Peds 20192168

Tummy Time and Infant Health
Outcomes: A Systematic Review

Lyndel Hewitt, PhD, Erin Kerr, BNutrDiet(Hons), Rebecca M. Stanley, PhD, Anthony D. Okely, EdD
CONTEXT: The World Health Organization recommends tummy time for infants because abstract
of the benefits of improved motor development and reduced likelihood of plagiocephaly.
Because of poor uptake of these recommendations, the association of tummy time with
other health outcomes requires further investigation.
To review existing evidence regarding the association of tummy time with a broad
OBJECTIVE:
and specific range of infant health outcomes.
DATA SOURCES: Electronic databases were searched between June 2018 and April 2019.
STUDY SELECTION: Peer-reviewed English-language articles were included if they investigated
a population of healthy infants (0 to 12 months), using an observational or experimental study
design containing an objective or subjective measure of tummy time which examined the
association with a health outcome (adiposity, motor development, psychosocial health,
cognitive development, fitness, cardiometabolic health, or risks/harms).
DATA EXTRACTION: Two reviewers independently extracted data and assessed their quality.
RESULTS: Sixteen articles representing 4237 participants from 8 countries were included.
Tummy time was positively associated with gross motor and total development, a reduction in
the BMI-z score, prevention of brachycephaly, and the ability to move while prone, supine,
crawling, and rolling. An indeterminate association was found for social and cognitive
domains, plagiocephaly, walking, standing, and sitting. No association was found for fine
motor development and communication.
Most studies were observational in design and lacked the robustness of
LIMITATIONS:
a randomized controlled trial. High selection and performance bias were also present.
CONCLUSIONS: These findings guide the prioritization of interventions aimed at assisting parents
meet the global and national physical activity guidelines.
Early Start, Faculty of Social Sciences, University of Wollongong and Illawarra Health and Medical Research Institute, Wollongong, New South Wales, Australia
Dr Hewitt conceptualized and designed the study, conducted the screening of records, appraised the quality of evidence, extracted, analyzed, and interpreted the data,
drafted the initial manuscript, and reviewed and revised the manuscript; Ms Kerr conducted the screening of the records, appraised the quality of evidence, extracted,
analyzed, and interpreted the data, and critically reviewed the manuscript for important intellectual content; Drs Stanley and Okely supervised data collection and
critically reviewed the manuscript for important intellectual content; and all authors approved the final manuscript as submitted.
This trial has been registered with PROSPERO (http://www.crd.york.ac.uk/prospero) (identifier CRD42017075156).
DOI: https://doi.org/10.1542/peds.2019-2168
Accepted for publication Mar 4, 2020
To cite: Hewitt L, Kerr E, Stanley RM, et al. Tummy Time and Infant Health Outcomes: A Systematic Review. Pediatrics. 2020;145(6):e20192168
PEDIATRICS Volume 145, number 6, June 2020:e20192168 REVIEW ARTICLE

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In 1992, the American Academy of which the association of tummy time METHODS
Pediatrics recommended that infants with specific aspects of motor
be placed supine to sleep.1 This was development (such as the ability to Registration
due to the high incidence of sudden move while prone, including the A systematic review of the literature
infant death syndrome (SIDS) caused ability to roll, sit, or walk) is was undertaken on the association of
from prone sleeping.1 This became investigated has not yet been tummy time with infant health
known as the Back to Sleep campaign, systematically reviewed. Additionally, outcomes. It was prospectively
which contributed to a 40% decrease the association of tummy time with registered with PROSPERO, the
in SIDS incidence in the United other infant health outcomes, such as International Prospective Register of
States.2 However, although the adiposity, psychosocial health, Systematic Reviews (http://www.crd.
incidence of SIDS was reduced, cognitive development, fitness, and york.ac.uk/prospero; identifier
infants placed supine to sleep had cardiometabolic health, is currently CRD42017075156) and was reported
slower achievement of their motor unknown because current evidence in accordance with the Preferred
milestones3,4 and an increased regarding tummy time interventions Reporting Items for Systematic
occurrence of head-shape is focused primarily on motor Reviews and Meta-Analyses
abnormalities.5 To counteract these development and head shape.21–23 A statement.27
effects, parents were encouraged to previous review investigating the
provide their infants with tummy effect of tummy time on other infant Search Strategy
time.6 Tummy time is a form of health outcomes has been Computerized searches of databases
physical activity recommended for conducted.24 However, to be included were completed in May 2018
infants ,6 months of age. It is in this systematic review, the and May 2019 by using Medline,
defined as awake prone positioning minimum sample size was 100 Cumulative Index to Nursing
on the floor that is encouraged and participants for observational studies. and Allied Health Literature,
supervised by an adult.7 Because As such, only 2 studies were found Scopus, and PsycINFO. The search
studies have demonstrated a positive relating to tummy time. One study was limited to titles and abstracts
association between tummy time and revealed a positive effect on motor containing “all infant (birth to
gross motor development,8–12 tummy development,23 and the other study 23 months)” and English and
time is a component of the national revealed a protective effect against humans. The Scopus search
movement guidelines in Australia, the deformational plagiocephaly.25 Some strategy was as follows: (TITLE-
United Kingdom, Canada, and South of the health benefits that may be ABSKEY((“tummy time” OR
Africa.13–16 It is also a component of present in other smaller studies may tummy OR prone OR position*
the guidelines from the National be a decrease in BMI in older OR abdomen OR stomach OR
Academy of Medicine17 and the children, fine motor skill belly OR front)) AND TITLEABS-
American Academy of Pediatrics18; development, cardiovascular fitness, KEY(effect* OR result* OR influence*
and is included in the World Health bone mineral density, and a reduction OR impression* OR appear* OR
Organization global guidelines for in other head-shape abnormalities achieve* OR consequence* OR
physical activity, sedentary behavior, such as brachycephaly. outcome* OR conclusion* OR
and sleep for children ,5 years of correlat* OR determin* OR
age.19 Thirty minutes of tummy time The early years are a crucial period of predictor* OR relationship* OR
spread over a 24-hour period is physical, cognitive, social, and associate* OR difference*) AND
recommended to optimize healthy emotional development.24,26 TITLE- ABS-KEY((infant* OR baby
growth and development. Identifying the association of tummy OR babies OR newborn))) AND
time with specific aspects of motor (LIMIT-TO(DOCTYPE,”ar”) OR
Evidence shows that only ∼30% of development as well as other health LIMIT-TO(DOCTYPE,”re”) OR LIMIT-
parents and 75% of child care outcomes is important for the TO(DOCTYPE,”ip”)) AND (LIMIT
educators adhere to these development of evidence-based TO(EXACTKEYWORD,”Human”) OR
recommendations.20,21 The potential interventions and may assist parents LIMIT TO(EXACTKEYWORD,”Humans”))
benefits of tummy time outlined in and educators in meeting the AND (LIMIT- TO(LANGUAGE,”English”)).
the current physical activity recommended guidelines of The following search terms (keywords)
guidelines include the effect of 30 minutes per day. Our purpose for were used: “tummy time” OR “tummy”
tummy time on an infant’s gross this systematic review was to OR “prone” OR “position*” OR
motor development. Whereas, the determine the association of tummy “abdomen” OR “stomach” OR “belly” OR
effects of tummy time on individual time with infant health outcomes “front” AND “effect*” OR “result*” OR
aspects of motor development are not across experimental and “influence*” OR “impression*” OR
currently highlighted. Research in observational study designs. “appear*” OR “achieve*” OR
2 HEWITT et al
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“consequence*” OR “outcome*” OR an age range was described rather prone positioning ability from an
“conclusion*” OR correlat* OR than the mean age, infants up to observational or experimental study.
determin* OR predictor* OR 12 months of age were included. If
The outcomes were various health
relationship* OR associat* OR a mean age or age range was not
outcomes; for example, adiposity (eg,
difference* OR investig*. Duplicates reported, participants who were
overweight, obesity, BMI), motor
were removed by using EndNote described as infants and newborns
development (eg, gross motor skills,
software, and the search output was were included. For longitudinal or
fine motor skills, specific components
screened manually also by using experimental studies, the age
of a motor skill, locomotor and object
EndNote. After duplicates were criterion is unlimited for the outcome
control skills), psychosocial health
removed, two researchers measures; however, the intervention
(eg, self-efficacy, self-esteem,
independently reviewed the titles of the must have taken place while the
prosocial behavior, social functioning,
articles to determine if they met the infant was between the ages of 0 and
depressive symptoms, anxiety
criteria for inclusion. Abstracts and full- 12 months old. Experimental and
symptoms), cognitive development
text articles were then studied to clarify observational studies were required
(eg, language development, attention,
and confirm eligibility. Any differences to have a minimum sample size of 15
executive functioning), fitness (eg,
between reviewers were discussed to (in 1 intervention group) and 30
cardiovascular fitness,
reach consensus regarding inclusion. participants, respectively.
musculoskeletal fitness), bone and
Reference lists of relevant reviews
skeletal health (eg, bone mineral
identified during screening were also The interventions comprised
density, bone mineral content,
checked for relevant studies. To capture different durations, frequencies,
skeletal area, vitamin D),
registered clinical trials, two trial patterns, types, and intensities of
cardiometabolic health (eg, blood
registries (https://clinicaltrials.gov/ and tummy time and/or prone
pressure, insulin resistance, blood
http://www.who.int/ictrp/en/) were positioning when awake. Tummy
lipid levels), and risks and/or harms
searched in May 2018 and May 2019 by time was defined as awake and
(eg, injury, plagiocephaly).
using the search term “tummy time” and supervised prone positioning. Prone
the infant age group. positioning ability was defined as an
Data Extraction
infant’s ability to move their body
Inclusion and Exclusion Criteria when placed on their stomach. This Data extracted included authors’
To be included in this review, the could include the ability to roll from names, publication year, country,
article was required to be peer- front to back, the ability to lift their study design, sample size,
reviewed, be published or in press, be head, the ability to push up with their characteristics of participants, tummy
written in English, and meet the arms, and the ability to move their time measure, health outcome
predetermined study criteria (see arms and/or legs.31 Studies in which measure, type of health outcome,
Supplemental Information). The only prone positioning during prone association of tummy time with an
review was based on the population, sleeping was investigated were infant health outcome, and the risk of
intervention or exposure, comparator excluded. Tummy time and/or prone bias. A finding was deemed to be
or control, and outcome study positioning ability could be measured statistically significant if P ,.05. Two
criteria28 from the Grading of objectively (eg, accelerometer, direct reviewers completed data extraction
Recommendations Assessment, observation) or subjectively (eg, for each included article and cross-
Development, and Evaluation proxy report). For experimental checked the findings.
framework.29,30 Conference abstracts, studies, interventions targeting
book chapters, and dissertations were tummy time and/or prone
Quality Assessment
excluded. positioning exclusively were included. Risk of bias was assessed at the
Interventions targeting multiple individual study level by using the
Population, Intervention, health behaviors (eg, tummy time and Cochrane risk of bias assessment for
Comparator, and Outcome observational and intervention
breastfeeding) were not included to
The population chosen to review was avoid over- or underreporting the studies.32 Selection bias, performance
apparently healthy (ie, general effect of tummy time on an infant bias, selective reporting bias,
population) infants aged from 0 to health outcome from a combined detection bias, attrition bias, and
12 months old. Studies that only intervention. other biases (eg, inadequate control
included children with a diagnosed for key confounders) were
medical condition (eg, Down The comparators were objective (eg, assessed.33 For all studies, risk of bias
syndrome), with the exception of accelerometer) or subjective (eg, was assessed independently by both
studies relating to prematurity, SIDS, proxy report, questionnaire) reviewers and then confirmed to
or low birth weight, were excluded. If measures of tummy time and/or ensure consistency. Overall quality of
PEDIATRICS Volume 145, number 6, June 2020 3

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4
TABLE 1 Descriptive Information of Included Studies (Ordered Alphabetically)
Author, Year Country Study Design Sex Age at Tummy Time Tummy Time Health Outcome Health Outcome Measure Association of Tummy Overall Association of
(Boys, Measurement Outcome Outcome Measure Type Used Time With an Infant Tummy Time With
Girls), Measure Used Measure Result (1 = Motor Health Outcome Health Outcome
n Development; (Positive, Negative, or
2 = Head Shape; Neutral)
3 = BMI-z; 4 =
Cognition)
Aarnivala et al, Finland Longitudinal 52, 47 3, 6, 12 mo Questionnaire Daily time spent 2 Three-dimensional Hours per day prone on Positive (beneficial)
201635 prone on the stereophotogrammetry (CI the floor when awake for brachycephaly;
floor when for brachycephaly and (effect of tummy time neutral for
awake (h) OCLR for plagiocephaly) on skull deformation plagiocephaly
after 3 mo of age):
a significant decrease
in CI scores (P ,.01);
no association with
OCLR (P ..05)
Carmeli et al, Israel Longitudinal 80, 0 1, 3, 6 mo Position log Preferred 1 AIMS No significant Neutral for AIMS
200939 position to be association of percentile
awake and to preferred play distribution; AIMS
play in; position or time in prone and supine
whether infant play position with categories analyzed
spent ,15 or motor development separately
.15 min in the
prone position

each day
Davis et al, United Longitudinal 172, 1 wk, 1–6 mo Position log Percentage of 1 Attainment of infant motor Increased prone Positive for supported
19983 States 179 time the infant milestones (rolls prone to playtime (supine- sitting (tripod),
spent in the supine, rolls supine to sleeping infants only) sitting
prone position prone, sits supported was significantly unsupported,
while awake [tripod], sits unsupported, associated with crawling, and
(measured as transfers objects, creeping earlier attainment of pulling to stand;
h/d) [pulling self along on supported sitting neutral for rolling
abdomen], crawling (tripod), sitting prone to supine,
[moving on hands and unsupported, rolling supine to
knees or hands and feet crawling, and pulling prone, transferring
with trunk off the ground], to stand (P ,.05). small objects
pulls to stand, walks 10–15 However, when between hands,
steps independently) maternal education, creeping, and
race, sex, birth wt, walking
and No. older siblings
were controlled for,
the difference was
significant only for
pulling to stand (P
,.01).
HEWITT et al
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TABLE 1 Continued
3 = BMI-z; 4 =
Cognition)
Dudek-Shriber United Observational 48, 52 Mean (SD): Questionnaire Amount of time in 1 AIMS Time spent in prone Positive for forearm
and Zelazny, States 134.8 (9.2) d a typical 24-h position while awake support 1, forearm
20079 period that the when 4 mo old was support 2, extended
infant spent on significant to predict arm support,
their tummy the achievement of rolling prone to
PEDIATRICS Volume 145, number 6, June 2020

while awake forearm support 1 supine, swimming,
(elbows in line with reaching, pivoting,
shoulders) (P =.001), supine hands to
forearm support 2 knees, supine active
(elbows in front of extension, rolling
shoulders) (P , .001), supine to prone,
extended arm sitting propped with
support (P , .001), arms, unsustained
rolling prone to sitting, and sitting
supine (P , .001), with arm support
swimming (P , .001),
reaching (P = .004),

pivoting (P = .001),
supine hands to
knees (P = .016),
supine active
extension (P = .001),
rolling supine to
prone without
rotation (P = .003),
sitting propped with
arms (P , .001),
unsustained sitting
(P , .001), and sitting
with arm support
(P = .001). Infants who
spent more time
awake in a prone
position at 4 mo old
achieved their
expected milestones
significantly more
compared with
infants who spent
less time awake in
5
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6
TABLE 1 Continued
3 = BMI-z; 4 =
Cognition)
a prone position (P ,
.001).
Jennings et al, United Nonrandomized 41, 37 6, 18 mo Questionnaire Regularity of 1 PDMS Infants placed in prone Positive for
200534 States intervention placing infant to play before the age locomotion (had
in prone for of 6 mo achieved tummy time before
play (seldom; a significantly higher 6 mo of age) and
sometimes: locomotion score locomotion
,1 time a d; when 18 mo old (P = (infants , 174 d old
frequently: .015). Infants ,174 d when they received
1 time a d; old who had tummy tummy time more
routinely: time routinely (more than once per day)
.1 time a d); than once per day)
age of infant had significantly
when started higher locomotion
placing them scores than other
prone for infants in the
playtime youngest group who

were seldom placed
prone to play (P =
.0012) or who were
placed prone less
than once per day
(P = .0367). There was
no significant
difference in
locomotion scores for
infants older than
174 d who were
placed seldom,
sometimes,
frequently, or
routinely in a prone
position to play.
HEWITT et al
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TABLE 1 Continued
3 = BMI-z; 4 =
Cognition)
Koren et al, United Longitudinal 70, 49 2, 4 mo Telephone Minutes of 1, 3 PDMS 2 (attainment of gross There was a significant Positive for attainment
201936 States survey tummy time and fine motor association between of prone motor
per day development) and BMI-z development, level of milestones (lifting
BMI-z, and time spent head, turning head,
in tummy time at 2 looking when talked

mo of age (P , to, bringing hand to
.0001). There was mouth, and kicking
a higher percentage on tummy),
of 2-mo-old infants decrease in BMI-z at
reaching 4 mo (tummy time
developmental .12 min at 2 mo),
milestones if they had and prediction of
more tummy time and BMI-z at 4 mo
if controlling for BMI- (tummy time at 2
z. More time in tummy mo); neutral for
time resulted in moving arms when
a higher percentage on tummy

of infants achieving
prone developmental
milestones, such as
lifting head (P =
.0001), turning head
(P = .0033), looking
when talked to (P #
0.0001), bringing hand
to mouth (P = .0284),
and kicking on tummy
(P = .0006). But the
outcome was neutral
for moves arms when
on tummy (P = .1072).
There was a decline in
the BMI-z at 4 mo as
daily tummy time at 2
mo increased past the
threshold of 12 min/d.
Tummy time duration
at 2 mo of age was
a significant predictor
of BMI-z at 4 mo (P =
7
.0412).
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8
TABLE 1 Continued
3 = BMI-z; 4 =
Cognition)
Kuo et al, Taiwan Longitudinal 152, 4, 6, 12, 24 mo Questionnaire Experience in 1 Attainment of motor Prone experience: Positive for attainment
200823 136 prone position milestones (rolling, Infants with prone of the following
(awake), crawling on abdomen, experience attained motor milestones:
duration in crawling on all fours, crawling on abdomen crawling on
prone play transferring objects, significantly earlier abdomen, rolling,
(min), and sitting, and walking), than infants without crawling on all
preference of GMDQ, FMDQ, and the prone experience (P = fours, sitting,
wakeful prone Comprehensive .012). There was so GMDQ,; neutral for
position Developmental Inventory effect on attainment rolling, crawling on
for Infants and Toddlers of the other all fours,
milestones. There was transferring
no effect on GMDQ objects, sitting,
and FMDQ. Prone walking, GMDQ, and
duration: Infants with FMDQ
longer prone duration
significantly achieved
rolling, crawling on

abdomen, crawling on
all fours, and sitting
earlier (P , .0167).
There was no effect
on transferring
objects or walking.
There was a higher 6-
mo GMDQ by using the
Krukal-Wallis test (P =
.018). There was no
effect on FMDQ. Prone
preference: The prone
preference group
attained rolling,
crawling on abdomen
and crawling on all
fours significantly
earlier than the
nonprone preference
group (P , .0167).
There was no effect
on transferring
objects, sitting, and
HEWITT et al
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TABLE 1 Continued
3 = BMI-z; 4 =
Cognition)
walking. There was
a higher 6-mo GMDQ
by using the
Mann–Whitney U test
(P = .037). There were

no significant
differences in FMDQ.
Majnemer and Canada Observational 38, 33 4, 6 mo Parent diary Duration (min/d) 1 PDMS (FMQ and GMQ), AIMS Exposure to prone Positive for the AIMS
Barr, 200510 (4 mo); spent awake in positioning while percentile (4 and 6
21, 29 prone position awake was mo old), FMQ (6
(6 mo) significantly positively mo), and GMQ (6
associated with the mo); negative for
AIMS percentile at the FMQ (4 mo old)
both 4 (P , .01) and 6
mo (P , .0001) of
age. Exposure to
prone positioning was

significantly
negatively associated
with the FMQ at 4 mo
of age (P , .05).
Exposure to prone
positioning while
awake was
significantly positively
associated with the
GMQ (P , .001) and
FMQ (P , .05) at 6 mo
of age.
Majnemer and Canada Observational 42, 41 4, 6 mo Parent diary Duration (min/d) 1 PDMS (GMQ), AIMS The mean daily exposure Positive for the AIMS
Barr, 200640 (4 mo); spent awake in to prone positioning prone score (4 mo),
32, 40 prone position while awake (min/d) AIMS total score (4
(6 mo) was significantly mo), AIMS
correlated with the percentile (4 mo),
AIMS prone raw AIMS prone score (6
score, total score, and mo), AIMS
percentile score at 4 percentile (6 mo),
mo of age (P , .05). and GMQ (6 mo)
The mean daily
exposure to prone
9
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10
TABLE 1 Continued
3 = BMI-z; 4 =
Cognition)
positioning while
awake (min/d) was
significantly
correlated with the
AIMS prone raw score
and percentile score
at 6 mo of age (P ,
.01) as well as with
the PDMS GMQ at 6
mo of age (P = .001).
Mawji et al, Canada Prospective 261, 9 wk (mean) Questionnaire Times per day, 2 Argenta scale Times per day: no result Neutral for
201437 cohort 179 7–12 wk length of specified; length of plagiocephaly
(range) (R R) tummy time tummy time received:
received; no association with
unclear if plagiocephaly (P =
length of .83).
tummy time is

measured in
min/h or time
since started
tummy time
Monson et al, United Observational 7, 23 6 mo Parent How often infant 1 AIMS Infants who received Positive for the AIMS
200311 States interview is placed on more tummy time in total score, AIMS
their stomach a day were associated percentile score,
to play (rarely: with a significantly AIMS prone score,
0–1 times higher AIMS raw and AIMS supine
a day; score (P = .004), score; neutral for
sometimes: percentile score (P = the AIMS sitting
2–3 times .003), prone raw score and AIMS
a day; score (P , .001), and standing score
frequently: supine raw score (P =
$4 times .019). There was no
a day) significant
association with the
No. experiences of
tummy time per day
with the AIMS
subscale sitting raw
score (P = .24) and
standing raw score
HEWITT et al
(P = .79).
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TABLE 1 Continued
3 = BMI-z; 4 =
Cognition)
Russell et al, South Africa Observational 59, 61 6 wk Questionnaire Length of time 1 Blys development guidelines: Spending .30 min/d in Positive for head
20098 (min) spent in when prone, their ability to tummy time was control in prone
prone position turn head, lift head 45°, associated with position (turn head,
when awake displace wt on upper trunk a significantly greater lift head, wt
(infants were or thorax, actively move ability in prone head displacement of

classified as arms, push up on arms, control (P , .0001), trunk), active
prone if they have elbow behind active movement of movement of arms
spent shoulder, bear wt on hands the arms, (P , .0001) when prone,
.30 min/d in with forearms in mid and pushing up on pushing up on arms
tummy time position, have hands open the arms (P , .0001), when prone, elbow
and nonprone or not open, move anterior elbow positioning in positioning in
if they spent thigh, and extend knee relation to the relation to the
,30 min/d in ,180°; when being pulled shoulder (P = .0039), shoulder when
tummy time) to sit: head control, wt bearing on hands prone, wt bearing
presence of shoulder in the mid position on hands when
girdle elevation, any (P = .0002), anterior prone, anterior
activity of the legs, and thigh positioning in thigh positioning

presence of hip flexion relation to the floor when prone, and
resistance (P = .0008), and knee knee extension
extension (P = .0334). when prone; neutral
There was no for hands open or
significant not open when
association with prone, pull-to-sit
keeping hands open action
or not and pull-to-sit
action (P . .05).
Salls et al, United Observational 66 in 2 mo Questionnaire Awake time spent 1 Denver II gross motor sector: Two-month-old infants Positive for gross
200212 States totala in prone per head up 45°, head up 90°, spending #15 min of motor milestones (2
day (0, 1–15, sitting with head steady, awake time in prone mo), head up 45° (2
16–30, 31–60, chest up with arm support, position passed the mo), head up 90° (2
61–90, 91–120, rolling over, pulling to sit gross motor mo), and sitting
and .120 (no head lag), sitting (no milestones at with head steady (2
min) support) significantly lower mo); neutral for
percentages. Infants chest up with arm
who spent .15 min/ support, rolling
d of awake time in over, pulling to sit
prone position at 2 (no head lag), and
mo of age were sitting with no
associated with support
a significantly earlier
11
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12
TABLE 1 Continued
3 = BMI-z; 4 =
Cognition)
achievement of head
up 45°, head up 90°,
and sitting with head
steady. No significant
association with time
spent awake in prone
position was noted at
4 and 6 mo of age.
Senju et al, Japan Longitudinal 898, 6 mo, 1, 1.5, 2, Questionnaire Ability in prone 1 ASQ-3 Significant difference Positive for gross
201841 906 2.5, 3 y position at 6 between prone and motor development,
mo old (can nonprone infants in personal-social
the infant the gross motor development, fine
straighten development domain motor development,
both arms and (P , .001), which problem-solving,
push their persisted until 3 y of communication,
whole chest off age (P = .001); in the and the ASQ-3 total
the floor when personal-social score

on their domain (P , .001),
tummy?) which persisted until
1.5 y of age (P = .035);
in the fine motor
domain (P , .001),
which persisted until
2 y of age (P = .009);
in the problem-solving
domain (P , .001),
2 y of age (P = .009);
in the communication
domain (P = .027),
1 y of age (P = .003);
and in the ASQ-3 total
score (P , .001),
2 y of age
Soska and United Observational 14, 15 6.02 mo Parent Frequency of 4 Scoring of manual, visual, No association between Neutral for manual,
Adolph, States (mean) interview playing with and oral exploration of frequency of play in oral, and visual
201438 toys while objects by using Datavyu (a prone position and exploration
prone (never, amount of manual,
HEWITT et al
evidence was evaluated by 1 reviewer
ASQ-3, Ages and Stages Questionnaires, Third Edition; CI, Cephalic index; FMDQ, fine motor developmental quotient; FMQ, fine motor quotient; GMDQ, gross motor development quotient; GMQ, gross motor quotient; OCLR, oblique cranial length ratio;
(Positive, Negative, or
Overall Association of
and verified by the larger

Tummy Time With
for plagiocephaly
Infants receiving tummy Positive (beneficial)
Health Outcome
Neutral) review team.
RESULTS
Description of Studies
d were at a significant
of age (P = .02). There

plagiocephaly at 7 wk
time ($3 wk of age)

Association of Tummy
time #5 min/d (P =
association between
(P = .7) and tummy

Time With an Infant
time ,3 times per
risk for developing
age of first tummy

After duplicates were removed, 4233
exploration overall
was no significant
Health Outcome
titles, 790 abstracts, and 130 full-text

oral, or visual
articles were screened (see Fig 1).

A total of 16 articles met the inclusion
criteria. Reasons for excluding articles
.6).
are summarized in Fig 1. The 16
computerized video coding
articles involved 4237 participants

diameter difference index)
Health Outcome Measure
from 8 different countries. The year

plagiocephaly (oblique
of publication ranged from 1998 to

Plagiocephalometry:
2018. An experimental study design

Used
was used in 1 article34; this was

software)
a nonrandomized intervention
(n = 1). Observational study designs
were used in the remaining 15
articles, 3,8,9,23,25,35–41which included
2 = Head Shape;
Health Outcome
3 = BMI-z; 4 =
Measure Type
Development;
(1 = Motor
Cognition)
longitudinal (n = 8) and cross-

2
sectional (n = 7) studies.
Tummy time was measured
subjectively in all 16 included articles
prone position;
frequency (per
duration (min)
sometimes, or
Measure Result
of prone play
put in prone
when awake
Tummy Time
infant when
play for the

infant while
age (wk) of
by using a questionnaire or parent

Positioning of
position to
Outcome
first time;
awake in
seldom,
interview (n = 12) or a position log or

d) and
often)
diary (n = 4). Parents were asked to

record or describe the amount of time
their infant spent in tummy time
Measure Used
Tummy Time
interview
Outcome
(hours or minutes per day) in

8 studies, to report the number of
Parent
times per day spent in tummy time

in 7 studies, to report the number
Measurement
Birth, 7 wk
of experiences spent in a prone

Age at
position when awake in 3 studies,

to outline their infant’s preferred
position in which to be awake and
(Boys,
Girls),
160,
197
Sex
play in 2 studies, to identify the age

n
at which the infant started tummy

time in 2 studies, and to report their
Study Design
van Vlimmeren Netherlands Longitudinal
infant’s ability to move while prone

in 1 study. Motor development was
PDMS, Peabody Developmental Motor Scale.
assessed as the health outcome of

interest in 12 studies,3,8,9,23,34,36,39–41
head shape in 3 studies,25,35,37 BMI in
a No. boys and girls not reported.
Country
1 study,36 and cognition in 1 study.38

The most common assessments for
TABLE 1 Continued
motor development were the Alberta

et al 200725
Infant Motor Scale (AIMS) and the

Author, Year
Peabody Developmental Motor Scale,

which were each used in 5 studies.
Further information on the study

by guest
TABLE 2 Risk of Bias (Observational Studies)
Observational Studies Selection Performance Detection Attrition Selective Other
Biasa Biasb Biasc Biasd Reporting Biasf
Biase
Author
Aarnivala et al35 High High Low Low Low Low
Carmeli et al39 High High Low Low High High
Davis et al3 High High Low Low Low Low
Dudek-Shriber High High Low Low Low Low
et al9
Koren et al36 High High Low Low Low Low
Kuo et al23 High High Low Low Low Low
Majnemer and High Low Low Low Low Low
Barr10
Majnemer and High Low Low High High Low
Barr40
Mawji et al37 High High Low Low Low High
Monson et al11 High High Low Low Low High
Russell et al8 High High Low Low Low Low
Salls et al12 High High Low Low High Low
Senju et al41 High High Low Low Low Low
Soska and High High Low Low Low Low
Adolph,38
van Vlimmeren High High Low Low Low Low
et al25
a How participants were selected to be in the study.
b How was tummy time measured? Was it a valid and reliable tool?
c How was the health outcome measured? Was it a valid and reliable tool?
d Did an adequate proportion of those consenting to participate in the study have complete data (ie, no more than 20% of data missing from a cross-sectional study and no more than
30% for a longitudinal study)?

e Incomplete or absent reporting of some outcomes and not others on the basis of the results.
f Other factors that may lead to an increased risk of bias.
design, sample size, tummy time regarding risk of bias of the included communication, and cognition. When
outcome measure, and association of studies is reported in Tables 2 and 3. separating these outcomes into more
tummy time with the health outcome Rules for classifying the strength of specific components, there were 16
is summarized in Table 1. tummy time and a summary of the health and development outcomes
association of tummy time31 with found, including brachycephaly;
The quality of included studies
health outcomes are reported in plagiocephaly; gross motor
ranged from low to high. All studies
Tables 4 and 5 respectively. development; fine motor
had high selection bias due to
development; total development;
homogenous participants in each of
Association With Infant Health ability to move while prone or supine,
the studies. Most studies relied on
Outcomes including sitting, standing, rolling,
unvalidated questionnaires or
crawling, and walking; personal and/
position logs to measure the amount All outcomes that had a positive,
or social communication; BMI; and
of tummy time the infant received. neutral, or negative association with
cognition (Table 5).
However, the majority of studies used tummy time are reported in Tables 1
a validated tool to measure the health and 5. In general, there were 5 health Experience in tummy time was found
outcome and had ,20% of and development outcomes to have a significant positive
participants drop out from the examined, including head shape, association with an infant’s total
studies. Further information motor development, BMI, social development (communication, gross
TABLE 3 Risk of Bias (Intervention Study)
Intervention Study, Selection Bias Performance Bias Detection Attrition Bias Reporting Other
Author Bias Bias Bias
Was the Allocation Was Allocation Blinding of Blinding of Incomplete Selective
Sequence Adequately Participants, Outcome Outcome Data Reporting
Adequately Concealed? Personnel, and Assessment
Generated? Outcome
Assessors
Jennings et al34 High High High High High High High
14 HEWITT et al
by guest
TABLE 4 Rules for Classifying Variables Regarding Strength of Association of Tummy Time With (P , .01)10,11,40 compared with
a Health Outcome infants who spent less time awake in
Studies Included in Review Supporting Summary Code Explanation of Code a prone position. Spending
Association, % .30 minutes per day in tummy time
0–33 0 No association was associated with a significantly
34–59 ? Indeterminate or inconclusive association greater ability in prone head control
60–100 1 Positive association (P , .0001), active movement of
60–100 – Negative association
the arms (P , .0001), pushing up
When an outcome was found $4 times, it was coded as 00 (no association), ?? (indeterminate), 11 (positive associ- on the arms (P , .0001), elbow
ation), or – – (negative association).
positioning in relation to the shoulder
(P = .0039), weight bearing on hands
motor and fine motor development, time and plagiocephaly (P = .83).37 in the mid position (P = .0002),
problem-solving, and social skills), However, it was found that infants anterior thigh positioning in relation
gross motor development, the ability who received tummy time ,3 times to the floor (P = .0008), and knee
to move while prone, supine, rolling, per day were at greater risk to extension (P = .0334).8 Likewise,
and crawling; a decrease in the BMI z develop plagiocephaly at 7 weeks of infants who spent .15 minutes
score (BMI-z); and the prevention of age (P = .02).25 per day of awake time in a prone
brachycephaly. Seventeen positive position at 2 months of age were
associations of tummy time with an Motor Development more likely to achieve earlier 45°
infant’s gross motor development The association between physical and 90° head up and were more
were found in 7 different studies, 26 activity and motor development was likely to sit head steady.12
positive associations of tummy time examined in 12 studies. Eleven
with an infant’s ability to move while studies revealed a positive effect, and BMI
prone were found in 6 different 1 study revealed a neutral effect. One One study revealed a significant
studies, 6 positive associations of nonrandomized controlled trial association between developmental
tummy time with an infant’s ability to revealed that infants ,6 months old milestones, level of BMI-z, and time
crawl were found in 2 different who had tummy time routinely (more spent in tummy time at 2 months of
studies, and 4 positive associations of than once per day) had significantly age (P , .0001). More time in tummy
tummy time with an infant’s ability to higher locomotion scores than other time resulted in a higher percentage
move while supine were found in 2 infants in the youngest group who of infants achieving prone
different studies. Indeterminate were seldom placed prone to play developmental milestones (P , .01).
associations were found between (P = .0012) or who were placed prone In addition, there was an association
tummy time and plagiocephaly; the less than once per day (P = .0367).34 between an increase in daily tummy
ability to sit, stand, and walk; Authors of the 4 longitudinal studies time past the threshold of 12 minutes
cognition; and personal and/or social reported a significant difference per day at age 2 months and a decline
domains. No association was found between prone and nonprone infants in BMI-z at 4 months.
between tummy time and fine motor in gross motor development
development and communication. (P , .001)41; achievement of rolling, Social Communication and Cognition
crawling on abdomen, crawling The authors of one study investigated
Head Shape on fours, and sitting earlier the association between tummy time
The authors of 3 studies examined (P , .0167)23; achievement of and communication. They found
the association between tummy time prone developmental milestones a significant difference between
and head shape. Plagiocephaly and (P , .01)36; and earlier attainment prone and nonprone infants in the
brachycephaly are defined as of supported sitting, sitting communication domain (P = .027)
flattening of the side and back of the unsupported, crawling, and pulling to that persisted until 1 year (P =.003)
skull by external forces, stand (P , .05).3 Interestingly, in one but no association after this age. In 2
respectively.42,43 There was of these studies, the gain in motor studies, authors investigated the
a significant decrease in development persisted until the child effect of tummy time on cognition. In
brachycephaly scores (P , .01) was 3 years of age (P = .001).41 The 6 one study, authors found a significant
associated with more hours per day observational studies also revealed association between the infant’s
prone on the floor when awake, but that infants who spent more time ability to move while prone at
there was no association with awake in a prone position achieved 6 months of age and cognition
plagiocephaly scores (P . .05).35 their expected milestones earlier (problem-solving), which persisted
Another study did not reveal an (P , .001)9 and had higher until the infant was 2 years old.
association between length of tummy AIMS percentile and prone scores However, combining this result with

by guest
TABLE 5 Summary of Reported Association of Tummy Time With a Health Outcome
Health Outcome Measure Investigated an Association Association Was Found Effect Sizes Summary Coding Summary Code
Association of Tummy (0, ?, –, or 1) for Studies With for Association
Time With the Health an Association, (0, –, 1,
Outcome (Reference) n/N (%) or ?)
Brachycephaly Aarnivala et al, 1, P , .01 Daily time spent in Coefficient estimate 1/1 (100) 1
201635 tummy time (h) 20.14; 95% CI
20.24 to 0.03
Plagiocephaly Aarnivala et al, 0, P . .05
Daily time spent in No effect size given 1/3 (33) ?
201635 tummy time (h)
Mawji et al, 201437 0, P = .83 Length of tummy time OR 0.93; 95% CI 0.61 — —
received (time to 1.41
measure not
reported)
van Vlimmeren et al, 1, P = .02 Tummy time ,3 times OR 2.7; 95% CI 1.12 — —
200725 per d to 6.55
AIMS percentile, total score, or Carmeli et al, 200939 0, P . .05 Preferred position to No effect size given 17/19 (89) 11
gross motor development be awake and play
in
Dudek-Shriber and 1, P , .001 Daily time spent in No effect size given — —
Zelazny, 20079 tummy time
Kuo et al, 200823 1, P = .018 Duration in prone play x23 = 10.1 — —
(min)
Kuo et al, 200823 1, P = .037 Preference in wakeful Mann–Whitney U — —
prone position test = 363.5
Kuo et al, 200823 0, P . .05 Experience in prone No effect size given — —
position when
awake
Majnemer and Barr, 1, P , .01 Exposure to prone Correlation matrix — —
200510 positioning when = 0.38
awake (AIMS
percentile, 4 mo old)
awake (AIMS
percentile, 6 mo old)
awake (GMQ, 6 mo
old)
Majnemer and Barr, 1, P , .05 Duration of tummy r = 0.27 to 0.33 — —
200640 time per day (min)
(AIMS total score, 4
mo old)
(AIMS percentile
score, 4 mo old)
Majnemer and Barr, 1, P , .01 Duration of tummy r = 0.39 — —
(AIMS percentile
score, 6 mo old)
Majnemer and Barr, 1, P = .001 Duration of tummy r = 0.49 — —
(PDMS GMQ, 6 mo
old)
Monson et al, 200311 1, P = .004 Times per day given No effect size given — —
tummy time (AIMS
raw score)
tummy time (AIMS
percentile score)
16 HEWITT et al
by guest
TABLE 5 Continued
Salls et al, 200212 1, P , .05 Awake time spent in x21 $ 3.84 — —
prone position at 2
mo old (min)
Senju et al, 201841 1, P , .001 Ability in prone g = 1.83; 95% CI — —
position at 6 mo old 1.67 to 2.00
(infant)
(1 y of age)
(1.5 y of age)
Senju et al, 201841 1, P = .001 Ability in prone g = 0.31; 95% CI — —
(2 y of age)
(2.5 y of age)
(3 y of age)
Ability to move while prone (AIMS Carmeli et al, 200939 0, P . .05 Preferred position to No effect size given 26/31 (84) 11
prone subscale, rolling prone to be awake and play
supine, forearm support, in
extended arm support,
swimming, reaching, pivoting,
head control in prone position,
active movement of arms when
prone, pushing up on arms when
prone, elbow position in relation
to the shoulder when prone, wt
bearing on hands when prone,
anterior thigh positioning in
relation to the floor, knee
extension when prone, keeping
hands open when prone, head up
45°, head up 90°, chest up with
arm support, lifting head,
turning head, looking when
talked to, bringing hands to
mouth, kicking on tummy)
(AIMS prone score, 4
mo old)
Majnemer and Barr, 1, P , .01 Duration of tummy r = 0.39 — —
(AIMS prone score, 6
mo old)
Monson et al, 200311 1, P , .001 Times per day given No effect size given — —
tummy time (AIMS
prone raw score)
Davis et al, 19983 0, P . .05 Hours per day spent in No effect size given — —
tummy time
Dudek-Shriber and 1, P = .001 Daily time spent in OR = 19.33 — —
(forearm support 1)
1, P , .001 OR = 5.41 — —

by guest
TABLE 5 Continued
Dudek-Shriber and Daily time spent in
(forearm support 2)
Dudek-Shriber and 1, P , .001 Daily time spent in OR = 3.60 — —
(extended arm
support)
Zelazny, 20079 tummy time (rolling
prone to supine)
(swimming)
(reaching)
(pivoting)
Russell et al, 20098 1, P , .0001 Tummy time .30 min/ No effect size given — —
d (turning head
while prone)
d (lifting head while
prone)
d (wt displacement
of trunk)
d (active movement
of arms)
d (pushing up on
arms)
Russell et al, 20098 1, P = .0039 Tummy time .30 min/ No effect size given — —
d (elbow
positioning)
d (wt bearing on
hands)
d (anterior thigh
positioning)
d (knee extension)
Russell et al, 20098 0, P . .05 Tummy time .30 min/ No effect size given — —
d (keeping hands
open)
Salls et al, 200212 1, P , .05 Tummy time .15 min/ x21 $ 4.91 — —
d (head up 45°; 2 mo
old)
Salls et al, 200212 1, P , .05 Tummy time .15 min/ x21 $ 8.90 — —
d (head up 90°; 2 mo
old)
Salls et al, 200212 0, P . .05 Tummy time .15 min/ x21 $ 0.01 — —
d (chest up with
arm support; 2 mo
old)
18 HEWITT et al
by guest
TABLE 5 Continued
Koren et al, 201936 1, P = .0001 Minutes of tummy time No effect size given — —
(lifting head)
Koren et al, 201936 1, P = .0033 Minutes of tummy time OR = 4.73; 95% CI — —
(turning head) 0.57 to 39.11
Koren et al, 201936 1, P , .0001 Minutes of tummy time OR = 10.06; 95% CI — —
(looking when 1.25 to 81.23
talked to)
(bringing hand to 0.88 to 8.36
mouth)
(kicking on tummy) 0.6 to 14.27
(moving arms) 0.56 to 5.23
Ability in supine (AIMS supine Carmeli et al, 200939 0, P . .05 Preferred position to No effect size given 4/6 (67) 11
subscale, rolling supine to prone, be awake and play
supine hands to knees, supine in
active extension)
tummy time (AIMS
supine raw score)
tummy time
Zelazny, 20079 tummy time (rolling
supine to prone)
Zelazny, 20079 tummy time (supine
hands to knees)
Zelazny, 20079 tummy time (supine
active extension)
Ability to sit (AIMS sitting subscale, Monson et al, 200311 0, P = .24 Times per day given No effect size given 7/12 (58) ??
supported sitting [tripod], sitting tummy time (AIMS
unsupported, unsustained sit score)
sitting, siting with arm support,
pulling to sit, sitting with head
steady)
Davis et al, 19983 1, P , .05 Hours per day spent in No effect size given — —
tummy time
(supported sitting)
tummy time
(unsupported
sitting)
Zelazny, 20079 tummy time (sitting
propped with arms)
(unsustained
sitting)
Zelazny, 20079 tummy time (sitting
with arm support)
Kuo et al, 200823 1, P , .0167 Duration in prone play No effect size given — —
(min) (sitting
earlier)

by guest
TABLE 5 Continued
Kuo et al, 200823 0, P . .05 Preference in wakeful No effect size given — —
prone position
(sitting)
Salls et al, 200212 1, P , .05 Tummy time .15 min/ x21 = 5.76 — —
d (sitting with head
steady; 2 mo old)
Salls et al, 200212 0, P . .05 Tummy time . 15 min/ x21 = 1.85 — —
d (pulling to sit, no
head lag; 2 mo old)
Salls et al, 200212 0, P . .05 Tummy time .15 min/ x21 = 3.00 — —
d (sitting with no
support; 2 mo old)
Russell et al, 20098 0, P . .05 Tummy time in min/ No effect size given — —
d (pulling to sit)
Ability to stand (AIMS standing Monson et al, 200311 0, P = .79 No. experiences of No effect size given 1/2 (50) ?
subscale, pulling to stand) tummy time per day
tummy time (pulling
to stand)
Ability in or to crawl (creeping, all Davis et al, 19983 1, P , .05 Hours per day spent in No effect size given 6/7 (86%) 11
fours, crawling on abdomen) tummy time
(crawling)
tummy time
(creeping)
(crawling on
abdomen)
(crawling on all
fours)
Kuo et al, 200823 1, P = .012 Experience in prone Log rank = 6.3 — —
(crawling on
abdomen)
Kuo et al, 200823 1, P , .0167 Preference in wakeful No effect size given — —
prone position
(crawling on
abdomen)
Kuo et al, 200823 1, P , .0167 Preference in wakeful No effect size given — —
prone position
(crawling on all
fours)
Walking Davis et al, 19983 0, P . .05 Tummy time, h/d No effect size given 3/6 (50) ??
Jennings et al, 200534 1, P = .015 Tummy time given No effect size given — —
before 6 mo of age
Jennings et al, 200534 1, P = .0012 Tummy time given No effect size given — —
more than once per
day
Jennings et al, 200534 1, P = .0367 Tummy time given less No effect size given — —
than once per day
but more than
seldom placed in
prone
Kuo et al, 200823 0, P . .05 Duration in prone play No effect size given — —
Kuo et al, 200823 0, P . .05 Preference of wakeful No effect size given — —
prone position
FMDQ, transferring small objects Davis et al, 19983 0, P . .05 Hours per day spent in No effect size given 5/15 (33) 0
between hands tummy time (FMDQ)
20 HEWITT et al
by guest
TABLE 5 Continued
position when
awake (FMDQ)
position when
awake (transferring
objects)
Kuo et al, 200823 0, P . .05 Duration in prone No effect size given — —
position when
awake (FMDQ)
Kuo et al, 200823 0, P . .05 Duration in prone No effect size given — —
position when
awake (transferring
objects)
prone position
(FMDQ)
prone position
(transferring
objects)
Majnemer and Barr, –, P , .05 Tummy time in min/ Correlation matrix — —
200510 d (4 mo old) = 20.29
Majnemer and Barr, 1, P , .05 Tummy time in min/ Correlation matrix — —
200510 d (6 mo old) = 0.33
position at 6 mo of 0.32 to 0.63
age (infant)
age (1 y of age)
age (1.5 y of age)
age (2 y of age)
age (2.5 y of age)
age (3 y of age)
Rolling (unspecified direction) Kuo et al, 200823 1, P , .0167 Duration in prone play No effect size given 2/3 (67) 1
(min)
Kuo et al, 200823 1, P , .0167 Preference of wakeful No effect size given — —
prone position
Salls et al, 200212 0, P . .05 Awake time spent in x21 = 2.96 — —
prone position in
min/d
Cognition (manual, oral, and visual Soska and Adolph, 0, P . .05 Frequency of playing in No effect size given 4/7 (57) ?
exploration, problem-solving) 201438 prone position
age (infant)
age (1 y of age)

by guest
TABLE 5 Continued
age (1.5 y of age)
age (2 y of age)
age (2.5 y of age)
age (3 y of age)
BMI-z Koren et al, 201936 1, P = .0412 Tummy time duration Slope 20.0384; 95% 1/1 (100) 1
at 2 mo of age CI 20.0752 to
20.0015
Communication Senju et al, 201841 1, P = .027 Ability in prone g = 0.20; 95% CI 2/6 (33) 0
age (infant)
age (1 y of age)
age (1.5 y of age)
age (2 y of age)
age (2.5 y of age)
age (3 y of age)
Personal-social Senju et al, 201841 1, P , .001 Ability in prone g = 0.58; 95% CI 3/6 (50) ?
age (infant)
age (1 y of age)
age (1.5 y of age)
age (2 y of age)
age (2.5 y of age)
age (3 y of age)
Total development (communication, Senju et al, 201841 1, P , .001 Ability in prone g = 0.96; 95% CI 4/6 (67) 11
gross motor, fine motor, position at 6 mo of 0.80 to 1.11
problem-solving, personal-social) age (infant)
age (1 y of age)
Senju et al, 201841 1, P = .001 — —
22 HEWITT et al
by guest
TABLE 5 Continued
Ability in prone g = 031; 95% CI 0.15
position at 6 mo of to 0.47
age (1.5 y of age)
age (2 y of age)
age (2.5 y of age)
age (3 y of age)
OR, odds ratio; CI, confidence interval; FMDQ, fine motor development quotient; GMQ, gross motor quotient; PDMS, Peabody Developmental Motor Scale; g, Hedge’s g; r, regression; 0, no
association; ?, indeterminate or inconclusive association; 1, positive association; 2, negative association; —, not applicable.
that of the other study investigating and early-care educators. Attainment Fourteen additional studies were
cognition resulted in an indeterminate of specific “small skills,” such as the found in the current review because
association overall (Table 5). ability of the infant to lift their head of new studies published and the
off the ground, the ability to move reduced number of participants
Fine Motor Development their arms and legs while prone, required in our inclusion criteria.
In 4 studies, authors investigated the the ability to reach while prone, It is also interesting to note that
association of tummy time with fine and the ability to sit with their the incidence of positional
motor development. No association arms supporting them, are small plagiocephaly in the population
was found in 10 of 15 outcomes yet tangible goals parents can measured by Mawji et al37 in 2014
measured. strive to meet. This was shown (n = 440) was 46.6% at 9 weeks of
in a previous study44 in which age. In the study by van Vlimmeren
tummy time was achieved by the et al25 in 2007 (n = 357), the
DISCUSSION infants’ first learning to lift their incidence was 22.1% at 7 weeks of
In this systematic review, we heads, then lift their legs, then lift age. Because a low level of motor
identified the association of tummy their arms. This order of achievement development is a risk factor for
time with a range of infant health and of tummy time was shown to be plagiocephaly,35 this rise in
development outcomes. Combining positively correlated with their ability plagiocephaly from 2007 to 2018
the current available evidence further to move when on their stomachs.31 may be a potential indicator of
confirms the importance of tummy Breaking down the achievement of a generation of infants not achieving
time to enhance infant development. “big skills,” such as rolling, sitting the motor development skills they
In addition, it highlights the up unsupported, and walking, into require. Previous studies also
association of tummy time with smaller, achievable stages of motor revealed an increased incidence in
specific aspects of motor development could be a motivating head-shape abnormalities after the
development (ability to move while factor, especially for those struggling introduction of the Back to Sleep
prone or supine, including rolling and with meeting the guidelines for campaign.3 Despite this, parents are
crawling), the reduction in BMI-z, and tummy time; however, this is encouraged to continue to place their
the prevention of brachycephaly. This currently unknown. infants supine to sleep and to
review also further reveals the need counteract these negative effects
The findings in this study are similar
for objective tummy time by ensuring participation in
to those in the systematic review
measurement techniques because recommended levels of tummy time
by Carson et al,24 who found that
subjective questionnaires or parent when their infants are awake and
tummy time participation of ,3 times
position logs were used in all supervised.45
per day was significantly associated
included studies.
with plagiocephaly in unadjusted To our knowledge, this is the first
Investigating specific benefits of models25 and that at least 30 minutes systematic review that includes
tummy time can be beneficial for of tummy time per day appeared a positive association of tummy time
parents, health care professionals, beneficial to motor development.23 with BMI.36 This information is vital

by guest
about tummy time,47 and receiving
information about tummy time
from a pediatrician has minimal
effect on tummy time.34 Further
investigation into the causes of
this low adherence rate and
strategies to improve adherence
is required.
Limitations of this study are the

small number of studies available
to review. A publication bias may
also be present because it is unknown
if other studies were conducted
but not published because of
null results. In addition, most
studies were observational in
design and lacked the robustness of a
randomized controlled trial design.
High selection and performance bias
were present for the majority of
studies, which reduces their ability to
be accurately representative of other
socioeconomic and cultural groups.
As such, race, ethnicity, country,
socioeconomic status, and cultural
effects on tummy time remain to be
investigated. Limits were placed on
the selection criteria to only include
studies written in English and studies
that included tummy time as awake
prone positioning on the floor. In
addition, in some studies, authors
FIGURE 1 combined various interventions
Flowchart of included and excluded studies. CINAHL, Cumulative Index to Nursing and Allied Health (supine positioning, prone
Literature. positioning, prone sleeping,
counseling, nutrition, etc) and
investigated the combined effect
to include in the list of health benefits global physical activity guidelines. of these interventions on infant
of tummy time for infants. Because These findings may also guide health outcomes. To include
there is currently only one study the prioritization of interventions these in the review would have
in which the association of tummy aimed at increasing tummy time confounded the effect tummy time
time with BMI is being investigated, practices for both healthy infants as alone had on infant health outcomes
further research into the effect of well as infants with developmental because it would be impossible to
tummy time on unhealthy weight disorders. determine the effect tummy time
gain among young children is alone had on the measured infant
recommended. At this time, the Current adherence to the infant outcomes. To ensure that the true
guidelines are focused on the physical activity guidelines is 30% (not confounded) effect of tummy
prevention of plagiocephaly and in Australia.21,46 Correlates that are time on infant health outcomes
the enhancement of motor negatively associated with tummy could be examined, studies were
development. The inclusion of the time are older parents, low education only included if the authors
benefit of a reduction in infant BMI-z level, and the amount of time spent conducted an exclusive tummy time
will be an important finding to awake in the supine position.31 It has intervention. As such, this may have
translate to assist parents and also been shown that knowledge of excluded some studies written in
educators with adherence to the tummy time, having a fearful attitude other languages, studies in which
24 HEWITT et al
by guest
authors investigated a combination impact on the health and well-being development, reduction in BMI-z,
of interventions, or studies that of the infant. prevention of brachycephaly, and
had tummy time on a location other ability to move while prone or
than the floor, which may have supine, including crawling and
revealed associations different from CONCLUSIONS rolling) can be used to educate
those in this review. In addition, In this study, we systematically parents about the benefits of
studies that had infants with and reviewed evidence from 16 studies tummy time.
without plagiocephaly grouped regarding the association of tummy • Further understanding of the
together were also excluded because time with infant health outcomes. effects of tummy time on infant
of the potential differences in motor Total development, gross motor health and development may assist
development that could not be development, and the ability to move to improve compliance with the
distinguished. while prone or supine (including World Health Organization tummy
Although authors of a number of crawling) were the health outcomes time recommendations of
systematic reviews have examined that had a significantly strong positive 30 minutes per day.
association. Studies, by using tummy
the effect of physical activity • This review reveals that further
interventions on older children’s time objective measurement
work is required regarding the
health outcomes,16,24 research to techniques and assessing a broader
objective measurement of tummy
examine the relationships between range of health outcomes, are
time rather than reliance on
physical activity and health among warranted to further inform future
parent-proxy questionnaires.
infants is limited. It is recommended physical activity guidelines for
that more research be conducted to infants.
examine the relationships between ABBREVIATIONS
physical activity and health indicators Clinical implications and public health
AIMS: Alberta Infant Motor Scale
significance are as follows:
in infants. This can ensure the BMI-z: BMI z score
identification of developmentally • Results from this review (tummy SIDS: sudden infant death
appropriate types and doses of time being positively associated syndrome
physical activity that have a positive with gross motor and total
Address correspondence to Lyndel Hewitt, PhD, Early Start, Faculty of Social Sciences, University of Wollongong, Wollongong, NSW 2500, Australia. E-mail: llh966@
uowmail.edu.au
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2020 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Supported by the Australian Government Research Training Program Scholarship (Dr Hewitt).
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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Tummy Time and Infant Health

Outcomes: A Systematic Review

PEDIATRICS Volume 145, number 6, June 2020:e20192168 REVIEW ARTICLE

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and veriﬁed by the larger

Neutral) review team.

of age (P = .02). There

time ($3 wk of age)

(P = .7) and tummy

time ,3 times per

risk for developing

age of ﬁrst tummy

titles, 790 abstracts, and 130 full-text

articles were screened (see Fig 1).

articles involved 4237 participants

from 8 different countries. The year

of publication ranged from 1998 to

2018. An experimental study design

was used in 1 article34; this was

longitudinal (n = 8) and cross-

play for the

by using a questionnaire or parent

interview (n = 12) or a position log or

diary (n = 4). Parents were asked to

(hours or minutes per day) in

times per day spent in tummy time

of experiences spent in a prone

position when awake in 3 studies,

play in 2 studies, to identify the age

at which the infant started tummy

van Vlimmeren Netherlands Longitudinal

infant’s ability to move while prone

assessed as the health outcome of

1 study,36 and cognition in 1 study.38

motor development were the Alberta

Infant Motor Scale (AIMS) and the

Peabody Developmental Motor Scale,

PEDIATRICS Volume 145, number 6, June 2020 13

30% for a longitudinal study)?

PEDIATRICS Volume 145, number 6, June 2020 15

PEDIATRICS Volume 145, number 6, June 2020 17

PEDIATRICS Volume 145, number 6, June 2020 19

PEDIATRICS Volume 145, number 6, June 2020 21

PEDIATRICS Volume 145, number 6, June 2020 23

Limitations of this study are the

PEDIATRICS Volume 145, number 6, June 2020 25

PEDIATRICS Volume 145, number 6, June 2020 27

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