Baby Swaddling was an art that I practiced for hours upon hours years ago when I was an overnight baby nanny and when I became a Postpartum Doula – way before I was a Parent Coach and Breastfeeding Educator. This was when swaddling first came back into fashion. It was all the rage! It was helping babies sleep longer and then sleep sacks were released to the market as a way to have something to contain a now bigger baby when they were too wily to stay in a swaddle. But it turns out that both of these were causing some problems.
Helping families with infant sleep specifically for over 10 years now, I have become less fond of swaddles and sacks. And everyone is asking me, “Should we, or shouldn’t we, swaddle or use a sleep sack?” The answer isn’t super clear, even for me. Each family and baby is unique and truly some babies really love to be swaddled or in a sack. But do I recommend to every family? Recently, three different swaddle or sleep sack companies have asked me to endorse them. That could be financially beneficial to me but I’ve said no thank you and here’s why:
1) Possible Hip Dysplasia. In 2011, a study by the National Resource Center on Child and Health Safety (NRC) and the American Academy of Pediatrics (AAP) concluded that swaddling can increase the risks of “serious health outcomes” and they concluded that “swaddling is not necessary or recommended” in any childcare setting*. Those serious health outcomes concluded that swaddling had long carried a known risk of hip dysplasia. Hip dysplasia used to be very common until swaddling went out of fashion in the 80’s. These new recommendations by the AAP were meant mainly for daycare centers but were otherwise mostly ignored and we see at least 10 new swaddle products on the market each year.
2) Restriction of movements, feeding cues, and unnatural positioning. A baby may be able to roll from back to tummy while swaddled but then they will not have the use of the limbs to roll into an airway-unrestricted position. This is a sleep death risk. Once a baby can roll over, he needs full use of his entire body, both in order to know how to use it to his advantage day and night, and this includes to help him turn his body away from something else which might be suffocating him.
The way babies are swaddled in the Harvey Karp 5-S way has baby’s hands down at her sides but is not a natural position for any new baby. Babies are born to be in a state of flexion, with elbows always bent and nearer the chest and mouth. A newborn baby who may be seen without a swaddle but has her hands down long at her sides is likely to be in some kind of neurological distress. If you do swaddle a baby to calm them, you can do so with the hands across chest and elbows bent which is a very helpful position if a baby is over-hungry and crying and needs to get onto the breast. As parents are now learning the calming skin-to-skin and anthropological “laid back” breastfeeding positions and babywearing and as we know how to read feeding cues earlier, we no longer have such a need for Harvey Karp’s “Happiest Baby” techniques like swaddling to calm babies. There are more biologically aligned ways to keep babies calm.
3) Baby cannot find fist. Before babies cry from possibly being over-hungry, babies show us they’re ready to eat now by sucking or licking a fist. We cannot see this if baby cannot reach the fist. Unrestricted movement includes finding the fist easily (which is really the only way that new babies will ever “self-soothe”). If you must swaddle to calm a baby who is already crying but is not hungry, consider a hands-up swaddle position so you can see when baby is hungry.
4) The chest wall can become compressed. Which can impede breathing. When you swaddle, make sure you can easily get two fingers between the chest fabric and the baby’s skin but that it isn’t much more loose than that.
5) Possible suffocation. With a blanket swaddle, babies DO get hands free. That hand could bring the swaddle blanket up over the face which is a suffocation risk.
A sleeping sack is generally used for older babies after a swaddle no longer works, and for older babies, this is a much safer option – the blanket cannot get pulled over the head, the arms are free etc. A sleeping sack is not tight and is not effective though for the hug swaddling that some babies love. Update: AAP confirms swaddling is an infant sleep death risk. Conclusions are that infants who could possibly roll should never be swaddled in sleep.
6) Though swaddling helps babies sleep more deeply, that deep, long sleep is associated with increased risk of sudden infant death. Swaddling is not needed or helpful if baby is kept close to mother and breastfeeds with skin-to-skin contact. Breastfeeding itself is proven to soothe babies and help them get to sleep much better than swaddling can.
7) Lack of weight gain in breastfed and swaddled newborns. One Russian study showed lack of weight recovery in newborns who were breastfed and swaddled compared to not swaddled. These infants were not nursing as well or as frequently and eventually needed formula supplementation. This likely has to do with a lack of rousing to eat frequently. http://www.ncbi.nlm.nih.gov/pubmed/16716541
We have a long fear that baby will self-harm if not restricted. We have a fear that baby will move about and not just sleep. We have a fear that baby will somehow escape. And we have a deep-seated belief that babies must be contained and as well as that, babies need STUFF to help them sleep.
While the reasons not to restrict baby in a swaddle or sleep sack above are actually dangerous, the next one is simply… frustrating.
8) It becomes a strong sleep association and dependency from which your child must be weaned – which can be difficult. One third of my sleep clients come to me with the goal to get out of the swaddler or sleep sack but are not sure how. I can help, but let’s not get there in the first place, shall we? Baby no longer has the strong startle reflex that these sleep aids were meant to help with, but baby now is not sure what to do with the limbs and is either frustrated by their movement or preoccupied in playing with the toes (hehehe). And more often, baby is moving around in the crib and getting twisted and frustrated – does not have the ease of movement he has during the day. When I was first an infant overnight nanny and a Postpartum Doula – I witnessed this frustration often in more mobile babies.
When to Use It:
It seems from all of this like nobody should swaddle – but wait, don’t throw the baby out with the bath water, so to speak. Just because it is possible to use a swaddle incorrectly – that does not mean you should not use it if you can do so correctly. And I’m not here to tell you that you should take a baby who sleeps well or is soothed by a swaddle right out of that thing! One size does not fit all families. I believe that parents get to make choices for their children and that children’s individual needs are unique (and sometimes those choices don’t always jive with what the AAP or professionals think). Like so many things in pediatrics – the second there is an issue from misuse of a product, everyone is told they should not use the product. And like so many things in parenting, you balance your own understanding of risks and benefits. So… Here’s When I DO recommend a baby be swaddled:
A) For newborn babies who are crying a lot, having a hard time adjusting to the new world, and you have found that swaddling works wonders. In fact, that’s the only way baby will relax and the only way you all can sleep? Great. Do this only up until 2.5 months and gradually take the hands out, then legs. Only use a swaddle product like the Ollie Swaddle, not a blanket that could come loose and be pulled over the face. This swaddle is designed so the hips are not constricted and so that baby won’t overheat.
Again, the best way to wrap a baby to calm her for a feeding is to wrap baby with fists on her chest. Do this by pulling the blanket sides from near the baby’s earlobe and down crossed over the fist at chest on both sides and bring the bottom part over perpendicular to the chin and wrap behind baby – a “square” swaddle. No need to pin or tighten around the legs. A fantastic video of two healthy styles is HERE.
B) If your newborn baby is crib-sleeping on her back and has a strong startle reflex. Make sure nothing but the swaddle is in the crib. And make sure baby isn’t wearing too many layers under the swaddle. A thin layer of cotton with socks is enough.
Why end swaddling at 2.5 months? By 3 months, baby can roll over and has a greater chance of suffocating. Doctors weigh in: http://aapnews.aappublications.org/content/34/6/34.full
What should you do if you don’t want to use a swaddle or sleep sack and your baby has a hard time sleeping on her back or has a strong startle reflex?
Though side-sleeping in a propped position is not considered as safe as back sleeping, many pediatricians recommend a propped side-sleeping position for newborns in cribs because it helps with the startle reflex (and can also help with gastrointestinal upset and GERD). So ask your pediatrician if they might recommend this for your family. Other family risk factors for infant sleep death should be considered because there is a small chance that an improperly bolstered side position would cause baby to roll onto his tummy. Side sleeping with a rolled blanket or wedge like this should be done only when baby is rooming with you in a crib, aka co-sleeping, which is fortunately now recommended by the AAP – so you can keep an eye on the sleep position.
Dr. William Sears on Side Sleeping Safety:
“To lessen the chances of a side-sleeping baby rolling onto his tummy, stretch his underneath arm forward. This arm can act as a stabilizer to keep baby from rolling onto his tummy. If the baby’s arm stays closely tucked into his side, it will be easier for him to roll onto his tummy. Wedges to keep baby sleeping on his side are helpful, but never use just a back wedge. Rolling up a towel as a wedge between baby’s back and the bed may encourage baby to roll from side to stomach rather than from side to back. Be sure not to use props that totally restrain the infant’s movement. Freedom of breathing implies freedom to adjust body position as needed. I’m concerned that the multitude of commercial baby wedges may be more restrictive than necessary, and they have not been proven either safe or effective. For these reasons, SIDS organizations and researchers do not endorse these products. If you choose to use a wedge to keep baby on his side, it seems the most sensible to use a front wedge only, which allows baby to roll onto his back if desired.”
If your newborn is unsettled and crying a lot, you can also get help from an IBCLC lactation consultant, a cranio-sacral therapist for infants, see a naturopath to think about the dairy or gluten in your diet that your baby may be sensitive to.
The origins and history of swaddling is in ancient Greece first. Europe and the West is riddled with child neglect and misguided notions about the needs of babies and their development. You can read a slide show about it here: https://bflrc.org/wp-content/uploads/2018/09/Swaddling-USLCA-webinar-2011-SMITH.pdf
It’s important to know the modern history of infant sleep – that for many decades American Pediatricians recommended tummy sleeping above all else because it was the most natural sleep position for babies and because it helped babies sleep for longer periods of time, because the startle reflex was not present in this position. This means that when they came out of REM at the end of each sleep cycle, they would not startle awake and would more likely go right back into another sleep cycle without calling out, as long as they weren’t hungry. We now believe that there are major suffocation risks associated with tummy-to-sleep. Still, it’s important to realize that we have been dealing with thwarting the startle reflex and helping to make babies comfy and to sleep better – since at least ancient Greece.
Note: SWADDLES AND SLEEP SACKS should NEVER BE USED WHILE BED SHARING WITH BABY! Many people do not know this. Swaddles and sleep sacks are only for cribs. (They are also not for sofas or sleeping on you or your bed, not for swings or car-seats or strollers!) For many of the reasons listed above, especially inability to turn away from something smothering them and overheating.
Each baby is soothed in a different way. Here’s hoping you find yours! My advice is just to wean from sleep aids early, as they become more of a strong sleep association over time.
My sleep support options for private coaching and online programs are here: https://www.savvyparentingsupport.com/baby-sleep-toddler-sleep/
*Explanation and Links:
The soothing and warming effect of swaddling has raised concern among some experts who fear that swaddling may increase SIDS risk because decreased arousal and overheating are theorized to be implicated in SIDS etiology (Kleemann, Schlaud, Poets, Rothamel, & Troger, 1996; Richardson, Walker, & Horne, 2009). Evidence related to these hypotheses is presented in the following sections.
Swaddled infants experience reduced spontaneous awakening and arousability, greater quiet sleep, decreased time awake, and increased sleep efficiency (Franco et al., 2005; Meyer & Erler, 2011; Richardson et al., 2009, 2010). Franco et al. (2005) however found that swaddled infants required less intense auditory stimuli to induce cortical arousal, whereas Richardson et al. (2009, 2010) found increased arousal thresholds, decreased spontaneous arousability, and heart rate variability in 3-month-old infants naive to swaddling but not in routinely swaddled infants
Franco, Scaillet, Groswasser, and Kahn (2004) found that swaddling decreased heart rate, but only in the supine position. Gerard et al. (2002) found that only a tight, traditional swaddle as compared with a looser swaddle caused heart rates to lower. Tight swaddling caused infant respiratory rates to increase during quiet sleep, although PaO2 level were unchanged. Richardson et al. (2009, 2010) found that respiratory rate increased with swaddling although they report no change in baseline heart rate, temperature, or oxygen saturation (Gerard et al., 2002). In contrast, Narangerel, Pollock, Manaseki-Holland, and Henderson (2007) found although the respiratory rate of habitually swaddled infants was lower than in those habitually nonswaddled, swaddling had no significant clinical effect on SaO2 in healthy 9- to 10-week old infants. Research about the impact of swaddling on arousability and vital signs is unclear, and further research is needed.
Bystrova et al. (2003) found prolonged skin-to-skin contact between mother and infant beginning soon after birth was more effective than swaddling in supporting transitional newborn thermoregulation. Risk of overheating related to swaddling however, is the concern related to SIDS risk. Bundling infants in two blankets and a hat has been found to significantly increase skin but not rectal temperature when compared with unwrapped infants (Grover et al., 1994). A rise in body temperature into the febrile range however, has been documented in newborn infants extremely overwrapped in five blankets and a hat (Cheng & Partridge, 1993), suggesting it is possible to overheat an infant through excessive swaddling. Fleming et al. (1990) found that overheating with heavy wrapping in clothes and bedding of >10 tog (thermal value) were independently associated with an increased risk of SIDS (RR 1.14 per tog above 8 tog), especially in infants aged 70 days or greater, and those sleeping prone. Also, Ponsonby, Dwyer, Gibbons, Cochrane, and Wang (1993) found that swaddled infants sleeping prone had a 12-fold increased SID risk. This may be because infants sleeping prone experience less heat loss than nonprone sleeping infants (Tuffnell, Petersen, & Wailoo, 1995).
Ill infants are at particular risk for hyperthermia. Those over 70 days old with a viral infection and clothing/bedding with a tog value of greater than 10 togs have been reported to have an increased risk of death (odds ratio of 51.1) (Gilbert et al., 1992), perhaps because infants older than 3 months are more likely to experience an increase in metabolic rate and become febrile at night than younger infants (Fleming, Howell, Clements, & Lucas, 1994).
Inadvertent head covering is also a concern associated with swaddling and an important consideration in relation to hyperthermia and SIDS risk. In a meta-analysis of 10 population-based, age-matched, controlled studies reporting on head covering among SIDS victims, Blair, Mitchell, Heckstall-Smith, and Fleming (2008) found the population-attributable risk was 27.1%, indicating that head covering is a SIDS-related risk for infants. They theorized that an infant’s head is a major source of heat production and loss, and may contribute to hyperthermia, especially in the prone position (Fleming, Azaz, & Wigfield, 1992; Fleming, Levine, Azaz, Wigfield, & Stewart, 1993).
Results of a meta-analysis of four case-control studies judged to be of good quality based on the Newcastle-Ottawa Scale (Wells et al., 2014) found an increased risk of SIDS with increasing age, and greatest risk among swaddled infants 6 months or older (Pease et al., 2016). They also found that the prone or side-lying position greatly increased SIDS risk among swaddled infants. Being swaddled and placed to bed supine, however, was still found to be associated with “a small but significant risk” when compared with controls (Pease et al., p. 6). The authors acknowledged many limitations to their analysis including variability in prevalence of swaddling between studies, a lack of a precise definition of swaddling, and inability to adjust for significant factors associated with SIDS risk such as bed-sharing. Thus, it cannot be definitively concluded that swaddling independently increases SIDS risk, although the evidence is clear that swaddled infants should always be placed to sleep supine and hyperthermia should be avoided.
Swaddling newborns is often discouraged by breastfeeding experts due to concerns that it may interfere with early maternal-infant interactions, feeding cues, breastfeeding opportunities, and milk production (Mohrbacher, 2010). Newborns placed skin-to-skin during the first 2 hours after birth rather than being swaddled have been found to have higher mean sucking competence during the first breastfeeding and to breastfeed sooner (Moore & Anderson, 2007). Also, early bathing followed by swaddling has been found to decrease the demonstration of infant feeding cues (Jansson, Mustafa, Khan, Lindblad, & Widstrom, 1995). Finally, traditional swaddling at birth has been correlated with decreased infant “wakefulness” during a breastfeeding 4 days after birth and a rougher maternal affective response (Dumas et al., 2013, p. 322)
The correlation between swaddling and an increased risk of developmental dysplasia of the hip (DDH) is clear (Loder & Skopelja, 2011). This association is strongly supported by findings that DDH is high among swaddled infants in cultures where they use various forms of swaddling that are tight around the hips such as in Turkey (Akman et al., 2007; Dogruel, Atalar, Yavuz, & Sayli, 2008; Guner et al., 2013; Kutlu, Memik, Mutlu, Kutlu, & Arslan, 1992), Saudi Arabia (Abd El-Kader Shaheen, 1989; Kremli, Alshahid, Khoshhal, & Zamzam, 2003), and Japan (Ishida, 1977). The independent association between DDH and swaddling is supported by the dramatic effectiveness of campaigns to change these traditional infant care practices in decreasing hip abnormalities (Chaarani, Mahmeid, & Salmon, 2002; Ishida, 1977). See Supplementary Digital Content 1, http://links.lww.com/MCN/A3 for study details.
The prevailing view for decades has been that tight swaddling likely does not “cause” DDH rather that it might worsen the condition in those infants who are genetically predisposed (Salter, 1968). This view is supported by the almost nonexistent incidence of DDH in populations such as the African country of Malawi, where infants are not swaddled, but rather “back carried” from 2 to 6 weeks until 18 to 24 months of age (Graham, Manara, Chokotho, & Harrison, 2015). The back-carrying practice promotes infant hip flexion and abduction, rather than the hip adduction caused by tight swaddling.
In a study using sonographic technology using a group of infants being treated for DDH, Harcke, Karatas, Cummings, and Bowen (2016) objectively demonstrated that tight swaddling limited hip flexion/abduction and even dislocated one unstable hip. When safe hip-healthy swaddling (loose around the hips) was used, there was no limitation of hip flexion and abduction, and no change in hip stability. This suggests, not all swaddling techniques place infants at an increased risk of DDH.
Other potential swaddling risks currently under investigation are an increased risk of acute respiratory infection (ARI) and vitamin D deficiency (rickets). In one large descriptive study in Turkey where tight swaddling is still common, Yurdakok, Yavuz, and Taylor (1990) found babies swaddled for a minimum of 3 months were four times more likely to develop pneumonia and ARI than babies who were not swaddled, perhaps because tight swaddling promotes shallow breathing and restricts lung expansion.
An alternative explanation for an association between tight swaddling and ARI is that ARI in swaddled infants may be related to decreased sun exposure and associated subclinical vitamin D level (rickets). Acute lower respiratory infection (ALRI) has been found to be associated with rickets in Indian children in the first 4 months of life, especially among infants swaddled when exposed to sunlight (Wayse, Yousafzai, Mogale, & Filteau, 2004). Mean vitamin D concentrations have also been shown to be lower in a group of infants admitted to a neonatal unit for ALRI than in control infants (Karatekin, Kaya, Salihoglu, Balci, & Nuhoglu, 2009).
In 2011, the American Academy of Pediatrics (AAP) published recommendations for a Safe Infant SleepingEnvironment(AAP Task Force on SIDS, 2011), which were recently updated (AAP Task Force on SIDS, 2016). In the latest report “Level A” recommendations (U.S. Preventive Services Task Force, 2014), based on consistent results from well-done studies, include: back to sleep for every sleep (supine sleep positioning), use of a firm sleep surface, breastfeeding, room-sharing without bed-sharing, keeping soft objects and loose bedding out of the crib, and avoiding overheating (AAP Task Force on SIDS, 2016, p. 2). Within these guidelines AAP addresses swaddling and safe infant sleep.
The AAP Task Force on SIDS (2016) position on swaddling is that “there is no evidence to recommend swaddling as a strategy to reduce the risk of SIDS” (p. 7). They further recommend if swaddling is used, the infant should always be placed supine to sleep, swaddling should be snug around the chest but allow room for movement around the hips and knees [related to the risk of hip dysplasia], and swaddling should be discontinued when infants first show signs of rolling over (AAP Task Force on SIDS, 2016, p. 7).
The AAP Task Force on SIDS (2016) recommendation on when to discontinue swaddling is related to the recent publication by McDonnell and Moon (2014) who retrospectively reviewed cases of 10 infant deaths related to wearable blankets or swaddle wraps, and 12 deaths related to swaddling in blankets reported to the Consumer Product Safety Commission between 2004 and 2014. One of these deaths was attributed to hyperthermia, one was placed prone to sleep, and six rolled into the prone position while swaddled. These findings highlight risks associated with placing swaddled infants prone and swaddling older infants. It should be noted among deaths associated with swaddling only one was not related to environmental risks such as blankets, pillows, and bumper pads, supporting importance of always adhering to Safe Infant Sleeping Environment guidelines (AAP Task Force on SIDS, 2016).
Risk of DDH associated with swaddling has been addressed through a joint statement from AAP, Pediatric Orthopaedic Society of North America (POSNA), International Hip Dysplasia Institute (IHDI), and American Academy of Orthopaedic Surgeons that recommends “hip-healthy swaddling” if parents chose to swaddle their infants (POSNA, 2015). This type of swaddling allows the infant’s legs “to bend up and out at the hips” and not “tightly wrapped straight down and pressed together” (IHDI, Are You Swaddling Your Baby Properly?, para. 3-4). The IHDI recommends sleep sacks only if they have a “loose pouch or sack” for the infant’s legs and feet, which allow hip movement (IHDI, What about sleepsacks andcommercial products, para. 1).
The AAP has also published a report related to safe sleep and skin-to-skin for healthy-term newborns in hospitals and birthing centers (Feldman-Winter, Goldsmith, Committee on Fetus and Newborn, & Task Force on SIDS, 2016). Recommendations are offered for improving safety while rooming-in and decreasing risk infant falls and sudden unexpected postnatal collapse, mostly related to suffocation or entrapment. These recommendations include: nurse-to-mother-baby couplet ratios that permit routine monitoring based on level of risk, education related to the risks of bed-sharing, and available assistance to transition newborns to a safe sleep location as needed when the mother is not awake and alert (Feldman-Winter et al.). During the newborn period in the hospital, swaddling an infant and placing them in their own bed may be appropriate.
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