Front Facing Out – A bad reputation deserved?

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Front facing out amongst babywearers has long been debated, questions still surround whether or not it’s a good idea, or if doing so will cause long term ramifications for either parent or child. The problems arise because it’s not something that can be studied in a controlled way. Long term effects can only be known from studying parents and children and relying on information passed on from those parents. Front facing out (FFO) is a relatively new practice only really being taken up over the past 10 years or so, but in that time there has been no proof that it is contributing to any discourse in babies. Although we know through lots of other studies than optimum practice is always going to be better for both parent and child.

I want to explore some of the current thoughts on FFO and challenge whether or not these thoughts have some truth, or if FFO in time will be an acceptable way of carrying.

Front Facing Out is the term used when a parent holds, or has a baby in a position with the baby’s back to the parent’s front, so the child is facing the same way as the parent.  There are only a few carriers that actively sell FFO as a feature. And general consensus with babywearers is FFO is not something that is advised. However this trend is changing as carriers are becoming more aware of the importance of good ergonomic positioning.

Hip Positioning Concerns

One of the most commonly thought problems with FFO is the challenge of getting the child’s legs in M positioning and supported from knee-pit to knee-pit. We know from front facing in that M positioning is that of which a baby assumes in the womb, and therefore from an evolutionary stand point is what we want to continue to emulate outside of the womb.

M positioning ensures that the hips of a child stay deep into the hip socket and at optimum angle for proper development, however it’s worth noting that even if this isn’t the case there is no evidence that it will cause malformation in a healthy hipped child.

FFO in most carrier’s means that the M position is harder to achieve and maintain, as the parents body is behind the child as opposed to in front, also gravity drags each heavy limb down without a sturdy surface to keep the leg supported at the knee-pit.

Spinal Concerns

The spine of a child is slightly curved and this means that gravity will pull the child’s head and neck forward, bringing the spine into a more pronounced C shape, which could, in younger children with lesser head and neck control, excerpt pressure further down the back or in the worst case scenario force the chin onto the baby’s chest and cause asphyxiation. The parent’s body is also shaped to accommodate a child facing toward them, rather than away from them. Especially evident in the mother with her breasts positioned high enough so that the curl of her infant is high enough for the face to be seen clearly, with legs able to curl up on the mother’s abdomen and later round her waist. Breasts also have the capability for increasing or reducing temperature in response to thermological baby’s need. A baby also has a higher fat content on its back which is thought to help insulate a child’s body heat from escaping when it’s positioned to face its mother.

Overstimulation

There is also some evidence that suggests when FFO, a child will become overstimulated rapidly as they have no way of shielding themselves from a barrage of sight and sound. For a younger child this is going to have some impact as they have nowhere to turn and hide from if it gets too much. A parent would need to be very aware of the cues that over stimulation is occurring, which will be relatively harder if you can’t see the child’s face. Unlike in-arms carrying facing out, where you can feel the subtle changes in body posture and tension, in a carrier it will be infinitely more difficult, but of course not impossible.

Early Cues for overstimulation would include:

  • Turning head to side
  • Covering face
  • Wiggling
  • Touching ears
  • Zoned Out/Blank Stare

Later Cues would include:

  • Increased fussing
  • Tired/Cranky
  • Jerky movements
  • Clenched fists
  • Arching back

One way to avoid overstimulation would be to limit the time spent FFO. Currently Ergo suggest a child only be front facing out for a maximum of 10-15 minutes. Whereas Boba do not advocate this at all. As a parent you will be able to decide for yourself the minimum/maximum time for your baby. All babies are different some will tolerate a lot more stimulation than others, knowing cues and responding accordingly will allow a parent to assess the impact FFO is having on your child minute to minute.

Does FFO really cause hip issues?

Another hot debate point of FFO is the link to hip dysplasia and whilst on the face of it, it does seem plausible that narrow base carriers and FFO may cause this as suggested by The Hip Dysplasia Institute, it is explained by a very compelling article called ‘Healthy Hips’ written by Babywearing Consultant and GP, Rosie Knowles,  that the likelihood of hip issues being caused by less than optimum hip positioning is very slim, unless of course you have underlying hip issues, in which case you would not be advised to wear FFO.

Whilst it is clear that a fully supported seated squat with legs supported in the M positioning is going to be the most optimum way of carrying a child in a sling, the limited time a child will spend FFO, in most cases will not cause any detrimental harm to the child.

What about spine issues?

This leads well onto how well a child’s back and spine are suited to FFO, its useful to know a bit more about spine physiology to be able to ascertain the potential pitfalls. A baby is born with a completely curved spine which is C in shape (Kyphosis). Its head which is large in comparison to its small body will be heavy and with no muscle tone to hold it up, will need supporting. Over the first year the child’s spine under goes major changes until it achieves the Lordotic curves of an adult, which consist of 4 curves at the neck (cervical), mid-back (thoracic), lower back (lumber) and base of spine (sacrum). These curves are achieved at various points over a child’s development in the first year. The cervical curve starts to form in the first few months as baby learns to hold its head up. At around 6-8 months as baby begins to sit up the thoracic region begins to form and finally as baby begins to pull up onto its knees and crawl the Lumbar curve starts to form and around the time of walking the spine will have fully formed all curves, which in most cases is around the one year mark.

FFO for young babies with no head or neck control is dangerous, without this control the weight of the baby’s head will cause its chin to drop onto it chest and puts baby at risk of asphyxiation. So for this reason it’s not suggested a child is FFO until they have very good head control which can be around 4-6 months of age, depending on baby’s development.

Wearing a child in front facing out, who is still very much developing its spine is going to put unnecessary stress on the lumber region of the spine. Baby’s spine, which is most likely still going to be curved, will be forced prematurely straight due to the adult’s front being flat or slightly bulbous. Given that the spine protects the nervous system and compression of this could affect the information being transported through it. Coupled with the gravitational force of their legs being pulled down, if nothing more, cannot be the most comfortable position, at worst could disrupt information travelling through which in turn would cause baby distress. Gravity will also be forcing the baby’s weight forward and will be concentrating it onto the groin area of the child, similar to an adult in a climbing harness, leading to chaffing and pressure.

There is no evidence that this will cause long term damage especially given that some parent do this in-arms regularly. This could be compensated for however, by offering the child Buddha positioning, where the legs are encouraged into a crossed position and allows baby’s spine to curve with hips and legs in a more optimum position in a wrap or ring sling.

Currently there are a few brands that offer FFO with their carriers, although some are thought to offer a more optimum experience than others:

  • Ergo 360
  • Beco Gemini
  • Catbirdbaby
  • Lillebaby
  • Baby Bjorn
  • Stokke
  • Caboo
  • Kari-me

Comfortability for parent

We have covered many aspects of how FFO could affect baby but what about the parent?

FFO is always never going to offer the same comfortability factor as facing in. Mainly due to the fact that facing in, the baby’s weight is going to against the wearer therefore, distribution of the weight will be through a mixture of shoulders, torso and waist through the legs to the floor. In FFO position gravity will be pulling the weight out and down mostly from the shoulders, which is going to force the wearer to assume a more curved posture, putting strain on the neck, shoulders and cervical curve.

If you are wearing for shorter periods in line with listening out for overstimulation in baby, this could be tolerable, however longer attempts may result in pain or discomfort for some.

The centre of the wearer’s gravity will also shift, which will make baby feel a lot heavier than if the baby was facing in, also there is a greater chance of the wearer becoming off balance and the risk of falling will be increased. It’s also worth noting that a mother who has recently given birth will still be subject to having increased levels of the hormone relaxin in their bodies, which is the hormone that allows the pregnant body to expand to accommodate a growing uterus, putting them at a greater risk of injury for up to a year after giving birth.

Other factors when FFO

FFO in most cases will leave the wearer feeling a greater need to protect baby and have one hand supporting baby, making FFO a less ‘hands free’ option, which is one of the main reasons parents carry their children – to free up their hands, still have baby close and get on with the challenges of life with both hands.

Many baby’s around the 4 month mark will start to become very interested in the outside world and will often crane their neck to see behind them, leaving parents feeling FFO is a better option.  It’s worth considering whether or not other positions are a more viable option. For example a hip carry would allow baby to stay in optimum positioning, it would allow them to be able to see outward from side to side and still be able to face the wearer if they become overwhelmed or needed to sleep. You would be able to share the world with baby in a hip carry, chat to them about what you both see and point out interesting things that are in view and baby will be able to read your cues, learning from you and the world around them. FFO is relatively harder for baby to be able to gauge your reactions and as they cannot see your face it will making learning from you and your facial expressions impossible.

You could also offer a high back carry, that way baby can see the world from an adults height, they can see to the front lessening the need for them to crane their neck, and have the ability to hide away if it became too much or to sleep.

There are many things to consider when deciding to FFO and with no concrete evidence to show FFO could harm a child, it’s important to assess your own reasons to want to do it, making sure that your child will be safe, secure and happy. Its worth investing in a carrier that offer more optimum positioning, like the Ergo and Lillebaby but if this is not possible really listening to your child while FFO would be advantageous for both the wearer and the child. Have fun babywearing, be aware of the babywearing TICKS and where possible try to make sure you are following them as much as you can. Safety and well-being are paramount.

 

References:
Kirkilonis, E. (2014). A baby wants to be carried
International Chiropractic Pediatric Association. Baby Wearing: Suggestions for Carrying your Baby.http://icpa4kids.org/Wellness-Research/baby-wearing-suggestions-for-carrying-your-baby.html
Sheffield Sling Surgery. Healthy Hips. http://sheffieldslingsurgery.wordpress.com/2013/09/19/healthy-hips-busting-some-myths/
Hip Dysplasia Institute. Hip Health in baby carriers, car seats, swings, walkers, and other equipment. http://hipdysplasia.org/developmental-dysplasia-of-the-hip/prevention/baby-carriers-seats-and-other-equipment/
Boba baby carriers. Nine Reasons Not to Carry Your Baby Facing Outhttp://www.boba.com/blog/2011/10/11/nine-reasons-not-to-carry-your-baby-facing-out/
Ergo Baby Carrier blog. Front-Outward Position. http://www.ergobaby.eu/blog/360carrier/
Everything Mom and Baby. Article written by Dr Maya Pande.http://www.everythingmomandbaby.com/2012/05/how-carrying-your-baby-front-facing-out.html
SlingGuide. About facing out. http://slingguide.co.uk.gridhosted.co.uk/safety-advice-links/about-baby-facing-out/
Raising Children Network. Overstimulation. http://raisingchildren.net.au/articles/overstimulation.html
Senseable Baby. Our baby. http://www.sense-ablebaby.com/Our_Baby.html
Ergobaby. Signs of overstimulation. http://blog.ergobaby.com/2014/04/is-it-too-much-baby-signs-of-over-stimulation/
Image:
Used with permission from Sheffield Sling Surgery
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