In the past few months, I have done ten evaluations for babies who have torticollis (a condition where the neck muscles are tight) and/or plagiocphaly (a condition where one side of the head is flat). The one thing that each of these babies had in common was that all of the babies slept in elevated position at all times, either in a carseat, bouncy seat, a swing or some other upright container (e.g. a Rock and Play). In fact, I have noticed over the last year that more and more parents are sleeping their babies in an upright position.
Don’t get me wrong, there can be a time and place for elevated sleeping and certainly it may be a necessity. If a baby has reflux, they need to be upright for at least 30 minutes after each feeding in order to allow the baby to properly digest their feeding and to decrease discomfort associated with acid reflux. Therefore, putting the baby in an upright seat for night sleeping may be necessary. However, out of the ten babies that I evaluated, only two were diagnosed as having reflux and were on reflux medications already. One of the parents thought that maybe the baby had reflux, therefore exercised reflux precautions to improve the comfort of her baby. Therefore, in this small sample, 70% of the babies were sleeping in an upright position because he or she “slept better” when in an upright position. As a Mom of three, I COMPLETELY understand the need to get sleep and the necessity at times to do whatever you can so that you and your baby sleep at least a few winks. However, I am going to try to help you understand why sleeping flat as soon as possible is essential for a baby’s developing muscles, head position, symmetry of movement and head shape.
Full term infants are born with what is called physiological flexion. They have tightness in the muscles in the front of their body. This includes the neck muscles. Initially a baby can only move his or her head approximately 45 degrees to either direction. In order to gain full rotation range of motion, a baby needs to be flat on his or her back allowing the weight of the head to lengthen the sternocleidomastoid muscle (the muscle of the neck that helps with rotation) and other muscles allowing for full rotation of the head so that the baby can get her chin over her shoulder. The baby also needs adequate tummy time so she can lift and turn her head from side to side to lengthen the neck muscles fully.
When a baby sleeps in a rock in play, swing, bouncy seat or another elevated surface day in and day out, gravity is not allowed to help the baby to lengthen their neck muscles fully, therefore the baby’s neck muscles remain tight. As a result of elevated sleeping, one of two things can happen
1. The baby consistently holds his/her head in the middle causing the head to get flat on the back of his or her head, called Brachycephaly . The muscles of the neck also get tight if the baby does not experience side to side movement causing restricted rotation of the head/neck, elevated shoulders and difficulties with lifting his/her head when the baby is on his or her tummy.
2. Since the baby does not have enough strength to hold their head up vs the pull of gravity, the baby’s head starts to fall to one side all the time causing flatening on one side of the head, called Plagiocephaly. This position, if continued, can also cause Torticollis (tightening of a neck muscle) or generalized tightness of neck muscles. If there is muscle involvement in the neck it can affect the baby’s ability to symmetrically use his body, preferring one side over another for movement.
So, you may be asking, my baby is sleeping elevated, how do I transition him to a flat sleeping position . . . When I do an evaluation for a baby that has been sleeping elevated, it is one of my goals to help the family transition baby to a flat sleeping position, not to just tell them that the baby has to sleep flat. Here are some tips to transition baby to flat sleep.
1. If your baby does have reflux, try to place a small wedge under the baby’s mattress (not under the cribsheet). The baby will be sleeping flat, but will be slightly elevated and will help the baby transition to a flat surface. If your baby has trouble transitioning and does not have reflux, this technique may also help.
2. Infants like the containment of a bouncy seat or swing, it feels like they are being held. Therefore, swaddling baby may be effective in getting baby to transition to a flat surface. (click here for video on how to swaddle)
3. Attempt flat surface sleeping when you are awake (e.g. for naps) at first. Attempting it for the first time at night will be very difficult for you and baby.
4. If your baby sleeps in a swing, with the swing moving, try to transition the baby to no movement in the swing before you transition the baby to flat sleeping.
5. Once your baby is sleeping flat, if he or she has a preference for head rotation to one side, try to rotate head to the opposite side each time you put him or her down even if they only tolerate that for a few minutes (or seconds) so they know this will be a consistent way you put them down. With time, the baby will improve his or her rotation. If you notice that the baby is unable to rotate to the opposite side, cries when attempting to rotate to the opposite side, or has significant flattening of his or her head on one side please discuss with your doctor and see a pediatric physical therapist who will help you to integrate exercises and positioning into your day in order to progress your baby’s symmetrical skills.