Written by: Dr. Maral Amani, PT, DPT

 

If you’re a parent to a newborn, you may have received questions from elders about why tummy time is so important, or comments like “I never did tummy time with my babies and they turned out fine.” A simple answer to this question is that the American Academy of Pediatrics recommends working up to 15-30 minutes of tummy time a day by the time your baby is about 2 months old (1). 

The more complex answer has to do with sleep, and more importantly safe sleep and reducing the risk of injury. To understand why tummy time is now recommended from day one, we’ll need to take a brief look at the history of the sleep recommendations. 

Quick Highlights on the Current Safe Sleep Recommendations

The Safe to Sleep campaign stresses two parts:

  1. Back to sleep: Healthy babies are safest when sleeping on their back at nighttime and during naps. 

  2. Tummy to play: Begin tummy time on day one when they are awake and supervised to help them build muscle strength and prevent flat head syndrome. 

Brief History

In 1994, the American Academy of Pediatrics (AAP) launched the “Back to Sleep” Campaign recommending that healthy babies be placed on their backs or sides to sleep. Based on additional research results, this recommendation was then updated in 1996 to state that babies should only sleep on their backs because this sleeping position was associated with lower risks. In 2012, the “Safe to Sleep” campaign replaced the “Back to Sleep” campaign, expanding on safe sleep practices beyond positioning (see below). The good news: it worked!! With this campaign, sleep-related injury rates declined by more than 50% in the U.S. from the early 1990s to the 2010s. 

“Back to Sleep, Tummy to Play”

When the “Safe to Sleep” campaign replaced the “Back to Sleep” campaign in 2012, tummy time was formally added as a recommendation by the AAP. This shift to back sleeping resulted in babies today spending significantly less time on their tummies compared to babies of previous generations. In fact, babies of earlier generations naturally spent more tummy time since they often slept in the prone (tummy) or side positions. This is why the previous generation of parents were not formally recommended to include tummy time into their baby’s awake time. 

Babies now experience up to 16 hours a day lying on their backs while sleeping, which is why pediatricians recommend placing babies on their tummy to play when awake to strengthen their head and neck muscles. Tummy time can begin on day one by placing your baby on your chest, and can continue on the floor once their umbilical cord stump falls off. A 2020 systematic review concluded that “tummy time was positively associated with gross motor and total development,” including prevention of flat head syndrome (brachycephaly- a type of plagiocephaly) (4).  

Plagiocephaly, or Flat Head Syndrome

While the current recommendations have successfully reduced SIDS rates, they have also led to an increase in Positional Plagiocephaly, also known as “Flat Head Syndrome” (2), which is when a baby develops a flat spot on one side of the head or the whole back of their head. This is because babies today are spending more time lying on their backs (up to 16 hours a day), which leaves less opportunity for natural muscle development compared to previous generations, when babies often slept in side or prone positions. This is because infant skulls are incredibly malleable and infants naturally have their head turned to one direction when placed on their back due to neck muscle weakness at this age. A recent study reported that up to 46.6% of infants between 7-12 weeks of age were observed to have some form of flatness on the backs of their head (3). Tummy time is therefore recommended to counteract this increase in flat head syndrome.

Flat head syndrome is not only a cosmetic concern, but it can affect a baby’s entire development, from their motor skills to feeding skills. If you’re noticing that your baby is developing a flat spot, reach out to your pediatrician and pediatric physical therapist for an assessment. Research shows that the earlier a flat spot is treated the better the results and shorter the duration of treatment (5).


Dr. Maral’s Tips on Preventing Plagiocephay (Flat Head Syndrome)

Given the rise in positional plagiocephaly due to the increased time babies spend lying on their backs, following these tips for increasing tummy time and providing varied positions for your baby is more important than ever. Try these actionable tips on reducing your baby’s risk:

  1. For full term babies, start tummy time on your chest from day one, and then once their umbilical stump falls off you can practice on a cushioned mat.

  2. Aim to double the amount of floor time, compared to time spent in containers. 

  3. Alternate which side of the bassinet your baby sleeps in so they naturally turn their head both ways. 

  4. Track your baby’s head shape by taking pictures from the Birds Eye view. Make sure to include their nose and ears in the photos for consistency with tracking. 

  5. Opt for babywearing when you can and make sure your turn your baby’s head to each direction!

  6. Side-lying play is a great way to offload pressure from the back of the head and is better tolerated than tummy time. If you notice flatness on one side, practice this on the other side.

Sometimes, despite all of your best efforts, your baby may develop a flat spot due to factors beyond your control. Babies are at an increased risk due to their positioning in the uterus (like the breech position) or if there are twins or multiples. While you can certainly help reduce the risk with the strategies above, please remember that your baby developing a flat spot is not a reflection of your parenting, and that you are not alone!


Recommended Resources on Safe Sleep:

  1. https://www.nichd.nih.gov/sites/default/files/2023-01/STS_2022_Brochure_English.pdf

  2. https://safetosleep.nichd.nih.gov/safe-sleep

  3. https://www.aap.org/en/patient-care/safe-sleep/?srsltid=AfmBOoosK7301b2utg2b5aNFgXkM3FRY4AbEZZk3LHRDuGBtX-hYAfum


Dr. Maral Amani, PT, DPT, is a licensed pediatric doctor of physical therapy who is certified in early intervention (children 0-3 years old). She is a play-based therapist who is passionate about supporting children with disabilities, delays, and neurodivergence through family-centered care. She educates parents and caregivers through her work as a child development expert and lead Disability Support Specialist at Lovevery, in-home therapy across San Diego, and on her Instagram!


Citations:

  1. American Academy of Pediatrics. (2025). Back to Sleep, Tummy to Play. Pediatrics, DOI: 10.1542/peo_document285. https://doi.org/10.1542/peo_document285

  2. Moon, R. Y., & Hauck, F. R. (2010). SIDS and other sleep-related infant deaths: Expansion of recommendations for a safe infant sleeping environment. Pediatrics, 126(5), e1243–e1252. https://doi.org/10.1542/peds.2010-1597

  3. Korner, A. F., O'Connor, L., & Kline, P. (2013). The incidence of positional plagiocephaly: A cohort study. Pediatrics, 132(2), 298-304. https://doi.org/10.1542/peds.2012-3438

  4. Duncan, P. M., & Williamson, M. (2020). Tummy time and infant health outcomes: A systematic review. Pediatrics, 145(6), e20192168. https://doi.org/10.1542/peds.2019-2168

  5. Blanco-Diaz, M., Marcos-Alvarez, M., Escobio-Prieto, I., De la Fuente-Costa, M., Perez-Dominguez, B., Pinero-Pinto, E., & Rodriguez-Rodriguez, A. M. (2023). Effectiveness of conservative treatments in positional plagiocephaly in infants: A systematic review. Children (Basel), 10(7), 1184. https://doi.org/10.3390/children10071184