Sunday, February 1, 2009

Why Tummy Time for Preemies - Part 3

Why Tummy Time for Preemies?
Part 3
Vickie Dakin PT

Welcome to Part 3 of why tummy time for preemies. I hope you took the time to do the homework from Part 2. Let’s review the homework.

Homework: Think about why this idea of adjusted age is important in tummy time. Figure out your babies’ adjusted age and see how your baby compares to other babies at that adjusted age. It is usually a nice surprise.

By now you know your babies adjusted age and are ready for the next step. Why is the adjusted age important for tummy time? The reason is that tummy time changes and evolves as the baby grows and develops. Knowing your babies’ adjusted age will give you a clear place to start.

Getting an early start. As we discussed in Part 1, the easiest way to be successful in tummy time is to start right away. In fact, if the NICU is not working on tummy time, you can ask them about it. There may be medical reasons for limiting tummy time, but ask to find out.

There is one more thing to mention before we talk specifics, the surface. The surface where tummy time is done is very important. Ideally the surface is firm with some give. A closed cell foam mat can be very helpful, especially for preemies because it stays “neutral warm” where vinyl, etc. can get rather chilly. Please do not use comforters, they are too soft and slippery for the baby to get any traction. If you have questions about surfaces or other tummy time questions, please contact me at

General Guidelines:

Below 0 to 1 month adjusted: This is a period of supportive positioning and gentle encouragement. Our goal during this period is to recreate how a full term newborn infant looks. Position your baby with their arms flexed and tucked into their body and their legs flexed up under them. Use towels, blankets or special equipment like Bendies to help your baby maintain the position. Start with short periods of time up to 5 minutes initially. Great activities during this period are patting the babies back while talking softly or singly soothingly to them. The goal during this period is to have the baby start lifting his head from the surface and beginning to turn their head from side to side.

1-2 Months Adjusted: During this period in a full term baby, there is less flexion (tucked in positioning). The baby is pushing up on their elbows, but the shoulders are still in front of the shoulders. For preemies, allow the legs to be away from the body. You may need to support the arms under the baby, but do not place the elbows directly under the shoulders. Encourage the baby to lift their head and turn it from side to side. Toys with bright colors and sounds like rattles are good toys to use at this time. Use simple toys without loud sounds. One technique that works well is to use a rolled up blanket or towel. Roll it tightly to the size that it fits under the arms and across the chest for support, but it allows the elbows to be on the surface. The towel takes some of the weight off and allows the baby to stay longer on their tummy before tiring.

3 months adjusted: At 3 months a full term baby is starting to push up on extended (straight) arms briefly. The shoulders are now aligned over the elbows and the baby is much more active. This is the time to start encouraging the preemie much more. Place them on their elbows on their tummy (prone on elbows) or (if they can) encourage them to push themselves up. Blow bubbles, sing songs, use toys with lights and sounds to increase the amount of time they tolerate prone (tummy) lying. Remember, preemies get bored quickly without stimulation. Once they can stay up on their elbows for 5-10 minutes, help them push up on extended arms (prone on extended arms). They will only do this for a few seconds at first.

4-5 months adjusted: At this time a full term baby is getting quite active. Rolling occurs by the end of this period. The baby also starts something called pivoting in prone, which is staying on the tummy but turning their body in a circle. This is important because by turning their bodies in a circle, they are learning all the motions they need to crawl on their bellies and later creep on all fours. During this time continue to encourage the prone on elbows and prone on extended arms. While they are on their tummy, encourage them to follow a toy just out of reach. Help them as little as possible, but allow them to get the toy. Keep working on this skill until they can go all the way around in a circle in both directions. This may take several months to fully achieve.

6 months adjusted: Six months is an exciting time. The baby can sit briefly once placed in sitting. ( They will not get into sitting by themselves until 9-10 months adjusted.) They will also get themselves into all 4’s and rock. This skill is very important, but can be difficult at first for preemies. Help them get into all 4’s and support them as much as necessary. Assist them to rock forward and backward. I like to sing/chant “giddy-up Johnny, giddy-up” or something similar to help them get the rhythm of the activity. This activity is difficult, so just rock 3-4 times at a time and stop. Keep practicing this activity until you see them do it without your help. Although it looks like they will creep in all 4’s soon after learning this skill, it usually takes until they are 9-10 months adjusted to be able to creep in quadruped.

By 6 months adjusted the work of “tummy time” is over. All the muscle are fully stretched, activated and strengthened. The shoulder blades are stable which makes using the arms more effective. The ribcage has moved down in the chest and stabilized allowing breathing to be more efficient and effective, which is especially important for preemies. With the basics of tummy time mastered, the baby is ready to take on the challenges of mobility. Congratulations mom and dad. Without you we’d have never made it. Oh yes, and to the little one, “Good Job!”

But please remember, every baby is different and preemies can be especially challenging. If you have specific questions about your preemie, contact me at

Sunday, December 28, 2008

Tummy Time for Preemies Part 2

Why Tummy Time for Preemies?
Part 2
Vickie Dakin PT

Welcome to Part 2 of “Why tummy time for preemies”. I hope you had the opportunity to do the homework from Part 1. Let’s review the homework.

Homework: Practice getting your baby to stop crying if only for a few seconds before you pick him up. This is especially important while you are working on tummy time. We will discuss why in our next article.

This exercise may be the hardest, but most effective activity you do with your baby. Why is that? First of all, let’s think about premature babies who have spent time in the NICU. To survive the NICU, they have to be tough and they have to find ways of getting us to meet their needs. As a result of this extremely significant need, (it’s a survival skill, really) they can become experts at controlling and calling the shots. Crying is one of the skills that allowed them to survive, but there is just one problem, they do not know everything they need. But they do know what they do (or do not) want. Unfortunately, their wants and their needs are not always the same and that’s why they need us. Crying is the best and most effective skill in their arsenal and this bit of knowledge they learn very quickly. As parents, therapists and caregivers, we do not like to hear them cry. True, the sound is unpleasant, but most importantly it’s frightening. This is especially true with preemies because we worry about burning calories, throwing up, discomfort, breathing issues, and many other things that are some what less worrisome with full term infants. Our first inclination then, is to immediately pick them up and ask “why” later. Before long, the baby has us trained to pick them up at the first cry. In many cases picking them up does not create a problem, but with tummy time, it can be disastrous. Before we go on, let me remind you of a few important facts:

1. Tummy time does not physically “hurt” your baby
2. Tummy time is the single most important activity for your baby and it will make the most difference for them over time
3. For the best possible outcome, 90 minutes of tummy time or more per day is the goal. It may take awhile to build up to 90 minutes. Consistency is the key.

You as caregiver know how important tummy time is and that your child needs it. Your baby doesn’t. Often when they cry it is just communication such as “What am I doing here; I didn’t ask for this” or “This is boring; get me out of here”. I am not asking you to ignore your babies cry. I am asking that you find a way to separate the connection between tummy time and being picked up. If you fail to make this disconnect, then baby will “learn” that to avoid tummy time, he need only cry. Remember, as we discussed earlier, babies can’t distinguish very well between what they need and what they want.

These are a few ideas that have worked for me and many parents:

• Try distraction; use toys, music, talking, other children to distract the baby either so they can stay a while longer or so you can pick them up when they are not crying.
• Pat their back and talk soothingly to them
• When nothing else works, roll them onto their side (preferable) or to their back. Try again to stop the crying. Then after at least 1 minute, pick them up even if they are still crying. The change in position has broken the link between crying and being picked up.

These techniques really work. If you can get everyone who interacts with your baby to follow the same rules consistently, the worst will be over in 2 weeks. Once the baby realizes the benefits of tummy time, they will enjoy it.

One word of advice, don’t try letting them cry for long periods of time. Preemies can outlast us, they are that tough. Eventually, you will pick them up and they will have just learned they just have to cry longer to get their way. Besides, our goal is to get them to like tummy time.

There is one more thing we need to discuss before we get to the “how to” of tummy time and that is age. With preemies, they have 3 ages, an actual age, a gestational age and an adjusted age. The gestational age is how many weeks was your baby in the womb before they were born. The adjusted age is how early your baby was compared to a baby born at 40 weeks gestation. To find your child’s adjusted age subtract their gestational age from 40. For example, if your baby was born at 28 weeks gestation, subtract 28 from 40 which leaves 12 weeks. Divide by 4 and get 3 months early.

Why is this important? If your baby is 3 months early, it is not fair to expect your child to perform 6 month old skills at 6 months of adjusted age. As a general rule, a baby’s age is adjusted for the first 2 years of life. In other words, a 9 month old baby who was 3 months early would be expected to act like a 6 month old baby. A premature baby “catches up” and by 2 years their skills are generally like a full term 2 year old. Often the area of gross motor development is the slowest to catch up and that is the area most greatly influenced by tummy time.

Now that we have the necessary background information, our next installment will start the real work.

Homework: Think about why this idea of adjusted age is important in tummy time. Figure out your babies’ adjusted age and see how your baby compares to other babies at that adjusted age. It’s usually a nice surprise.

Monday, November 24, 2008

Why Tummy Time for Preemies - Part 1

Why Tummy Time?
Vickie Dakin PT

Have you ever heard your baby needs more tummy time? Probably much more than you want, especially if your child is premature ( a preemie). Why is it so important and what difference does it make? In my 30+ years as a pediatric physical therapist, I have recommended tummy time to hundreds of parents. However, before we discuss tummy time, let’s first talk about babies initial developmental hurtles.

In a typical full term newborn, the challenge for the baby is to move from a compressed ball like position into a fully extended position. Development generally goes from the head down and the first step is to achieve an upright head position against gravity. Once this is achieved, the head starts to turn to either side and the head gets higher off the surface. Pretty soon the arms are involved and the baby starts pushing up on their elbows and shifting from side to side. With each new developmental skill, the extension moves farther down the spine. The next step is pushing up on extended (straight) arms and getting the chest off the surface. Rolling is next and by the time a full term baby is 6 months old they have complete extension in their spine, their hips are fully extended and their shoulders are strong and stable. All of this can happen naturally, as long as the baby gets enough tummy time. But this window is brief, so it’s important to pay attention to tummy time early.

These days all too many full term babies are not getting enough tummy time. As a result, their development is at best choppy. But what about preemies? As you have seen with your babies, preemies generally appear weaker than their full term counterparts. They can and usually are weaker but more importantly, they are missing something called “physiological flexion”. Physiological flexion is that balled up position that full term babies have and it acts as a protection for them against gravity. This physiological flexion provides a structural support that allows the full term baby to move against gravity without collapsing into the surface. Think of it as a coiled spring, like the one you might find in an ink pen. If you hold it in your fingers at one end, you can push or pull it back and forth or right and left with ease. Release it, and boing, it jumps right back to vertical. Well, a full term baby is a lot like that spring. Baby can move his limbs in different directions via his muscles (against gravity) but the phenomenon of physiological flexion pulls him back to the curled position on its own. With effort (again, against gravity) baby moves away from the curl, but returns to his comfy balled up place with ease. For a preemie, it is different. He not only has to battle to move his limbs, but he has no naturally occurring curled position to return to. This missing physiological flexion causes much of the difficulty that premature babies have in early developmental skills. You may have noticed that babies in the NICU, unless they are well supported, tend to be stretched out with their arms and legs extended away from their body. This “flattened” position does not provide any leverage for the baby to move against gravity. Of course the earlier and the smaller the baby the more difficult it is to move against gravity.

Our challenge is to support the premature baby while helping them to build up enough strength to move against gravity. If you just placed a preemie on their tummy and did not support them, it would not help their development and it could make them feel even more helpless. That is where tummy time with a twist comes in. We will help the preemie get to the point where they can take on their own tummy time development and progress like their full term counterparts.

Before we move on, let’s talk about why preemies dislike tummy time.
1. Babies who spent a lot of time in the NICU are used to seeing a lot of action and tend to get bored easily. Preemies are nosy and want to see what’s going on. It is hard to see from your tummy
2. For many, tummy time is new and seems hard at first. The more premature they are the harder it will be because of the lack of physiological flexion
3. A babies sense of time is different from ours and they think they will be on their tummy “forever”

Important facts for parents:
1. Tummy time does not physically “hurt” your baby
2. Tummy time is the single most important activity for your baby and it will make the most difference for them over time
3. For the best possible outcome, 90 minutes of tummy time or more per day is the goal. It may take awhile to build up to 90 minutes. Consistency is the key.

In the next article we will begin the “how to” section to make tummy time fun and functional for you and your baby.

Homework: Practice getting your baby to stop crying if only for a few seconds before you pick him up. This is especially important while you are working on tummy time. We will discuss why in our next article.

Saturday, October 25, 2008

Standing Tips

If you are concerned that your baby is not walking, here are a few tips for you.

* Put their toys up high so that they have to stand up to play with them
* Have them wear shoes with firm soles, especially if they tend to stand
on their toes
* Put a child's sized chair in front of the coffee table and put their
favorite toy on the table and encourage them to stand up.
* Minimize carrying
* Discontinue using a walker

For safety use a floor mat. There is an inexpensive mat available at Sam's club for $19.95.

Monday, October 13, 2008

Tummy Time and the Olympics

We just experienced the Olympics in China. It was great. One thing that struck me was that often the winner only won by inches or fractions of inches or even by fractions of seconds. The difference between gold and 4th place, out of the medals, was so small. Think about this, inadequate tummy time could make the difference between being an olympian or a really good athlete. Give your child the best chance to be their personal best, make sure they get enough tummy time.

Wednesday, September 24, 2008

Check Out Your Toys Carefully

The other day I was shopping in Wal-mart. I spent some time in the baby aisle checking out the baby rattles. They had a large selection and the prices ranged from $1.96 to 6.96 per rattle. Most of them were too large for a new baby or premature baby, but the one thing I noticed that really surprised me was a warning that was on most of the packages. The warning was DO NOT SUBMERGE IN WATER. That was a real surprise. Is that safe for a baby that puts everything in their mouth?How do you adequately clean such a rattle?

Read those labels.

Sunday, September 21, 2008

Toys for Premature Babies and Newborns

I would like to know what toys parents and therapists have found that work for newborns and premature (preemie) babies?