Research Report
Baby-Carrying Method Impacts Caregiver
Postural Sway and Pain During Prolonged
Standing
Erin M. Mannen, PhD1,2
Kathryn L. Havens, PhD3
Alexandra Kahney, SPT2,4
Erika Nelson-Wong, PT, PhD4
ABSTRACT
Background: Infant carrying is necessary for caregivers
of babies. While in-arms carrying of infants is common,
babywearing offers hands-free infant transport. Postural
impacts of carrying methods are unknown.
Objectives: Goals of this biomechanics study were to
quantify differences in women holding infants in arms and
in baby carriers compared with unloaded conditions dur-
ing prolonged standing, and subgroup women into those
who develop pain during standing (PDs) and those who
do not (NPDs) to investigate differences in responses to
baby-carrying conditions.
Study Design:  Single-subject design.
Methods: Ten healthy nulliparous females (aged 27.4 ±
4.1 years) performed 15-minute quiet standing trials with
each foot on a force plate in 3 conditions: holding nothing
(unloaded), holding an infant mannequin in arms (arms),
and holding an infant mannequin in a baby carrier (car-
rier). Participants completed a 10-cm Visual Analog Scale
for pain before and after each trial.
Results:  Thirty percent of participants reported pain in the
unloaded and carrier conditions compared with 50% in the
arms conditions. Participants shifted their weight more fre-
quently, spent more time in asymmetrical stance, and had
1Department of Orthopaedic Surgery, College of Medicine,
University of Arkansas for Medical Sciences, Little Rock.
2University of Denver, Denver, Colorado.
3Division of Biokinesiology and Physical Therapy,
University of Southern California, Los Angeles.
4College of Physical Therapy, Regis University, Denver,
Colorado.
Conflicts of Interest and Source of Funding: This study was
funded by Ergobaby, Inc., and National Institute of General
Medical Sciences of the National Institutes of Health under
Award Number P20GM125503. The funding sources had
no influence in study design, experimentation, analysis, or
manuscript preparation.
Corresponding Author: Erin M. Mannen, PhD, University
of Arkansas for Medical Sciences, 4301 West Markham St,
Slot 531, Little Rock, AR 72205 (emannen@uams.edu).
DOI: 10.1097/JWH.0000000000000163
Journal of Women’s Health Physical Therapy © 2020 Academy of Pelvic Health Physical Therapy, APTA
Copyright © 2020 Academy of Pelvic Health Physical Therapy, APTA. Unauthorized reproduction of this article is prohibited.
Research Report
larger sway areas in the arms condition. When examining
the PD versus NPD subgroups, PDs remained more station-
ary in all conditions, though the carrier caused PD partici-
pants to weight shift more often, a positive change for PDs.
Conclusion: In-arms carrying altered postural sway com-
pared with the unloaded condition, while using a baby
carrier provided more similar biomechanics compared
with the unloaded condition. Participants exhibited less
reported pain using the baby carrier, and caregivers who
develop pain during standing may find additional benefits
from babywearing.
Key Words: attachment parenting, child holding, infant
transport, low back pain, mother-infant proximity
INTRODUCTION
Babywearing, the practice of transporting an infant
or child in a carrier on the body, provides physical
closeness of an infant to the mother or caregiver. The
infant-mother proximity has been shown to have
emotional, physical, and physiological benefits for the
baby in both animal and human species. Stemming
from survival instincts, separation from the mother
is viewed as a life-threatening situation for offspring,
causing them significant distress.1 Maternal carrying
of the offspring has been shown to trigger a calming
response demonstrated by central, motor, and cardiac
signals in distressed infants.2,3 In addition, skin-to-
skin contact of premature human babies with their
mothers or other caregivers, called kangaroo care,
has been shown to decrease infant mortality rates,
increase breastfeeding success, reduce agitation and
sleep apnea, and improve infant respiratory and tem-
perature regulation.4–8 Furthermore, a separate study
has linked babywearing to a decreased likelihood of
hip dysplasia in infants and young children.9
Babywearing allows the caregiver to be physi-
cally close to the baby while remaining hands-free.
Physical closeness benefits the mother as well as
the baby. Mothers across species show increased
47
 Research Report
oxytocin levels, responsiveness, and breast milk pro-
duction when in close proximity to their infants.3,10
Babywearing offers mothers the benefits associated
with infant proximity without the energetic burden
of using arms to carry.11 New research highlights
the strength of the mother-infant bond attributed to
utilizing an infant carrier for as little as 1 hour each
day.12 Two recent studies have identified biomechani-
cal advantages for the caregiver of holding an infant
with an aid (sling or carrier) compared with in-arms
carrying during walking.13,14 However, the postural,
fatigue, and biomechanical effects of infant-carrying
methods on the woman’s body during other tasks of
daily living such as standing have not been studied.
Low back pain (LBP) is of particular concern for
this population. Females are at an especially increased
risk for LBP during pregnancy and postpartum, with
45% to 72% reporting LBP during their first preg-
nancy, increasing to 85% to 94% with subsequent
pregnancies.15–17 Standing for prolonged periods has
been shown to induce LBP in 40% to 70% of other-
wise healthy people,18–21 and transient LBP develop-
ment during standing is predictive for future clinical
LBP.22 People who develop LBP during standing have
consistently demonstrated biomechanical differences
from those who do not, indicating suboptimal con-
trol strategies that may be considered risk factors for
LBP.18,19,23 Standing is a critical component of many
tasks of daily living, which caregivers of small chil-
dren must accomplish while holding or carrying the
infant. One previous survey study has examined mus-
culoskeletal disorders in relation to traditional infant-
carrying methods of Nigerian mothers, finding that
back-carrying results in the most LBP during daily
life compared with other infant-carrying methods.24
However, the impact of different methods of infant
carrying on standing-induced LBP or risk factors for
LBP has not been investigated.
The goal of this study was to quantify the postural
differences of females holding infants in arms and in
baby carriers compared with an unloaded condition
during prolonged standing. We hypothesized that car-
rying an infant in a baby carrier and in arms would
cause differences in postural sway and asymmetrical
loading parameters when each were compared with
an unloaded condition. A secondary goal was to
subgroup females into those who develop LBP during
standing (PDs) and those who do not (NPDs) to inves-
tigate potential differences in biomechanical param-
eters and responses to baby-carrying conditions.
METHODS
Participants
Ten healthy females of childbearing age (27.4 ± 4.1
years), healthy body mass index (21.5 ± 2.5 kg/m2),
48 © 2020 Academy of Pelvic Health Physical Therapy, APTA
Copyright © 2020 Academy of Pelvic Health Physical Therapy, APTA. Unauthorized reproduction of this article is prohibited.
and no previous babywearing experience volunteered
from the university population to participate in this
institutional review board-approved study (University
of Denver, Denver, Colorado). Exclusion criteria
included pregnancy within the past 9 months, ortho-
pedic- or musculoskeletal-related disorders, chronic
LBP, and neurologic disorders; all participants ver-
bally confirmed that no exclusion criteria were met
prior to enrollment in the study. Before participating,
subjects were informed of the testing procedures and
provided written informed consent.
Instrumentation
Two 40 × 40-cm force plates embedded into the
floor (Bertec, Columbus, Ohio) were used to capture
ground reaction forces under each foot during the
testing at 1000 Hz, similar to previous prolonged
standing biomechanical studies.23
Procedures
All testing took place at the University of Denver,
Denver, Colorado. Participants’ age, height, and
weight were recorded. The Chalder Fatigue Scale, a
commonly used self-administered questionnaire with
high reliability of 0.83 to 0.90,25,26 was administered
to determine whether participants exhibited mental
or physical fatigue.27
Participants performed 15-minute quiet standing
trials where they were instructed to look forward and
stand comfortably with 1 foot on each force plate in
3 conditions: holding nothing (unloaded), holding
an infant mannequin (6-month-old; Dietz, Freiburg,
Germany) in arms (arms), and holding an infant
mannequin in the baby carrier (carrier) (Figure 1).
Trials were of 15 minutes’ duration, as this length
of time was chosen because it has previously been
shown to be a long enough time to predict back pain
in prolonged standing studies.28 Participants were not
told to maintain a specific foot position throughout
the testing, but only to remain standing comfortably
with 1 foot on each force plate to replicate a real-life
scenario. For the arms condition, participants were
instructed to hold the mannequin as if it was a real
baby who has good head control. Carrying strategy
and position were self-selected by participants. For
the carrier condition, participants self-fit the baby
carrier after watching an instructional video from
a certified babywearing consultant explaining cor-
rect techniques for fitting the All Position 360 soft-
structured baby carrier (Ergobaby, Los Angeles,
California). They practiced fitting the baby carrier
with an inward-facing infant mannequin on them-
selves prior to the standing trials.
Trials were conducted in a random order for each
participant. Before and after each 15-minute trial,
participants completed a 10-cm Visual Analog Scale
Volume 44 • Number 2 • April/June 2020
 Research Report

Figure 1. Experimental setup of one participant in the (A) unloaded condition, (B) carrier condition, and (C) arms condition.
This figure is available in color online (https://journals.lww.com/jwhpt).

(VAS) survey for pain and discomfort described in
3 regions: back, hips, and legs.29,30 If a participant
reported pain of greater than 6 cm on the 10-cm VAS
at any point during the testing, the participant would
be asked to discontinue participation in the study to
prevent further discomfort. Participants were given
approximately 5 minutes to sit and relax between tri-
als to ensure they were well rested.
Data Analysis
Symmetrical stance was defined as the participant
standing with 50% ± 15% of their weight on each
force plate, as determined from weight-normalized
vertical ground reaction force recordings. Weight
shifts were defined as shifts of more than 65% of
body weight or body weight plus infant mannequin
onto 1 leg for more than 1 second,23 determined
using custom Matlab scripts (version R2016b; The
MathWorks, Inc, Natick, Massachusetts). Average
weight shift frequency was calculated by determining
the total number of weight shifts during the 15-min-
ute trial and dividing by time. Percent time in asym-
metrical stance was defined as the amount of time
in asymmetrical stance divided by total time in trial,
multiplied by 100. Postural sway parameters were cal-
culated from the force plate data using custom Matlab
scripts and included center-of-pressure (COP) path
length, 95% confidence ellipse sway area, and medial-
lateral (ML) and anterior-posterior (AP) excursions,
and root-mean-squared (RMS) or sway variability.
Journal of Women’s Health Physical Therapy © 2020 Academy of Pelvic Health Physical Therapy, APTA
Copyright © 2020 Academy of Pelvic Health Physical Therapy, APTA. Unauthorized reproduction of this article is prohibited.
Secondary Analysis: PD Versus NPD
Because there was a clear divide in VAS scores
between participants, we grouped participants into
those who developed pain (PDs) during any testing
condition (a >1-cm increase in VAS score during any
standing condition) and those who did not develop
pain (NPDs).18,19
Statistics
Test of normality determined that nonparametric tests
were appropriate for the variables of interest. To deter-
mine whether participants were properly rested between
trials, VAS scores at time 0 were compared between the
3 carrying conditions (unloaded, carrier, and arms) using
nonparametric Friedman tests (α ≤ .05). Nonparametric
Friedman tests were used to determine whether differ-
ences exist between carrying conditions for the postural
sway variables or weight shift variables (α ≤ .05). When
a significant main effect was identified with a Friedman
test, post hoc Wilcoxon signed ranks tests were used
for pairwise comparisons, with significance adjusted
for multiple comparisons (α ≤ .05/3 ≤ .017). Effect
sizes were calculated from post hoc Wilcoxon tests. All
statistical analyses were performed using SPSS software
(version 18; SPSS, Inc, Chicago, Illinois).
RESULTS
In this study, we aimed to quantify the postural
differences of females holding infants in arms and
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 Research Report

Figure 2. Box plots of (A) weight shift frequency (number of shifts per minute) and (B) asymmetric stance time (%) for all
participants in all conditions, *P < .017. This figure is available in color online (https://journals.lww.com/jwhpt).

in baby carriers compared with an unloaded condi- Postural Sway

tion during prolonged standing. Our secondary goal
was to explore biomechanical differences in PDs
compared with NPDs in response to baby-carrying
conditions.
Baseline
All participants scored 3 or less on the Chalder
Fatigue Scale (1.0 ± 1.2), indicating no underlying
mental or physical fatigue. No significant difference
was found in the VAS scores prior to any testing
condition, indicating individuals were properly rested
between trials. No individuals reached a 6-cm score
on any VAS and therefore all completed testing.
Weight Shift
A statistically significant difference was found between
conditions in weight shift frequency (χ22 = 7.467, P =
.024), although pairwise comparisons did not reach
significance (P > .017) (Figure 2A). A statistically
significant difference between all condi­tions in per-
cent time in asymmetrical stance was found (χ22 =
10.903, P = .004) (Figure 2B). Individuals spent sig-
nificantly more time in asymmetrical stance during the
arms condition than in the unloaded condition (P =
.012), with a large effect size (r = −0.80).
A statistically significant difference between all condi-
tions for sway area was found (χ22 = 7.8, P = .02)
(Figure 3A). When compared with the unloaded
conditions, individuals exhibited significantly greater
sway area in the arms condition (P = .017), with
large effect size found (r = −0.76). A statistically sig-
nificant difference between conditions for ML sway
variability (RMS) was found (χ22 = 7.8, P = .02)
(Figure 3B). When compared with the unloaded con-
ditions, individuals exhibited significantly greater ML
sway variability (RMS) in the arms condition (P =
.013), with a large effect size (r = −0.79). Friedman
tests did not identify statistically significant differ-
ences between conditions for COP path or AP sway
variability (P > .05).
Secondary Analysis: PD Versus NPD
Immediately following the 15-minute trial, 3 of 10
individuals in the unloaded condition, 3 of 10 indi-
viduals in the carrier condition, and 5 of 10 individu-
als in the arms condition reported an increase in pain
(a >1-cm increase in VAS score) in at least 1 region
of the body. Therefore, 5 participants were classified
as PDs and 5 were NPDs. A post hoc power analysis
comparing PD versus NPD time shifted revealed that

Figure 3. Box plots of (A) sway area (cm2) and (B) medial-lateral root-mean-squared (mm2) for all participants in all condi-
tions. aP < .017. ML indicates medial-lateral; RMS, root-mean-squared. This figure is available in color online (https://
journals.lww.com/jwhpt).
50 © 2020 Academy of Pelvic Health Physical Therapy, APTA Volume 44 • Number 2 • April/June 2020
Copyright © 2020 Academy of Pelvic Health Physical Therapy, APTA. Unauthorized reproduction of this article is prohibited.

Figure 4. Box plots of (A) weight shift frequency (number of
shifts per minute) and (B) time in asymmetrical stance (%)
for all conditions comparing participants who develop pain
(solid bars) with those who do not develop pain (hatched
bars). PD indicates pain developers; NPD, nonpain devel-
oper. This figure is available in color online (https://journals.
lww.com/jwhpt).
our n = 5 per group sample only reached a power of
1 − β = 0.46 and that group sizes of n = 10 were
required to achieve sufficient power (1 − β > 0.80).
Because this secondary analysis was underpowered,
only descriptive statistics are provided.
In the unloaded condition, NPDs shifted their
weight 20 times more frequently and spent 36 times
longer in asymmetrical stance than PDs (unloaded
condition; Figure 4). For the PD group, the arms con-
dition caused an increase in both frequency and time
shifted by a factor of 3 compared with the unloaded
condition, whereas the carrier condition caused a
5-times increase in frequency of shifts and a 10-times
increase in time spent in asymmetrical stance com-
pared with the unloaded condition (Figure 4). For the
NPD group, each carrying condition increased sway
frequency compared with the unloaded condition by
a factor of 3 for the carrier and a factor of 4 for the
arms. Both the carrier and arms conditions nearly
doubled the time spent in asymmetrical stance com-
pared with the unloaded condition. Little difference
was observed between carrying styles for NPDs.
DISCUSSION
Primary Implications
Caregivers spend hours each day holding and trans-
porting infants.31 As with any load-carrying scenario,
understanding the biomechanical impact of different
carriage methods is the first step in optimizing the
task and reducing injury risk for the caregiver. In our
study, we analyzed the effects on postural control of
2 common infant-carrying methods: in arms and in
Journal of Women’s Health Physical Therapy © 2020 Academy of Pelvic Health Physical Therapy, APTA
Copyright © 2020 Academy of Pelvic Health Physical Therapy, APTA. Unauthorized reproduction of this article is prohibited.
Research Report
a soft-structured baby carrier. Overall, utilizing the
soft-structured carrier to hold an infant mannequin
provided a more biomechanically similar experience
to an unloaded condition in contrast to carrying
in arms, which was significantly different from the
unloaded condition during prolonged standing.
When compared with the unloaded condition,
individuals carrying in arms had greater asymmetri-
cal stance time, sway area, and ML sway variability.
Taken together, these suggest a more destabilizing
pattern during stance for in-arms holding. In contrast,
the carrier condition resulted in more similar postural
control variables to the unloaded condition. These
differences between the arms and carrier conditions
compared with unloaded are interesting, given that
the load magnitude of the infant mannequin did not
change, only the holding method.
Interpretation of postural sway patterns is chal-
lenging. On the one hand, we know that too much
motion during standing may indicate instability and
balance problems; on the other hand, too little
motion is linked to pain development.28 There is
likely an optimal range of weight shifting and COP
motion that avoids the drawbacks of both too much
and too little postural sway; however, those threshold
values have not been defined in the literature. The
increased sway area and ML sway variability during
the in-arms condition may indicate that stabiliza-
tion during this condition is more challenging, as the
woman sways more often to maintain her center of
mass over her base of support. However, without a
carrier holding the infant in place, the caregiver can
shift the weight of the baby during standing, which
may reduce fatiguing effects on the lower extremi-
ties. One clear benefit of babywearing is the ability
to remain hands-free. Without the need to hold the
baby with at least 1 arm, caregivers may be more
able to complete activities of daily living or to catch
themselves if they were to lose their balance.
Pain Developers Versus Nonpain Developers
While all participants in this study were healthy and
did not have clinically diagnosed orthopedic condi-
tions, some did develop pain while standing for a pro-
longed period. While unloaded, individuals who did
not develop pain in this study shifted their weight more
frequently and spent more time in asymmetrical stance.
This is consistent with previous research demonstrat-
ing that NPDs have greater weight shift frequency
than PDs.28 Female NPDs have also been shown to
have greater asymmetry in weight shifting than female
PDs during prolonged standing trials.23 Furthermore,
decreased weight shift frequency in the first 15 min-
utes of standing has been shown to be predictive of
LBP development with continued standing duration.28
Thus, our results are consistent with previous research
51
 Research Report
suggesting that PDs remain more stationary during
prolonged standing than NPDs and further support
that PDs may benefit from increasing the time and fre-
quency of weight shifting during prolonged standing to
reduce the risk of pain development.28,32
When considering the infant-carrying method in
each group, little difference was found in the NPDs,
but carrying method did affect the observed biome-
chanics in the PD group. The carrier condition result-
ed in the highest frequency and time spent weight
shifted for the PD cohort, with weight shifting mea-
sures approaching those of the NPDs in the unloaded
condition. Thus, PDs may be more sensitive to an
optimized and centered load that may allow for more
freedom of movement. While we are unable to draw
definitive conclusions based on these findings due to
a small sample size, the carrying method appears to
have a different impact on PDs compared with NPDs,
and we suspect that the use of an infant carrier may
be more beneficial for PDs. The VAS scores support
the idea that increasing weight shifting may benefit
PDs during load carriage, as only 3 of 10 participants
reported pain or discomfort during the carrier trial
compared with 5 of 10 during the arms trial.
Considerations
Although not exclusionary for enrollment in this study,
no participant had children. Junqueira et al33 did not
find significant differences in postural changes between
mothers and nonmothers during quiet stance with
infants held in arms symmetrically at the front of the
trunk. Participants in our study were not directed to
hold the infant mannequin in any specific way, so it is
possible that mothers with experience holding infants
may utilize different postural strategies when compared
with nonmothers. In addition, infant mannequins were
used instead of living babies in the current experiment,
and previous research has reported that mothers car-
rying their actual infants had slightly different spinal
angles compared with carrying infant mannequins.33
While spinal angle differences were less than 2°, it
is possible that utilizing living infants in our study
would have produced varying results in all measures.
However, we concluded that utilizing living infants
would introduce a myriad of unnecessary variables for
our study. Furthermore, our study limited the infant
size to that of a 6-month-old baby. Caregivers likely
utilize different carrying strategies based on infant size,
age, and musculoskeletal development.
Although participants were able to watch the
instructional video to appropriately fit the carrier
as many times as they wanted, it was observed that
many had questions as to the correctness of the fit
of the carrier. The research team did not provide the
participants with input regarding the fit of the carrier,
but future studies should consider using a certified
52 © 2020 Academy of Pelvic Health Physical Therapy, APTA
Copyright © 2020 Academy of Pelvic Health Physical Therapy, APTA. Unauthorized reproduction of this article is prohibited.
babywearing instructor to check for appropriate posi-
tioning of the carrier. Similar to the documented ben-
efits of a lactation consultant for postpartum nursing
mothers on breastfeeding duration and success,34
appropriate in-person babywearing instructions to
new mothers or caregivers may further improve the
biomechanical advantage provided by baby carriers.
In addition, a variety of carrier types and carrying
styles exist in the marketplace: unstructured slings,
structured carriers, forward-facing and inward-facing
carriers, backpack carriers, and more. The carrier
used in this study was chosen in part because it is a
commonly used device and has been named a “hip-
healthy” carrier by the International Hip Dysplasia
Institute as the design may optimize the hip position-
ing of infants. Furthermore, front-carrying of infants
has been shown to result in fewer musculoskeletal
problems for the caregiver than back-carrying of
infants, possibly due to the weight distribution of
front-carrying being similar to that during pregnan-
cy.24 Although no previous research has been done
on the impact of carrier type on balance parameters
of the caregiver during standing, the results of our
study suggest that symmetric front-carrying with a
soft-structured infant carrier may play an important
role in reducing the biomechanical impact of holding
an infant during prolonged standing, particularly for
those females who develop LBP. Clinically, provid-
ers should consider how baby-carrying method may
impact their individual patients, particularly those
who may be susceptible to back pain.
Future studies should expand upon our prolonged
standing pilot study to examine the impact of the many
different infant-carrying methods on a variety of activi-
ties of daily living. As our sample size limited our inter-
pretation of pain results, future studies could incor-
porate individuals with LBP. It is also critical to study
postpartum mothers carrying infants, as this popula-
tion is most likely to be impacted by infant-carrying
methods. Finally, as more males and grandparents
are becoming primary caregivers of infants, this study
should be expanded to also include these populations.
CONCLUSION
Regardless of the biomechanical cost, mothers will
continue holding and transporting infants until the
end of time. The results of this study suggest that
babywearing may offer the caregiver a biomechanical-
ly advantageous way to hold infants during prolonged
standing, particularly for those who develop pain.
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