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?

Sunday, June 29, 2008

How much Tummy Time is enough?

This question about tummy time has been asked a lot, but now there is an answer. A study was presented at the NDTA 2008 National Conference which revealed that the minimum amount of tummy time was one and one half hours a day ( 1 1/2 ). More time is better but 1 and 1/2 hours spread out during the day was the minimum amount that made a difference. For best results, start tummy time as soon as your baby gets home from the hospital. There will be less protests from the baby and the benefits will start right away. This is important for all babies but especially for preemies and babies with other issues at birth.

It's great to finally have an answer to the question, "How much tummy time does my baby need?"

Vickie PT

Tuesday, April 15, 2008

Arching, What Does It Mean and How to Help

Does your baby arch their body when upset? It's not unusual, but it can be scary. In very young and early babies arching is a sign of an immature nervous system. We are all born with a set of reflexes that help us fight gravity. With preemies, because of their early arrival, their muscle are weak and they have a hard time moving against gravity. Those reflexes allow them to "cheat" and they can use the reflexes to move. Unfortunately, the reflexes only allow certain movements and one of them is arching. The reflex starts at the head and neck, so the best way to minimize it is to curl your baby into a ball. It often helps to rock the baby and hold them against your body so that they relax. The strongest position for the reflex is supine (back lying). Sidelying is a wonderful position if you can place them against a firm, cushioned surface. Sidelying also helps them get their hands to midline which is soothing to them.

I hope this information has been helpful. Please contact me if you have questions or would like to hear about other topics.

Vickie PT