolonged labor, unusual birth position, multiparity,and male gender. They concluded that localized occiputattening at birth might also be a precursor to defor-mational plagiocephaly. What is thought to happen isthat the infant, unable to roll on its own and withoutintervention from caregivers, lies supine with the headturned to the attened side. Parents need to be awareof their infants head position preference and rememberto alternate head positions when putting the infant tosleep. This is even more important when cranial at-tening is noted immediately following the birth of aninfant.

Kane, Mitchell, Craven, and Marsh (1996) reviewedthe charts of 269 infants presenting to a craniofacialcenter between 1979 and 1994 to determine and verifyan increase in referral of infants with plagiocephalywithout synostosis. The researchers discovered that, inthe period of time between 1992 and 1994, the numberof referrals was six times greater than that during thepreceding 13 years. This provided evidence suggestinga causal relationship to AAPs recommendation for su-pine sleeping.

Turk, McCarthy, Thorne, and Wisoff (1996) re-viewed 52 consecutive patients presenting to a craniofa-cial center with deformational plagiocephaly from1992 to 1994. The mean age at which cranial asymme-try was noted was 3.6 months. Following a marked in-crease in the referral of infants with this problem totheir center, their objective was to study the etiologiesof deformational plagiocephaly and possible correla-

tion with infant head position. The researchers discov-ered that all of the affected infants included in thisstudy were put to sleep in the back- or side-lying posi-tion showing a direct association with the change tononprone sleep position and the nding of an increasedincidence of deformational plagiocephaly. Of these in-fants, 73% resolved with frequent head turning, 23%resolved with helmet molding therapy, and 4% re-quired surgery.



7/11

Positional plagiocephaly results when an externalmolding force is applied to an infants cranium. Skullbones in infants less than 6 months of age tend to be

very soft, malleable, and maneuverable. In most cases,similar to torticollis, positional plagiocephaly is causedby infants holding their heads in a single position atrest. Prior to the change in sleep position, this was a rel-atively rare condition (Littleeld, Reiff, & Rekate,2001), with cranial deformation or head molding seenprimarily in the premature population (Chan, Kelley,& Khan, 1995). The length of time required to pro-duce a lasting deformity of the cranium is severalweeks to 3 months (Ripley et al., 1994).

Positional plagiocephaly is characterized by asym-metrical occiput attening, with resulting compensa-tory changes in other areas of the skull. Contralateralbrow lowering or inferior displacement of the brow,contralateral forehead or frontal region attening, andipsilateral anterior ear shift may occur. An ipsilateralanterior orbit and cheek shift may also result. All ora combination of these may result in facial asymmetryor distortion (Littleeld et al., 2001; Turk et al., 1996).Diagnosis of this condition is fairly easy and is accom-plished by observing the childs head from a posterior-superior view. Plagiocephaly may not be as obvious onthe frontal view of the infants head. Typically, this canbe identied by the 2-month well-baby visit. Early,mild asymmetry may be missed due to the deformityoccurring over time. The back of the head isaffected, which is not as noticeable, and the head cir-cumference is usually within normal limits (Najarian,1999).

Treatment of plagiocephaly involves the use of ac-tive counter-positioning, helmet orthotics, or surgery.In infants less than 6 months of age, counterposition-ing is effective in returning the head to a more normalshape. After that time, infants will often choose theirhead position themselves, making this process more

difcult to achieve (Littleeld et al., 2001). Lovedayand de Chalain (2001) compared active counterposi-tioning and orthotic helmets as treatment options forpositional plagiocephaly. Using a random sample of 74infants, of which 45 were managed with active coun-terpositioning and 29 with orthotic helmets, resultsshowed that the outcomes were comparable, but themanagement period with the helmets was approxi-mately three times shorter.

Helmet treatment for positional plagiocephaly wasdeveloped in the late 1970s as a nonsurgical alternativetreatment for positional head molding (Clarren, Smith,& Hanson, 1979). Currently, a helmet called a thermo-plastic orthotic device involves the use of thermoplasticmaterials that can be molded directly onto the infantshead. The device is lined throughout, using a soft ma-terial to protect the skin of the infant. It is light, com-fortable, and tolerated well by the infant (Aliberti,Pittore, Ruggiero, Cinalli, & Maggi, 2002). This modeof treatment is most effective if initiated prior to 6months of age and involves the infant wearing the hel-met for several months with weekly adjustments madeby a specialized technician (Littleeld et al., 1998).

Helmet treatment is not offered in all geographicalareas. It is expensive and currently covered by onlya few insurance plans. To achieve optimal results, thistherapy requires a very compliant and diligent parent.For these reasons, counterpositioning may be the besttreatment for mild to moderate cases of positionalplagiocephaly, with the use of helmet treatment con-sidered only for the most severe cases. Surgery is men-tioned in the literature as a treatment for the mostsevere cases of plagiocephaly. However, due to the risksinherent in any surgical procedure, conservative ther-apy is optimal and preferred (OBroin, Allcutt, &Earley, 1999).

Positional plagiocephaly is not life threatening, butit does have some potential adverse consequences.Panchal and colleagues (2001) examined 42 infants

with plagiocephaly without synostosis to determine if they had any signicant differences on a standardizedtest of cognitive and psychomotor skills. The mean agewas 8.4 months at testing, using the Bayley Scales of Infant Development II. The scores were then comparedto a standardized population sample. Within the groupof infants with plagiocephaly, the scores were signi-cantly different from the normal curve distribution( p < 0.001). Zero percent of the subjects in the group

Treatment of plagiocephaly involves the use of

active counterpositioning, helmet orthotics, or

surgery.




8/11

were accelerated, 67% were normal, 20% had a milddelay, and 13% had a signicant delay indicating that,before any intervention was done, this group of infantsdemonstrated delays in cognitive and psychomotor de-velopment. The researchers postulated that the ipsilat-eral attening may result in some focal restriction of the occipital cerebral cortex. Repeating this study withlarger numbers of infants, using children without anyanomalies for a control group, and following the in-fants to an older age would be important to verify thesignicance of these differences.

Miller and Clarren (2000) performed a retrospectivemedical record review of 64 patients with persistentplagiocephaly without synostosis and were able to doc-ument the need of special education services needed in39.7% of children with this condition. This was con-trasted to 7.7% of siblings within these families, whichserved as controls. This nding suggests that this groupof children might be at risk for developmental difcul-

ties during the school-age years. Again, studies usingstandardized controls and larger sample numberswould give a more accurate picture of developmentalrisks. However, the two studies together suggest thatuntreated plagiocephaly may have some risk for long-term developmental consequences.

Untreated plagiocephaly can also cause abnormalocclusion, temporomandibular joint difculties, andstrabismus (Neufeld & Birkett, 2000). Altered physical

appearance, without treatment, may be permanent(Marshall, Fenner, Wolfe, & Morrison, 1997). It canalso be especially disturbing to parents. Some studieshave suggested that the altered physical appearance re-duces perceived attractiveness, which may affect bond-ing between the infant and parent (Budreau, 1987;Chan et al., 1995).

Implications for Perinatal EducatorsMorbidity from supine positioning is preventable. It isalso easily treatable if identied early (see Table 1 forstrategies for the prevention and treatment of infantswith head molding). Childbirth educators, along withother health professionals involved in perinatal educa-tion, are in an excellent position to inform and educateexpectant parents about the importance of infant head

Table 2 Strategies for Promoting Prone Play*

Provide supervised prone or side-lying playtime, daily. Begin with 15 minutes per day and increase by 1 minute per

week. If infant does not initially like being in prone position, placeblanket roll under its chest so it can see beyond the oor andthen decrease the thickness over time as the infants skillsprogress. This allows the infant to work on head control aswell as upper body strength while he/she is in a more func-tional position for visual stimulation and play activities.

Parent can lie supine with the infant prone on the parentschest to interact with the infant.

Parent can place the infant in prone position on a table or inan infant seat and then sit within the infants range of visionwhile keeping a hand ready for safety.

Put interesting objects (e.g., toys, pictures, or even goldsh ina bowl) in the infants visual eld. Remember that the most in-teresting object to an infant is the parents face.

*Information gathered from clinical experience as well as thefollowing sources: Belkengren, Sapala, & Gale, 1998; Hunter &Malloy 2002; and Neufeld & Birkett, 2000.

Table 1 Strategies to Prevent and Treat Infant HeadMolding*

Change the position of the infants head throughout the day to

prevent pressure to same side. Limit the time in supine position in car seat, infant swing, andinfant carriers.

Change the position of the infants crib relative to the door inorder to encourage the infant to look in the opposite direc-tion.

Reverse the head-to-toe position of the infant in the crib,weekly.

Provide visual stimulation to the infant in all vision elds. Change toy, mobile, and crib positions, weekly. Watch for high guard positioning (arms held up and exter-nally rotated), and make sure the infant has midline play op-portunities.

Recognize and treat torticollis, plagiocephaly, and shoulder re-traction as early as possible for optimal treatment.

*Information gathered from clinical experience as well as thefollowing sources: Belkengren, Sapala, & Gale, 1998; Hunter &Malloy, 2002; and Neufeld & Birkett, 2000.

Childbirth educators and other health professionals

are in an excellent position to inform and educate

expectant parents about the importance of infant

head positioning and prone playtime.



9/11

positioning and prone playtime. Supine sleep must bestressed, but this needs to be accompanied by promot-ing supervised prone playtime as well. Additionally, pa-rents need to be aware of the importance of providingmultiple head position changes of infants during theday to prevent positional deformities.

As mentioned previously, parents need to be awarethat infants who sleep supine initially may not like tobe in the prone position. They may fuss and carry on,which can be distressing to parents. Prior knowledgeof the possibility of this occurrence will decrease pa-rental distress as well as potentially increase compli-ance in providing prone playtime. Parents should beinformed that developmentally, the majority of infantsare unable to sustain lifting their chins while in the

prone position until 1 month of age. Spending pronetime looking at the oor when compared to their pa-rents faces or stimulating toys can be frustrating to aninfant. Parents can promote comfort in a prone posi-tion with a new infant by placing themselves down onthe oor or within eye level of their infants, providingpleasant and engaging stimulation. Eventually, the in-fant will gain upper body strength and be able to liftits head and chest up in a more functional position to

explore the environment on its own (see Table 2 forstrategies to promote prone play).

All health professionals working with mothers and

infants should also be aware of and continue to pro-vide appropriate information to parents regarding su-pine sleep and other risk factors for SIDS (see Table 3for strategies to reduce the risk of SIDS).

ConclusionsSupine sleeping continues to be recommended as thesafest position for the majority of infants and shouldbe continued, unless medically contraindicated, for atleast the rst 6 months of the infants life. Many in-fants will continue to sleep in this position. Along withsupine sleep position, it is essential to provide supervisedprone playtime as well as other position changes duringthe day to avoid gross motor milestone delays, headmolding, shoulder retraction, and tortocollis. Infantswho sleep supine may not initially like prone positioning,but even as much as 15 minutes a day may make a differ-ence in motor milestone acquisition. Watching for occi-put attening and treating early with counterpositioningmay be the easiest ways to avoid complications requiringtherapy and other interventions.

ReferencesAliberti, F., Pittore, L., Ruggiero, C., Cinalli, B., & Maggi, G.

(2002). The treatment of the positional plagiocephaly witha new thermoplastic orthotic device. Child Nervous Sys-tem, 18 (6e 7), 337 e 339.

American Academy of Pediatrics [AAP] Task Force. (1998).Back to sleep: Questions and answers for professionalson infant sleeping position and SIDS . [Pamphlet]. Bethes-da, MD: National Institute of Child Health and HumanDevelopment.

American Academy of Pediatrics [AAP] Task Force on InfantPositioning and SIDS. (1992). Positioning and SIDS. Pedi-

atrics, 89 , 1120 e 1126.American Academy of Pediatrics [AAP] Task Force on Infant

Positioning and SIDS. (1996). Positioning and sudden in-fant death syndrome (SIDS): Update. Pediatrics, 98 ,1216 e 1218.

American Academy of Pediatrics [AAP] Task Force on InfantSleep Position and SIDS. (2000). Changing concepts of sudden infant death syndrome: Implications for infantsleeping environment and sleep positions. Pediatrics, 105 ,650 e 656.

Table 3 Strategies to Decrease the Risk of SuddenInfant Death Syndrome*

For the rst 6 months of life, the infant should be placed in

a supine position to sleep, unless specically medically indi-cated otherwise. Side-lying is preferred to prone; however, because the babymay inadvertently roll, side-lying is not as safe as supine.

Infants who are able to roll over should still be placed in su-pine position for sleep, initially.

Mattress should be rm, not soft. Soft bedding under the infant may cause suffocation or stran-gulation. This includes pillows, quilts, waterbeds, and sofas.

Adult beds may increase the risk of SIDS. Infant may becometrapped between the mattress and bed or wall, causing suffo-cation and strangling.

Pillows and blankets should be avoided. Use blanket sleepersif room or home temperature is cold.

Overheating may increase the risk of SIDS. Try to avoid over-

dressing the baby or overheating the room. Avoid smoking in home with infants. Passive smoke increasesthe risk of SIDS.

Stuffed animals should not be placed in bed with infant. Breastfeeding should be encouraged.

*Sources: AAP, 1996, 1998, 2000; Hunter & Malloy, 2002; andWillinger et al., 1998.




10/11

Belkengren, R., Sapala, S., & Gale, D. M. (1998). Pediatricmanagement problems . deformational posterior plagioce-phaly. Pediatric Nursing, 24 (1), 82 e 85.

Boere-Boonekamp, M., & van der Linden-Kuiper, L. (2001).Positional preference: Prevalence in infants and follow-upafter two years. Pediatrics, 107 (2), 339 e 343.

Budreau, G. (1987). Postnatal cranial molding and infant at-tractiveness: Implications for nursing. Neonatal Network,4, 13e 19.

Chan, J., Kelley, M., & Khan, J. (1995). Predictors of postna-tal head molding in very low birth weight infants. Neona-tal Network, 14 (4), 47 e 51.

Clarren, S. K., Smith, D. W., & Hanson, J. W. (1979). Helmettreatment for plagiocephaly and congenital muscular torti-collis. Journal of Pediatrics, 94 , 43e 46.

Davis, B., Moon, R., Sachs, H., & Ottolini, M. (1998). Effects

of sleep position on infant motor development. Pediatrics,102 (5), 1135 e 1140.

Dewey, C., Fleming, P., & Golding, J. (ALSPAC Study Team).(1998). Does the supine sleeping position have any adverseeffects on the child? II. Development in the rst 18 months.Pediatrics, 101 (1), E5.

Emery, C. (1997). Conservative management of a congenitalmuscular torticollis: A literature review . Physical and Oc-cupational Therapy in Pediatrics, 17 (2), 13 e 20.

Frankenburg, W., Dodds, J., Archer, P., Shapiro, H., & Bres-nick, B. (1992). The Denver II: A major revision and re-standardization of the Denver Developmental ScreeningTest. Pediatrics, 89 (1), 91 e 97.

Galland, B. C., Bolton, D. P., Taylor, B. J., Sayers, R. M., &Williams, S. M. (2000). Ventilatory sensitivity to mild as-phyxia: Prone versus supine sleep position. Archives of Disease in Children, 83 (5), 423 e 428.

Golden, K. A., Beals, S. P., Littleeld, T. R., & Pomatto, J. K.(1999). Sternocleidomastoid imbalance versus congenitalmuscular torticollis: Their relationship to positional pla-giocephaly . Cleft Palate and Craniofacial Journal, 36 (3),256 e 261.

Hunter, J., & Malloy, M. (2002). Effect of sleep and play po-sitions on infant development: Reconciling developmentalconcerns with SIDS prevention. Newborn and Infant Nurs-

ing Reviews, 2 (1), 9e

16.Hylton, N. (1997). Infants with torticollis: The relationshipbetween asymmetric head and neck positioning and pos-tural development. Physical and Occupational Therapyin Pediatrics, 17 (2), 91 e 117.

Ishikawa, T., Isono, S., Aiba, J., Tanaka, A., & Nishino, T.(2002). Prone position increases collapsibility of the pas-sive pharynx in infants and young children. American Jour-nal of Respiratory Critical Care Medicine, 166 (5),760 e 764.

Jantz, J., Blosser, C., & Fruechting, L. (1997). A motor mile-stone change noted with a change in sleep position. Ar-chives of Pediatric Medicine, 151 , 565 e 568.

Jeffery, H. E., Megevand, A., & Page, H. (1999). Why theprone position is a risk factor for sudden infant death syn-drome. Pediatrics, 104 (2, Pt.1), 263 e 269.

Kane, A., Mitchell, L, Craven, K., & Marsh, J. (1996). Obser-vations on a recent increase in plagiocephaly without syn-ostosis. Pediatrics, 97 (6), 877 e 885.

Littleeld, T., Beals, S., Manwaring, K., Pomatto, J., Joganic,E., Golden, K., & Ripley, C. (1998). Treatment of cranio-facial asymmetry with dynamic orthotic cranioplasty . The Journal of Craniofacial Surgery, 9 (1), 11 e 17.

Littleeld, T., Reiff, J., & Rekate, H. (2001). Diagnosis andmanagement of deformational plagiocephaly . Barrow Neu-rological Institute Quarterly, 17 (4), 18 e 25.

Loveday, B. P., & de Chalain, T. B. (2001). Active counterpo-sitioning or orthotic device to treat positional plagioce-phaly? Journal of Craniofacial Surgery, 12 (4), 308 e 313.

Luther, B. L. (2002). Congenital muscular torticollis. Ortho- pedic Nursing, 21 (3), 21 e 27.

Marshall, D., Fenner, G., Wolfe, A., & Morrison, G. (1997).Abnormal head shape in infants. International Pediatrics,12(3), 172 e 177.

Mildred, J., Beard, K., Dallwitz, A., & Unwin, J. (1995). Playposition is inuenced by knowledge of SIDS sleep positionrecommendations. Journal of Pediatric Child Health,31(6), 499 e 502.

Miller, R. I, & Clarren, S. K. (2000). Long-term developmen-tal outcomes in patients with deformational plagiocephaly.Pediatrics, 105 (2), E26.

Monfort, K. P., & Case-Smith, J. (1997). The effects of a neo-natal positioner on scapular rotation. American Journal of Occupational Therapy, 51 , 378 e 384.

Najarian, S. P. (1999). Infant cranial molding deformationand sleep position: Implications for primary care. Journal of Pediatric Health Care, 13 (4), 173 e 177.

Neufeld, S., & Birkett, S. (2000). What to do about at heads:Prevention and treating positional and occipital attening.Axon, 22 (2), 29 e 31.

OBroin, E. S., Allcutt, D., & Earley, M. J. (1999). Posterior

plagiocephaly: Proactive conservative management. British Journal of Plastic Surgery, 52 , 18e 23.Panchal, J., Amirsheybani, H., Gurwitch, R., Cook, V., Fran-

cel, P., Neas, B., & Levine, N. (2001). Neurodevelopmentin children with single-suture craniosynostosis and plagio-cephaly without synostosis. Plastic and Reconstructive Sur- gery, 108(6), 1492 e 1498.

Peitsch, W. K., Keefer, C. H., LaBrie, R. A., & Mulliken, J. B.(2002). Incidence of cranial asymmetry in healthy new-borns. Pediatrics, 110 (6), E72.



11/11

Ratliffe, K. (1998). Clinical pediatric physical therapy: A guide for the physical therapy team . St. Louis, MO: Mos-by.

Ripley, C., Pomatto, J., Beals, S., Joganic, E., Manwaring, K.,& Moss, S. D. (1994). Treatment of positional plagioce-phaly with dynamnic orthotic cranioplasty. The Journal of Craniofacial Surgery, 5 (3), 150 e 159.

Salls, J., Silverman, L. N., & Gatty, C. M. (2002). The rela-tionship of infant sleep and play positioning to motor mile-stone achievement. The American Journal of Occupational Ther apy , 56(5), 577 e 580.

Skadberg, B. T., Morild, I., & Markestad, T. (1998). Aban-doning prone sleeping: Effects on the risk of sudden infantdeath syndrome. Journal of Pediatrics, 132 (2), 340 e 343.

Turk, A., McCarthy, J., Thorne, C., & Wisoff, J. (1996). TheBack to Sleep Campaign and deformational plagioce-phaly: Is there cause for concern? The Journal of Craniofa-cial Surgery, 7 (1), 12 e 18.

Waters, K. A., Meehan, B., Huang, J. Q., Gravel, R. A., Mi-chaud, J., & Cote, A. (1999). Neuronal apoptosis in sud-den infant death syndrome . Pediatric Research, 45 (2),166 e 172.

Willinger, M., Hoffman, H. J., Wu, K. T., Hou, J. R., Kessler,R. C., Ward, S. L., Keens, T. G., & Corwin, M. J. (1998 ).Factors associated with the transition to nonprone sleepingpositions of infants in the United States: The National In-fant Sleep Position Study. Journal of the American Medical Association, 280 (4), 329 e 335.

Updates on Prone Sleeping Position for Infants

The Committee on Fetus and Newborn of the American Academy of Pediatrics continues to recommendsupine sleep position, safe sleeping environments, and elimination of exposure to tobacco smoke to decreasethe risk of SIDS (Committee on Fetus and Newborn, 2003).

Researchers agree that re-breathing expired air may be a lethal hazard for sleeping infants in the proneposition (U.S. Consumer Product Safety Commission, 1996). However, some authors and product sales per-sons assert that the answer is to use bedding designed to ventilate the mattress covers undersurface in order todirect dangerous gases away from the baby. Others claim the answer is to wrap crib mattresses, as opposed tohaving babies sleep in the supine position. Research on these last two assertions is scant or absent.

Childbirth educators can tell expectant parents who ask that perhaps sound research will eventually informus of mattress materials that provide a safe environment for infants sleeping in the prone position. For now,though, the recommendation remains back to sleep and prone to play.

ReferencesCommittee on Fetus and Newborn, 2002 e 2003, American Academy of Pediatrics (2003). Apnea, sudden infant death

syndrome, and home monitoring [Electronic version]. Pediatrics, 111 (4), 914 e 917. Retrieved February 12, 2004, fromhttp://pediatrics.aappublications.org/cgi/content/full/111/4/914

U.S. Consumer Product Safety Commission [CPSC]. (1996). CPSC scientic research helps save lives: Preventing infant suffocation . Retrieved February 12, 2004, from http://www.cpsc.gov/CPSCPUB/PUBS/SUCCESS/infsuff.html



Documents

Supine and Prone Infant Positioning