ARTICLE
Parental Information and
Behaviors and Provider
Practices Related to Tummy
Time and Back to Sleep
Ainat Koren, PhD, RN, Susan M. Reece, DNSc, PNP, BC,
Linda Kahn-Dangelo, PT, ScD, & Dorothy Medeiros, RN, FNP
ABSTRACT
Introduction: This exploratory study aimed to discern paren-
tal understanding and behaviors, provider practices, and
available online information related to infant positioning in-
cluding Back to Sleep and Tummy Time (TT) during Web sites were inconsistent regarding TT initiation and dura-
early infancy.
Method: The study employed three methods of exploration:
surveys of 119 mothers of newborns, a focus group of nine
health care providers, and an analysis of popular parental
Web sites.
Results: Ninety percent of the mothers reported receiving in-
formation about positioning the infant while asleep. How-
Ainat Koren, Assistant Professor, Department of Nursing,
University of Massachusetts Lowell, Lowell, MA.
Susan M. Reece, Professor, Department of Nursing, School of
Health and Environment, University of Massachusetts Lowell,
Lowell, MA.
Linda Kahn-Dangelo, Professor, Department of Physiotherapy,
School of Health and Environment, University of Massachusetts
Lowell, Lowell, MA.
Dorothy Medeiros, Nurse Practitioner, Boston Medical Center,
Wakefield, MA.
Conflicts of interest: None to report.
This study was funded by the University of Massachusetts Lowell
School of Health and Environment Development Grant.
Correspondence: Ainat Koren, PhD, RN, Department of Nursing,
University of Massachusetts Lowell, 3 Solomont Way, Suite 2,
Lowell, MA 01854; e-mail: Ainat_koren@uml.edu.
0891-5245/$36.00
Copyright Q 2010 by the National Association of Pediatric
Nurse Practitioners. Published by Elsevier Inc. All rights
reserved.
doi:10.1016/j.pedhc.2009.05.002
222 Volume 24  Number 4
ever, only 55% mothers postpartum and 26% at 2 months
after birth received information regarding infant positioning
during awake time. Providers reported barriers such as lack
of time and confusing guidelines to TT education. Parenting
tion information.
Discussion: Study outcomes suggest that, with the implemen-
tation of Back to Sleep guidelines, there has been a need
for parental education about positioning infants during sleep
and awake times. J Pediatr Health Care. (2010) 24, 222-230.
KEY WORDS
Back to Sleep campaign, tummy time, infant development,
plagiocephaly, parenting practices, infancy
The purpose of this exploratory study was to assess
parental and provider behaviors and practices related
to infant positioning, including Back to Sleep (BTS)
and Tummy Time (TT) during early infancy. Since
1992, the American Academy of Pediatrics (AAP)
(1992) has recommended that all infants be placed su-
pine for sleep (BTS) to prevent sudden infant death syn-
drome (SIDS). They also recommended that infants
spend some time awake prone (called tummy
time) to prevent head deformity and promote motor
development. Interestingly, the AAP did not define
some in their BTS guidelines. The guidelines state
that parents should be counseled about infant position-
ing sometime by 2 to 4 weeks after the infant is born.
They specify: When the infant is awake and being ob-
served, the infant should spend time in the prone posi-
tion. The infant should spend minimal time in car seats
or other seating that maintains supine positioning
(Persing, James, Swanson, & Kattwinkel, 2003, p.
Journal of Pediatric Health Care
201). More recently, the AAP Task Force on Sudden
Infant Death Syndrome (2005) revisited statistics for
SIDS and the BTS guidelines. These guidelines, specif-
ically aimed at preventing SIDS, have one section
devoted to preventing positional plagiocephaly. They
encourage TT when the infant is awake and ob-
served, encourage cuddle time, and advise the supine position: odds ratio [OR] 3.39, P < .0001, 87% ac-
avoidance of excessive time in car-seat carriers and
bouncers (p. 1252). OR 2.21, P = .0001, 69% accuracy), and sitting mile-
In 2008, the AAP (2008) once again revised their in-
formation for parents in their Back to Sleep, Tummy
to Play brochure, available online. The new guidelines
stress the importance of BTS and also include a revised
section on TT. This section notes that TT should begin
on the first day home from the hospital. TT practice
should increase in frequency over time from two to
three times a day and increase in length from 3 to 5 min-
utes per time. Suggestions are also provided on how to
avoid having a baby with a flat head, how to deal with
an infant who does not like being in TT, and how to ex-
ercise the baby while he/she is in TT (AAP, 2008). Even
the most recent TT guidelines lack clarity as opposed to
the BTS guidelines. Further, families themselves may be
concerned about the possibility of SIDS should TT be
practiced. As such, the purpose of this study was to be-
gin to explore parent information and informational
sources during the early postpartum period, as well as
provider beliefs and practices related to infant position-
ing early in life.
LITERATURE REVIEW
Research reported that, since the BTS recommenda-
tions, major motor milestones were achieved later (Da-
vis, Moon, Sachs, & Ottolini, 1998; Majnemer & Barr,
2006). Using the Alberta Infant Motor Scale (AIMS) in
a study of 71 well 4-month-old infants, Majnemer and
Barr assessed the relationship between sleep position
and motor development. The AIMS specifically looks
at motor development and postural control in four po-
sitions: supine, prone, sitting, and standing positions.
The authors found that, at 4 months, the AIMS motor
scores tested while the infant was in the prone position
were higher in infants who spent more time in the su-
pine position. Differences between the two groups
were more marked when the infants were 6 months
of age. Those who slept and spent more time in the
prone position had higher scores on both the AIMS total
scores, whereas 22% of those in the supine group had
some gross motor delays. By the age of 15 months, no
differences existed between the two groups. These
and other studies suggest that BTS temporarily inter-
fered with gross motor function (Janz, Blosser, &
Fruechting, 1997). In another study, 2-month-old in-
fants who followed the supine/side lying recommenda-
tion were significantly behind the normative
population in gross motor milestones (Salls, Silverman,
& Gatty, 2002).
www.jpedhc.org
Dudek-Shriber and Zelazny (2007) used the AIMS in-
strument to investigate motor development related to
prone positioning in 74 four-month-old infants. For ex-
ample, the authors found that the more time infants
spent in the prone position while awake predicted ear-
lier achievement of prone milestones (roll from prom to
curacy), supine milestones (supine active extension:
stones (sit propped with arms: OR 4.12, P < .0001,
68% accuracy). The authors also commented that
most of the infants in their study spent 30 minutes or
less per 24 hours in the prone position and that most
of the parents noted that their infants were not tolerant
of being put in the prone position; as such, the parents
did not follow the recommendations of their providers
for TT (Dudek-Shriber & Zelazny).
Sleep position and decreased activity levels recently
have led to increases in plagiocephaly and brachyceph-
aly (abnormalities in head shape such as skewness and
occipital flattening) (Persing et al., 2003). A retrospec-
tive record review of all infant patients (N = 269) with
plagiocephaly diagnosed between 1979 and 1994
from a tertiary pediatric center in the Midwest showed
a significant increase in the diagnosis beginning in
1992 (P < .05). The authors noted that these increases
coincide with the BTS recommendation of the AAP
(Kane, Mitchell, Craven, & Marsh, 1996).
In a longitudinal study of 200 infants, prevalence of
these deformities at 6 weeks was 16%, and at 4 months,
19.7%, with an overall prevalence rate of 29.5% of all of
the infants at some stage of the study. Of concern is that
at 6 weeks, infants with the deformity spent on average
19 hours in the supine position, whereas the control
subjects spent 15 hours in the supine position. Half of
the infants with the deformity were spending more
than 21 hours per day in the supine position. Also, at
4 months, infants with the diagnosis of head deformity
were more likely to have low activity levels and to sit at
an older age (Hutchinson, Hutchinson, Thompson, &
Mitchell, 2004).
In a prospective study of 380 healthy infants exam-
ined at birth and at 7 weeks, 84 (22%) had a severe skull
deformity (plagiocephaly) (van Vlimmeren et al.,
2007). Multivariate regression analyses with plagioce-
phaly as the outcome demonstrated that risk factors
for plagiocephaly included placement in TT less than
three times per day (crude OR: 2.7; 95% confidence in-
terval [CI]: 1.12-6.55) and lower parental education
(crude OR: 1.8; 95% CI: 0.93-3.43). For mothers with
lower education, an additional risk factor was parents
not putting the infant in TT until he or she was 3 weeks
of age or older (crude OR: 1.7; 95% CI: 1.06-2.66). Addi-
tional factors predicting plagiocephaly were birth order
(firstborn), male gender, bottle feeding, and bottle
feeding on the same side. The research also suggested
that parents with lower educational levels position their
July/August 2010 223
infants in TT for shorter and less frequent periods.
TABLE 1. Demographic data of mothers and
These authors summarized that perhaps parents are
infants (N = 119)
over-interpreting the AAP BTS recommendations and
recommended that parents vary infant position begin- n %
ning at birth when their infants are awake and under su- Gender of infant
pervision (van Vlimmeren et al.). Male 68 57
The American Physical Therapy Associations 2008 Female 32 43
survey of physiotherapists reported increased reports Maternal age (X, range) 28.68 18-48
Race/ethnicity
of motor delay in infants. They attributed this increase
White 65 54.6
to the fact that these infants spend too much time on Asian 15 12.6
their backs and in car seats, swings, and strollers, Latino 15 12.6
thereby increasing the amount of time the infants are Black or African American 11 9.2
in one position. Moreover, a higher percentage of these Cambodian 8 6.7
Brazilian 5 4.2
infants are referred to specialists. Because a develop-
Maternal education
mental delay may be associated with positioning, this Less than high school 14 11.8
issue has ramifications regarding the assessment of in- High school diploma 23 19.3
fants at risk and inappropriate referrals (Majnemar & Vocational school 8 6.7
Barr, 2006). Some college 17 14.3
College degree 41 34.5
Little is known about how much parents vary their in-
More than college 16 13.4
fants position when awake. One study that examined Marital status
the use of infant seating devices in day care centers Married, cohabitating 77 64.7
through 120 minute-by-minute observations found Married, not cohabitating 0 0
that, among the 38 infants from eight licensed day Cohabitating, not married 30 25.2
Not married/not cohabitating 6 5
care centers observed, the infants spent more than 62
Not married or in a relationship 6 5
out of 120 minutes in seating devices (Myers, Yuen, & Delivery type
Walker, 2006). The youngest infants (2 to 3 months of Cesarean delivery 63 52.9
age) spent the most time in these devices, with an aver- Health insurance
age of 87.5 minutes out of 120 minutes (Myers et al., Health maintenance organization 56 47.06
State insurance plan 43 36.13
2006).
Preferred provider organization 15 12.61
Gaps in knowledge exist about parental views on in- Military 4 3.36
fant positioning and infant care practices. In the study None 1 0.84
by Davis and colleagues (1998), researchers found Maternity leave
that parents were reluctant to place their infants prone Not employed 45 37.8
Paid leave 41 34.5
because of concern about SIDS. Even greater gaps exist
Unpaid leave 33 27.7
related to provider practices regarding educating par- Eligibility for Women, Infants and 50 42
ents about both BTS and TT. Children services: yes (women and
The Internet provides increasingly fast and easy ac- children)
cess to medical information for the general population.
Online, parents can search the medical literature and
also have access to self-help support groups (Khoo,
Bolt, Babl, Jury, & Goldman, 2008; Mandl, Feit, Pena, using both quantitative and qualitative methods. Paren-
& Kohane, 2000; Williams, Mughal, & Blair, 2008). Al- tal data were gathered by survey methodology, pro-
though the importance of the Internet as a health infor- vider data were obtained through focus group
mation source is emerging, face-to-face counseling also methodology, and Internet data were compiled
remains important in providing parents with the health through an analysis of popular Internet parenting
information they need (Dinkevich & Ozuah, 2002). Web sites.
Given what has been found in the literature, this
study is a preliminary exploration of what parents Sample
know and practice regarding early infant positioning, The convenience sample consisted of two groups of
what education providers give parents in relation to in- participants: 119 newly delivered mothers recruited
fant positioning, and sources of information about BTS from an urban hospital postpartum unit and nine health
and TT. care providers from a clinic in the same city. Inclusion
criteria for the mothers were that they speak English
and be at least 18 years of age with healthy, term (37-
STUDY DESIGN AND METHODS 41 weeks) newborns. The baseline group (N = 119) av-
This study explored parental information and behav- erage age of the mothers was 28.9 years, with a range of
iors and provider practices related to infant positioning 18 to 48 (Table 1). Although the researchers recruited

224 Volume 24  Number 4 Journal of Pediatric Health Care

mothers from a hospital in a city of significant diversity,

American Baby Parenting Family Circle

the majority of the mothers were White. Approximately

American Academy of Pediatrics

National Institutes of Health, NLM

38% of the mothers had a vocational or high school di-

Dominion Enterprises, Landmark

Christianity Today International

ploma or less, and 35% had graduated from college.

Site sponsor
Forty-five (38%) were not employed at the time of
data collection, and 50 (42%) received Women, Infants

Parenting Magazine

Communications
and Children (WIC) services. For 36.9% of the mothers,

NBC and ivillage

this was their first infant. When the infant was 2 months

Boys Town
old, the mothers were contacted via phone interview.
This time 88 participants were reached (77%). The
nine pediatric providers were from a major pediatric
clinic serving a diverse population in the hospital area

Active play with parent on floor face-to-

with parents sitting with knees bent

and consisted of three physicians, one pediatric nurse

Active play with you and toys, on

face, on parents chest, or on lap

practitioner, two registered nurses, and three licensed
practical nurses. A 1-day Internet search of Web sites

How to facilitate
for parenting was the third sample.

Instruments

your chest
The investigators developed the Demographic Data

Active play
Survey (DDS) to assess maternal health, education,

ivillage
TABLE 2. Google search parenting (enter tummy time in search box), September 23, 2008
family demographics, and plans for infant feeding. Be-
cause no survey was available in the literature to inves-
tigate parental beliefs and behaviors about infant

time, so she can strengthen her arms

exercise for her to have some tummy
2-3/day for 3-5 minutes, increase
Frequency/duration tummy time

When the baby is awake, it is good

positioning, the investigators collaborated in the devel-

Giving her several 5- to 10-minute

Few minutes several times a day
opment of the Infant Positioning Survey (IPS) to assess

and head and neck muscles

parental knowledge and information sources of BTS
and TT recommendations. The immediate postpartum

Total 30 minutes a day

Unless you sign up for

sessions each day

survey has a total of 30 items, whereas the 2-month
as child enjoys

postpartum survey has a total of 66 items. Each investi-

gator, using his or her expertise in his or her pediatric
specialty, provided input into item generation. Sample
questions were: Have you received any information
about how to put your baby down when he/she is
asleep? and Have you received any information about
In first part of article, 3 to 4 month, and

how to put your baby down when he/she is awake? Babies need time on their stomachs,
later on in same article, newborn
Age to begin tummy time

Further questions assessed sources of information

1st day home from hospital

such as prenatal class, nurses and physicians on the

head, neck, and shoulder
Once the cord has fallen off

postpartum unit, the health care provider, and the me-

The Web site address in bold represents an official Web site.

dia. When the infant was 2 months old, a researcher
contacted the mothers and interviewed them over the
No information
No information

No information

phone. Additional questions in the 2-month survey in-

Early weeks

cluded inquiries about positioning practices, informa-

tion sources, and infant responses to TT. Examples
were: When your baby is asleep/awake, what position
do you put him/her most of the time? and, What hap-
http://www.nlm.nih.gov/medlineplus/

pens when you put your baby in tummy time? Re-

NLM, National Library of Medicine.
http://www.webmd.com/parenting/
http://www.christianitytoday.com/
developmental_milestones.html

searchers also asked questions regarding frequency

Name of site/address
Healthy Child Care America

and amount of time in TT.

http://www.parenthood.com/
http://parenting.ivillage.com/
http://www.parenting.com/

http://www.parenting.org/

The investigators asked providers about their own

http://www.parents.com/

beliefs and practices related to infant positioning, in-

cluding TT, through a semi-structured review guide.
parenting.html
article-topics/

Sample questions were: What is your interpretation

parenting

of the recommendation for time spent on the tummy

per day in young infants? and What do you recom-
mend to parents? and How do parents interpret
your recommendations about tummy time?

www.jpedhc.org July/August 2010 225

Procedures

American Academy of Pediatrics

Parental surveys

Pathways Awareness Foundation

Researchers informed all mothers of healthy newborns

USA Today (Gannett Co., Inc.)

Orthoamerica Products, Inc

born in an urban hospital in the Northeast between

New York Times Company

Site sponsor
March and July, 2007, about the study. Those who
were interested completed the informed consent form
that had been approved by the University and Hospital

BabyCenter LLC

BabyZone, Inc.
Institutional Review Boards. One of the researchers in-
terviewed the mothers, using both the DDS and the IPS.

MSNBC
When the infant reached 2 months of age, the same re-
searcher contacted and interviewed the mothers by
telephone. The researcher entered the data from these
interviews into an online survey during the interview.

On caretakers lap, chest, carry in prone

Active play, massage, sibling distraction

Carrying, snuggle, play, feeding, slides

position; links to American Physical

Active play video and pictures on site
Health care provider focus group

Play, on pillow, rolled up blanket

Therapy Association brochure

Providers met with two researchers at the clinic during

How to facilitate

Visual tracking, carry in prone

a scheduled lunch break. All providers signed the ap-

Play, on rolled up blanket

Self/toy for active play
proved consent form. The 45-minute focus group meet-
ing was tape recorded while one researcher took notes.

Internet search

TABLE 3. Google search parenting (enter tummy time in search box), September 24, 2008
The researchers conducted two Internet searches using

position
Google at the end of September 2008 to ascertain what
online information about TT is available to parents.
Googles search engine uses a PageRank system to
Frequency/duration tummy time

help rank Web pages that match a given search string.

Start with 2-3 min/day; work up

3-5 minutes 2 to 3 times/day
The PageRank algorithm computes a score for Web

to 20-30 min 1 to 2/day

pages based on the weighted sum of the PageRanks

Few minutes/several times,

30 min; can be broken into

10 seconds and work up

to 1 hour by 3 months
of the pages linking to them. The PageRank derives

Short periods of time

from user-generated links and is thought to correlate

increase with age

well with users concepts of importance, simply stated
multiple times

as the most hit Web sites (Brin & Sage, 1998). The re-
As tolerated

searchers performed two searches to get a broader view

of the first 10 high-ranked sites that were commonly
None

used. All 10 sites that came up were included, whether

or not they included the specific information we were
Age begin tummy time

seeking. Search terms were parenting with tummy

Home from hospital

time entered into search button of sites, and tummy

Babies of all ages

time (Tables 2 and 3).

No information

The Web site address in bold represents an official Web site.

Data Analysis
2 months

Newborn

Newborn

Newborn

The researchers used SAS statistical software to analyze

Day 1

the mothers DDS and IPS data for measures of central

tendency. Data from the provider interviews were tran-
scribed and analyzed for themes relating to beliefs and
http://www.healthychildcare.org/pdf/

http://pediatrics.about.com/od/infants/a/
http://www.babyzone.com/askanexpert/

http://www.usatoday.com/news/health/

behaviors regarding infant positioning using the coding

http://www.pathwaysawareness.org/
2008-06-29-baby-workout_N.htm

method recommended by Morse and Field (1995). Indi-

http://www.orthomerica.com/pdf/
Name of site/address

vidually, each researcher identified major themes

http://www.babycenter.com/

http://www.msnbc.msn.com

within the transcripts and from the notes of the focus

0607_tummy_time.htm

group meeting. Researchers met to agree on color cod-

SIDStummytime.pdf

tummytimetools.pdf

ing the major themes. After revisiting and analyzing the

tummy-time-101

transcripts multiple times, the researchers reconvened

to discuss the themes and validate exemplars for each
theme. Consensus defined the major themes of the fo-
cus group. The researchers used an identical methodol-
ogy to analyze findings from the Web site in the area of
TT, such as age of initiation, frequency, and duration.

226 Volume 24  Number 4 Journal of Pediatric Health Care

 TABLE 4. Reported instructions and TABLE 5. Two months parent infant
instruction sources about infant positioning positioning most of the timereported
postpartum (N = 119) practice (N = 88)
n % n %
Positioning when infant is asleep Positioning when infant is asleep
On back 95 79.8 On back 69 79.31
On side and back 8 6.7 On side 12 13.79
On side 4 3.4 On tummy 3 6.9
No information received 12 10.1 Positioning when infant is awake
Positioning when infant is awake On back 61 70.11
On back 21 17.65 On side 3 3.45
On side and back 8 6.72 On tummy 9.2 8
On side 3 2.52 Sitting at a 45 degree angle 16 14.94
On tummy 18 15.13 Hold in arms 2 2.3
Rotate tummy/back 14 11.76 Times per day tummy time
Hold in hands 2 1.68 0 1 1
No information received 53 44.54 1 27 33
Sources of instruction* 2 30 37
Nurses on the parent-infant floor 46 38.6 3 13 16
Physician in hospital 4 3.3 >3 11 13
Pediatrician 17 14.28 Length per tummy time episode (min)
Relative or friend 15 12.6 0-2 11 13
Media magazines/newspapers 10 8.4 3-5 31 38
Internet 0 0 7-10 22 27
Previous experience (work or child) 15 12.6 >10 18 22
*Sources of information will not add up to 100% because the
mothers could choose several sources of information. recommendation of the BTS campaign. When our sur-
veyed mothers were asked if they received information
regarding awake and asleep time between discharge
RESULTS
and 2 months of age, only 26.44% of the mothers had
Maternal Survey Outcomes
received information regarding awake time infant posi-
Time 1 tioning, compared with 83.72% of the mothers having
At the time of the first interview (immediately postpar- received information regarding asleep time infant posi-
tum), approximately 90% of the mothers had received tioning. Sources of information regarding infant posi-
information about infant positioning. Ninety-five tioning were once again the nurses at the mother/
mothers (80%) had received information on positioning child unit and the pediatrician. The Internet was noted
the infant on her or his back when asleep (BTS). As for as a resource only for position at sleep time 12% of
positioning infants when awake, only 19 (15%) re- the time.
ceived information on positioning the infant on her or
his abdomen. Fifty three of the mothers (45%) received
no information on positioning when the infant was Provider Focus Group Findings
awake or on TT (Table 4). Nurses on the postpartum Two major themes were identified during the analysis
floor gave the majority (38%) of the instruction. The of the transcripts of the provider focus group. They
hospital physician gave only 3.3% of the information were provider practices and perceived barriers regard-
about infant positioning. Of note is that no mothers ing implementing TT discussion with parents (Table 6).
noted the Internet as a resource of information regard- Examples of one providers practices regarding infant
ing TT at this stage. positioning and TT included random counseling re-
garding TT when the infant was approximately 2 to 3
Time 2 months of age. The amount of time the provider recom-
At the second interview (2 months), approximately 90% mended ranged from 2 to 15 minutes per day as toler-
of the mothers reported that their infant spent some time ated, and frequency was a few times per day. The
in TT. Approximately 70% reported the infant was provider noted that SIDS prevention, however, was
placed most of the time on his or her back during sleep covered at each visit. Among the provider focus group,
time (Table 5). This percentage is consistent with the the age of the infant at which infant positioning was
Centers for Disease Control and Prevention (CDC) discussed at well-visits ranged from 2 months to 6
findings from a survey conducted in 2003 (National months. Overwhelmingly, the providers noted barriers
Center for Health Statistics, CDC, 2003). The CDC survey to counseling. Providers barriers were: availability of
results showed that 72% of parents place their infants time, confusion regarding the guidelines, and legal
on their back when asleep, conforming to the implications. Family infant barriers were: confusion,

www.jpedhc.org July/August 2010 227

 TABLE 6. Provider themes relative to recommending tummy time
Theme
Practices Begin counseling at 2 to 3 months; not
Confusion regarding
guidelines
d Use AAP guidelines
(unable to remember
specific
recommendations)
Perceived barriers Fear legal implications; time limitation:
Provider related
Family-infant related Fear; confusion; culture; babys frustration
Summary of practices Exemplars
We do the Denvers.and say at about 6
formal, random; range: 2-15 minutes of months if they havent rolled over . I ask
tummy time recommended as tolerated them you know, does the baby have tummy
a few times per day time? And they will look at me, whats tummy
time or not understanding.
Tummy Time is more of an informal conver-
sation we have with families during visits
We do not have specifics, just a few minutes
(relate to tummy time)
.You tell them about it but pretty much the
emphasis of sudden infant death child does it on its own anyway. As far as
syndrome as a priority over counseling back to sleep, it is an AAP recommendation,
about tummy time so you cant tell them to do otherwise. That
would be risking getting sued and if anything
happens to the kid, its our fault
At our office its just 10 minutes for a physical,
so we really dont have a lot of time to go over
this
No, I do not think I pay attention unless it is
abnormal.otherwise I think those 5 minutes
I might spend doing something else
Ive had a couple of families who are scared
about SIDS and they did not want the baby
to role over.
Im just anticipating that it is confusing, or
could be confusing.always always when
they are napping, always when you are not
with them, always on their back. not on
their side.but everyday we also want you to
put them on their stomach just because the
back to sleep part it is very confusing
.I would ask a family from my culture, just
from Cambodia, do you give the baby any
tummy time? They will look at me like, what
are you talking about? They just assume
once they hit a certain age they know how to
roll themselves
.all of our parents also have three kids at
home, so if there is one frustrated on the floor,
she is not going to let him stay on the floor.

fear, the babys frustration when in TT, and cultural DISCUSSION

practices. Providers stressed that information on the
importance of BTS was given at every visit, as they
considered SIDS prevention counseling as a safety
concern.
Parenting Web Sites Findings
Outcomes from the analysis of Web site content demon-
strated that there is wide variability of information avail-
able to parents on infant positioning (Tables 2 and 3).
Web sites ranged from providing no information to
recommending that TT begin anywhere from birth to
3 to 6 months of age. Recommended duration for TT
ranged from 1 minute to 30 minutes. All sites that rec-
ommended TT emphasized that the infant should be
awake and supervised throughout the TT. Several sites
recommended strategies to make TT more tolerable
and fun for parent and infant.
Research has shown that, since the BTS recommenda-
tions were published, major motor milestones have
been achieved later. Moreover, research has shown an
increase in head shape abnormalities (Davis et al.,
1998; Majnemer & Barr, 2006). Results from this explor-
atory study demonstrated that a low percentage of
mothers received information regarding TT during
awake time at birth (55%) and at 2 months (26%).
When their infants were awake, most of the mothers
practiced TT one to three times for only 3 to 5 minutes
when the infant was 2 months old. Most of the mothers
(71%) put their infants in TT two times per day or less,
and more than half of the infants were in TT for 3 to 5
minutes or less. Placing the infant in a supine position
when awake was the most common practice. Barriers
for TT for mothers included frustrated and unhappy in-
fants, time, and uncertainty. Barriers for educating on

228 Volume 24  Number 4 Journal of Pediatric Health Care

TT as stated by providers were time constrictions, prior-
ities, uncertainty, and confusion. Parenting Web sites
provided an inconsistent and confusing range of infor-
mation. There is no consensus as to when, how many
times, and for how long to practice TT. This situation
might cause confusion and uncertainty among parents
using the Internet as an information source for this
topic.
Limitations
There are several limitations of this exploratory study
that suggest limits in generalizability and clinical appli-
cability of the study findings. First, the convenient sam-
ple and its demographics was limited to a relatively
small cohort of mothers who gave birth during a specific
time frame and volunteered to participate in the study.
All mothers and babies were from the same geographic
location (northeastern Massachusetts) and gave birth at
the same hospital. The provider sample also was lim-
ited, because it represented only one single practice.
Still, previous publications support similar concerns
raised by these research findings (American Physical
Therapy Association, 2008; Chizawsky & Scott-Findlay,
2005; Johnson, 2004). The providers focus group might
not have revealed all existing practices and opinions.
The existence of several hierarchic levels in the same
group (physicians, nurses, and LPNs) may have inter-
fered with the confidence of some participants to ac-
tively share their practices and opinions. To prevent
this bias, we would recommend either holding focus
groups with providers of the same occupation or other-
wise having separate interviews.
CONCLUSION AND RECOMMENDATIONS
Despite its limitations, this study has important implica-
tions for clinical practice and future research in the area
of maternal-infant nursing. Outcomes suggest that with
the implementation of BTS guidelines, there has been
a lack of clarity and education for both parents and
providers about the importance of TT when young in-
fants are awake. Although it was apparent that the
BTS campaign had reached most of the mothers in
this study, TT was limited in terms of frequency and du-
ration. The important role for nurses on the postpartum
floor as providers of much of the education related to
infant positioning was highlighted. Once mothers and
infants are home, the responsibility of this education
is shifted to providers in their anticipatory guidance
sessions with parents. Different educational methods
could achieve this goal. For example, a study by
Jennings, Sarbaugh, and Payne (2005) concluded that
the intervention may be as simple as handing out a bro-
chure containing consistent explanatory information
about the importance of early and regularly practiced
tummy time. In their study, 88% of babies whose
parents received the brochure were placed in the prone
www.jpedhc.org
position more than one time per day, and these infants
scored significantly higher on a development scale
(Jennings et al.). On a policy level, because current
guidelines for parents
are inconsistent, the Outcomes suggest
guidelines should be
clarified and given to
that with the
practitioners to em- implementation of
phasize the impor- BTS guidelines,
tance of TT as they
pass along the BTS rec-
there has been
a lack of clarity and
ommendations. In ad-
dition to highlighting education for both
the need for future
research on parental
parents and
providers about the
understanding about
infant positioning, this importance of TT
study also suggests
the need for future re-
when young infants
are awake.
search to provide an
evidence base for TT
education for parents of young children and for the pos-
sibility of a marketing campaign to better educate par-
ents about this important aspect of infant care.
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WANTED: CASE STUDIES

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230 Volume 24  Number 4 Journal of Pediatric Health Care