A 31-day-old, former 33 week premature infant was seen in the resident continuity clinic for his weekly follow-up. He had been born and monitored in the neonatal intensive care unit where he received pressure support ventilation for 9 days. He was weaned off all support and supplemental oxygen by 17 days and was discharged home. He had been gaining weight at 15-20 grams/day for the past 10 days. His mother knew from her last child that she was supposed to do “tummy time” with infants but wasn’t sure what to do because he was premature.
The pertinent physical exam showed a well appearing male whose weight was 2.876 kg, length was 47 cm and head circumference was 32 cm. All were approximately the 50th percentile. Neurologically, he still had primitive reflexes and these were somewhat exaggerated but appropriate. He would lift his head off the table.
The diagnosis of a 37 week infant who was a former 33 week premature infant was made. The pediatrician said that she was not specifically aware of any recommendations for tummy time for premature babies. “I see that you are putting him on your chest and he holds his head well. I would continue to do that. I think you could also try to put him on the floor on his tummy too and see how he does. No matter how old the infants are, if they have their tummies down, they need to be awake and watched at all times. You need to make sure he doesn’t put his head down too far and tries to collapse his airway. That is less likely as he is now older but you need to watch him closely when he is on his tummy. If you see any problems then move him on his back right away and we can talk about when to try again. Remember though when you go to place him to sleep he should always be laid on his back,” the pediatrician recommended.
Tummy time (TT) is one of a newborn’s and young infant’s major physical activities. TT is when an infant is placed awake on a firm surface (such as a floor) in a prone position while supervised by an adult. This encourages the infant to elevate their head and push up with arms to elevate their upper torso. TT is encouraged to be done in short amounts of time several times a day and to increase the amount of time in this supervised position up to 30 minutes total per day. TT has been associated with gross motor movement and development and is a component of the World Health Organization’s and several other national movement guidelines. Data shows that only 30% of parents and 75% of child care professionals adhere to these guidelines though.
A systemic review of TT and infant health found that TT is associated with “gross motor and total development, a reduction in [obesity], prevention of brachycephaly, and the ability to move while prone, supine, crawling and rolling.”
The American Academy of Pediatrics’ 2022 technical report on infant sleep states about TT: “Supervised, awake tummy time is recommended to facilitate infant development and to minimize development of positional plagiocephaly. Parents are encouraged to place the infant in tummy time while awake and supervised for short periods beginning soon after hospital discharge, increasing incrementally to at least 15 to 30 minutes total daily by 7 weeks of age.”
This author was not able to identify specific guidelines for premature infants and TT. Infants who had chest or other surgeries may have similar issues. One study of infants < 4 months old (and as young as 2 days) who had undergone cardiac surgery and who had been instructed to do TT, found improved motor skill outcomes.
Questions for Further Discussion
1. What physical activities do you recommend for different ages of children?
2. What do you recommend to help patients and families with obesity?
3. What are some of the special nutritional needs for premature infants?
4. What are infant sleeping guidelines for newborns?
- Symptom/Presentation: Health Maintenance and Disease Prevention
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Hewitt L, Stanley RM, Cliff D, Okely AD. Objective measurement of tummy time in infants (0-6 months): A validation study. PLoS One. 2019;14(2):e0210977. doi:10.1371/journal.pone.0210977
Hewitt L, Kerr E, Stanley RM, Okely AD. Tummy Time and Infant Health Outcomes: A Systematic Review. Pediatrics. 2020;145(6):e20192168. doi:10.1542/peds.2019-2168
Koren A, Kahn-D’angelo L, Reece SM, Gore R. Examining Childhood Obesity From Infancy: The Relationship Between Tummy Time, Infant BMI-z, Weight Gain, and Motor Development-An Exploratory Study. J Pediatr Health Care. 2019;33(1):80-91. doi:10.1016/j.pedhc.2018.06.006
Uzark K, Smith C, Yu S, et al. Evaluation of a “tummy time” intervention to improve motor skills in infants after cardiac surgery. Cardiology in the Young. Published online September 27, 2021:1-6. doi:10.1017/S1047951121003930
Moon RY, Carlin RF, Hand I, THE TASK FORCE ON SUDDEN INFANT DEATH SYNDROME and THE COMMITTEE ON FETUS AND NEWBORN. Evidence Base for 2022 Updated Recommendations for a Safe Infant Sleeping Environment to Reduce the Risk of Sleep-Related Infant Deaths. Pediatrics. 2022;150(1):e2022057991. doi:10.1542/peds.2022-057991
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa