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    Move Forward Guide

    Physical Therapist's Guide to Container Baby Syndrome

    A “container baby” is a newborn baby or young infant who is placed in a container, such as a car seat or stroller, for an excessive amount of time in a given day. “Container baby syndrome” is the name used to describe a range of conditions caused by a baby or infant spending too much time in such containers. These conditions can cause movement, cognitive, and social interaction problems, and may even cause deformity.

    Once symptoms of container baby syndrome are recognized by the family or a health care provider, the involvement of a physical therapist (early intervention) helps ensure successful treatment. A physical therapist can design an individualized treatment plan to address the problems of a container baby, and help build strength, restore movement, and address skeletal deformities.


     

    What is Container Baby Syndrome?

    Container baby syndrome (CBS) is a collection of movement, behavior, and other problems caused by a baby or infant spending too much time in a container—any commonly-used piece of baby equipment that resembles a container, including:

    • Car seats
    • Strollers
    • Bumbo seats
    • Bouncy swings
    • Rockers
    • Bouncer seats
    • Nursing cushions
    • Vibrating chairs
    • Jumpers
    • Exersaucers
    • Activity gyms/centers

    Although these containers and equipment are used to help keep the baby safe from accidents, allow parents and caregivers to more easily transport the baby, and give the baby play time, this equipment is also confining, keeping babies from moving all parts of their bodies. Spending a lot of time lying on the back in a container, for example, allows little to no movement of the baby's neck, spine, or body. Although some parents believe that leaving the baby in the container or equipment is safer, more convenient, and enjoyable for the baby, this kind of immobilization can actually cause delayed development of common skills like rolling, crawling, and walking.

    Staying in a container for a prolonged time can eventually cause issues, such as:

    • Flat head. The back or the side of the head is abnormally flat.
    • Facial asymmetry. The sides of the baby's face may appear unequal as a result of skull deformity and flatness.
    • Torticollis. The baby has difficulty turning the head to one side, or keeping the neck and head straight due to muscle tightness on one side of the neck.
    • Decreased movement, strength, and coordination.
    • Speech, sight, hearing, and thinking problems.
    • Attention deficit hyperactivity disorder (ADHD).
    • Increased weight/obesity.

    Background

    In 1992, new guidelines were promoted to parents to help prevent Sudden Infant Death Syndrome (SIDS), which was thought to be caused by infants sleeping on their stomachs with soft materials around them that could block their breathing and cause the infant to suffocate. The phrase Back to Sleep was coined to help parents remember to clear the crib of soft blankets, pillows, and stuffed toys, and place the baby on its back to sleep, all of which was intended to keep the baby’s airway free of obstacles.

    Although SIDS has decreased by 50% since the guidelines were introduced, reports of CBS rose to 1 in 7 children by 2008; some researchers say incidents of CBS increased 600% in just the years 1992 to 2008.

    Difficulties with skills that develop during the first few years of life, such as crawling, rolling, sitting, running, and speaking are referred to as developmental delays. The number of children with mild developmental delays thought to be associated with spending more time on their backs and less time on their stomachs (called tummy time), has increased since the early 1990s when the anti-SIDS campaign began.

    Many parents mistakenly extend the Back to Sleep approach throughout the day, using containers to keep their babies in the “right” position, whether sleeping or awake. Other parents find that keeping the baby in a container for much of the day is convenient, and seems restful for the baby. Because of this positioning, the baby spends less time lying on its tummy, sitting up on its own, and holding its own head up (as it does when it’s being held by a person). As a result, movement skills are not developed by the baby. The constant pressure on the back of the head while in a container can also lead to a skull deformity called flat head syndrome (plagiocephaly or brachycephaly, depending on where the head is flattened).

    A baby who has been fully supported in a container most of the day may express unhappiness by crying when taken out of a container and put on its tummy for play. This may make the parents think this crying means the tummy position is not good for the baby, so they place the baby back into the container.

    However, work and play in the tummy position is integral to development. The baby is likely crying because this position requires more work for the baby. Tummy time strengthens muscles of the neck and trunk, promotes and maintains a rounded skull shape, and fosters the development of movements and coordination.

    Physical therapists educate parents that an active, early approach to preventing and correcting the deformities and muscle problems caused by CBS is necessary to avoid lifelong consequences.

     

     

     

    How Is It Diagnosed?

    Parents, family members, or daycare providers may be the first to notice that the baby is not fully turning its head or moving its body very much. They may also notice that the baby’s head is becoming flattened on the back or on one side, or stays tilted to one side. If you see these problems, contact a physical therapist immediately!

    Your physical therapist will conduct a thorough evaluation that includes taking the baby's health history. Your physical therapist also will ask you detailed questions about how the baby is handled and the baby's activity level each day, and gently test for signs and symptoms of common CBS problems, such as:

    • Delayed movement and skills. The baby may not be able to roll, sit up, crawl, or, when on the tummy, lift the head or reach with the arms in a way expected for the baby’s age.
    • Vison or hearing problems. The baby may show a delay in the development of vision or hearing skills, such as following moving objects with the eyes and seeing toys from different distances.
    • Delayed thinking abilities. The baby may have delayed development in problem-solving, in understanding their surroundings, and with language skills.

    Your physical therapist may collaborate with a physician or other health care provider to make a final diagnosis. Further tests may be necessary to confirm the diagnosis, and to rule out other problems.

    If your physician notices signs of CBS before you do, the physician may refer your baby to a pediatric physical therapist for evaluation and treatment.

     

    How Can a Physical Therapist Help?

    Your physical therapist will first evaluate your baby by examining:

    • The shape of the skull and face and how the baby holds the head and neck
    • The baby’s muscle development
    • How your baby moves the head, body, and limbs
    • How well your baby can lift the head and limbs when lying on the tummy
    • How well your baby can roll over, crawl, and change body positions
    • How well your baby can track objects with the eyes

    Based on the findings during the examination, your physical therapist will make a treatment plan just for your baby's specific needs.

    Physical therapy should be started early, often prior to the baby being 3 months old, but a physical therapist can also help a child who is older regain strength and well-being. Your physical therapist will help improve your baby's:

    Movement skills and strength. Your physical therapist may employ appealing toys, games, and songs to encourage your baby to learn new movements and strengthen underdeveloped muscles.

    Positioning. The physical therapist will teach you where to reposition your baby and how to aid in developing more normal movements, strength, and skull shape. This usually consists of increased floor time and tummy time, and increased times of sitting upright without the use of a container. Recent guidelines recommend that the baby enjoy tummy time 3 times a day, with constant adult supervision, and not sleep in a carrier or stroller at night.

    Parent education. Your physical therapist will help you learn to safely place your baby on its tummy after every feeding, nap, diaper change, and whenever the baby is awake and alert. The physical therapist will also explain how holding your baby for feedings rather than feeding it in a carrier or stroller allows the baby to look around, improving neck and eye movement. Additional suggestions will likely include using a playpen to allow baby to be active and safe without being confined to a container, and changing the position of toys and mobiles in the crib to encourage turning of the head in different directions.

    Modalities. Based on each child's condition, the physical therapist may prescribe different modalities, such as protective head gear, to gently aid treatment.

     

    Can this Injury or Condition be Prevented?

    Container baby syndrome is 100% preventable!

    Expectant or new parents are strongly encouraged to follow the guidelines listed here, and contact a physical therapist to learn specific ways to prevent CBS from developing. You can protect your baby from day one by following this advice:

    Guidelines for Preventing CBS

    • Limit your baby’s time in containers, such as car seats and strollers, to only when the baby is actually being transported somewhere.
    • Increase the time your baby lies on the tummy when awake (with adult supervision).
    • Hold your baby in your arms or a sling for short periods of time throughout the day, instead of just leaving your baby in a container.
    • Let your baby play freely in a playpen.
    • Allow your baby to frequently play on a blanket on the floor—on the tummy or the back, but outside of a container—with adult supervision.
     

    Real Life Experiences

    Sarah’s parents adored her the second she was born. They did everything their family and friends said would protect her from injury. They regularly used the car seat that friends had given them as a gift. Sarah’s mom appreciated that Sarah easily fell asleep in her car seat while in the car, and she found it easy to keep Sarah in the car seat when she carried her into the house, and even feed her a bottle while still in the car seat. Sarah’s parents felt like their infant was safe in the car seat, and Sarah seemed content and comfortable.

    Sarah's grandmother commented on what a quiet baby Sarah was. Sometimes Sarah’s parents let her stay in the car seat at night because taking her out might lead to crying, and require more time to settle her down for the night. Sarah did not like to be on her tummy and would cry when placed there. Sarah’s mom was sure that the most important thing was for Sarah to be comfortable and happy in her first few months of life.

    Two months after Sarah’s birth, during a well-baby check, her physician noticed that her head was flattened in the back. He also noted that Sarah could not hold her head up as well as a typical 2-month-old baby should, and that she protested vigorously whenever she was placed on her tummy. He noticed that she could not lift her head up when she was on her tummy. Her eyes didn't follow his finger when he moved it in front of them. The physician recognized that Sarah was showing signs of container baby syndrome.

    The physician referred Sarah to a pediatric physical therapist who performed additional testing. She asked Sarah’s parents how many hours a day she was in her car seat, how many hours a day she had tummy time or floor time, how many hours she was held in someone’s arms or in a body sling, and what position she slept in.

    Her physical therapist noted that Sarah's head appeared flat in the back, and that she couldn't lift her head or chest off the floor when on her tummy. Sarah also didn’t kick her legs or reach with her arms as much as a typical infant her age. Her physical therapist confirmed a diagnosis of container baby syndrome.

    Sarah's physical therapist designed a program of specific activities to help encourage Sarah to strengthen her muscles and gain the ability to move better. She also taught Sarah's parents how to increase her floor time and tummy time, and to hold her in their arms more—all in order to give Sarah a chance to practice and improve her movement skills. 

    Sarah's parents learned that she should be on her tummy at least 3 hours a day when awake, be carried upright in a sling or her parent's arms, and be allowed to play in a playpen. Her physical therapist helped Sarah’s parents understand that repositioning her out of a container was the most important step in allowing her flat skull to correct itself.

    Sarah's physical therapist treated her twice a week for 8 weeks, using gentle exercises and hands-on therapy, by which time Sarah could lift her head for 20 seconds at a time while on her tummy, and could roll from her tummy onto her back. Toys and games helped Sarah enjoy her new positions. As she gained strength in her muscles, and learned to use her eyes better, she started to play more. The back of her head began to be more rounded and less flat.

    By 4 months of age, Sarah was able to roll, follow objects with her eyes, reach with her arms, and hold up her head much better. Her head was a normal, rounded shape. Overall, she was a much more active, interactive, and happy baby—and her parents were relieved and thrilled to see her improvement!

    This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.

     

    What Kind of Physical Therapist Do I Need?

    All physical therapists are prepared through education and experience to treat individuals with CBS. However, you may want to consider:

    • A physical therapist who is experienced in treating children with CBS, torticollis, or flat head syndrome.
    • A physical therapist who is a board-certified specialist in pediatrics, or who has completed a residency in pediatric physical therapy. This physical therapist has advanced knowledge, experience, and skills that may apply to working with children.

    You can find physical therapists who have these credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

    General tips when you are looking for a physical therapist (or other health care provider):

    • Get recommendations from family and friends or from other health care providers.
    • When you contact a physical therapist practice for an appointment, ask about the physical therapists’ experience in working with children with CBS.
    • Check the physical therapist’s website, which may have information on training and experience.
    • During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible.
     

    Further Reading

    The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for a visit with their health care provider.

    The following articles provide some of the best scientific evidence related to physical therapy treatment of individuals who have container baby syndrome. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked to a PubMed* abstract of the article, or to free full text so that you can read it or print out a copy to bring with you to your health care provider.

    American Academy of Pediatrics. What to look for tool. Does my child have physical developmental delays? Accessed November 28, 2018.

    Centers for Disease Control and Pevention. Learn the signs. Act early. Accessed November 28, 2018.   

    Lack of “tummy time” leads to motor delays in infants, PTs say [media release]. Alexandria, VA; June 3, 2013. Accessed November 28, 2018.

    Coulter-O’Berry C, Lima D. Tummy time: tips for parents. MoveForwardPT.com.  Accessed November 28, 2018.

    van Wijk RM, Pelsma M, Groothuis-Oudshoorn CG, IJzerman MJ, van Vlimmeren LA, Boere-Boonekamp MM. Response to pediatric physical therapy in infants with positional preference and skull deformation. Phys Ther. 2014;94(9):1262–1271. Free Article..

    McCullough A. Diagnosing flat head syndrome. Primary Health Care. 2013;23(5). Article Summary Not Available in PubMed.

    Flannery AB, Looman WS, Kemper K. Evidence-based care of the child with deformational plagiocephaly, part II: management. J Pediatr Health Care. 2012;26(5):320–331. Free Article.

    Robinson S, Proctor M. Diagnosis and management of deformational plagiocephaly. J Neurosurg Pediatr. 2009;3(4):284–295. Article Summary in PubMed.

    Persing J, James H, Swanson J, et al. Prevention and management of positional skull deformities in infants: American Academy of Pediatrics Committee on Practice and Ambulatory Medicine, Section on Plastic Surgery, and Section on Neurological Surgery. Pediatrics. 2003;112(1 Pt 1):199–202. Free Article.

    Hunziker U, Barr R. Increased carrying reduces infant crying: a randomized controlled trial. Pediatrics. 1983;77:641–648. Article Summary Not Available on PubMed.

    * PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.

    Revised by Chandi Edmonds, PT, DPT, board-certified pediatric clinical specialist. Authored by Andrea Avruskin, PT, DPT. Reviewed by the MoveForwardPT.com editorial board.

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