Can we settle the swaddling controversy?

An old method of soothing a crying infant, swaddling or tightly wrapping in cloth, has become controversial lately with the National Resource Center for Health and Safety in Child Care and Early Education recommended against swaddling, saying it could increase the risk of Sudden Infant Death Syndrome in 2011.  It is now illegal in child care centers in Minnesota and caregivers in some states like Pennsylvia are strongly discouraged to use swaddling.

This month, the American Academy of Pediatrics' news magazine, AAP News, has a news story refusing to either issue a "blanket" endorsement or rejection of the process.

Wrapping up a baby very tightly in a blanket or cloth goes back to ancient times.  We believe it works because it reproduces the feeling of being in the mother's womb. The Native American's papoosing is one of the best known examples and young nurses are still taught how to take a simple cotton baby blanket and turn it into a comfort machine.

Swaddling is one of the 5 S's that soothe a baby in Dr. Harvey Karp's bestselling book, "The Happiest Baby on the Block," along with sucking, shussing, swinging and side/stomach sleeping. This last recommendation is clearly condemned by the AAP as leading to potential suffocation and Sudden Infant Death Syndrome.

Proper swaddling consists of wrapping the baby firmly, but not too tightly.  A correct swaddle lets the baby move its feet, but swing against a surface.  For babies two months and older, their arms should be free to keep the babies out of danger. A video is available at BabyCenter on how to properly swaddle.

So what is good about swaddling?  There is no question that a good swaddle will calm down almost any baby.  Sometimes a baby gets so upset that it is unable to calm down on its own.  Unfortunately, an incessantly crying baby can lead to a very upset adult and that adult can harm the baby either intentionally or unintentionally.  Many severely injured children with Shaken Baby Syndrome involved a very upset infant who could not stop crying with an unprepared or immature teen or adult who just did not know what to do to end that crying and did so in a very bad way.  Crying infants have also been poisoned after given something such as illegal drugs or a massive overdose of acetaminophen to end the weeping.

Then why are we worrying about swaddling?  Babies that are always tightly swaddled, especially if the legs are kept straight down as in a papoose, can develop dislocated hips.  Babies that are two months and older in tight swaddles can roll over on their stomach face down and suffocate if their hands are not free to get their face out of the soft bedding. Excessively tight swaddles can actually prevent the baby from taking a deep breath if they need to.

So what is the answer?  Honestly, it is not completely clear, but a well done swaddle in which the baby can swing its feet a little, which is tight enough to stay on and yet allows an adult hand to slip between blanket and the baby's chest and which lets the arms come out, can be a welcome relief to an exhausted parent.  Unfortunately, bad things can happen, but we can exercise caution to try to avoid them.

Edit: June 27, 2013

Letter from:
Harvey Karp, MD, FAAP
Assistant Professor of Pediatrics
USC School of Medicine
www.happiestbaby.com

Dear Dr. Emmett,

Thank you for your article about swaddling. You mention the many misunderstood aspects about swaddling. I want to offer two corrections to your article and some comments:

Your comment that The National Resource Center on Health and Safety has "recommended against swaddling" is not accurate. They have taken a neutral position (neither recommending nor banning it in day care settings). Also, The Happiest Baby on the Block DVD/book clearly state that babies should only sleep on the back (the side/stomach positions are only to be used when the baby is held in the parents arms). Almost 3,000 trained professionals currently teach the 5 S's to promote good parenting and safe sleep in hospitals and public health programs across the US.

Parents should feel reassured that swaddling is recommended by the American Academy of Pediatrics (AAP) in its parenting books and website. That is because research shows that this ancient practice reduces infant crying and improves sleep.

You raise the question, "At what age babies no longer be swaddled?" I recommend swaddling for at least 4 months. Two months is actually the worst time to stop it because that is the peak time of nighttime crying, parental exhaustion...and the peak time for the very serious problems triggered by crying/exhaustion: postpartum depression, child abuse, unsafe sleep practices, breastfeeding failure, maternal cigarette smoking, overtreatment with medication, and obesity (most of which remain major risks until the baby is 4-6 months of life).  For example, the peak age of Shaken Baby Syndrome (SBS) is at 2-4 months. SBS causes ~300 deaths/year and ~1000 cases of permanent brain damage. It is directly triggered by infant crying (especially among stressed/exhausted parents), which is why swaddling is a key recommendation in the AAP's child abuse prevention program.

You voiced three potential worries about swaddling that I'd like to address:

1) Dislocated hips - There are no reports of hip dislocation caused by our modern form of swaddling (even though millions of babies are swaddled every year). As you note, hip problems have only been reported among babies whose parents used archaic swaddling techniques, which prevent the normal flexion of the hips and knees by tightly wrap the legs together. 

2) Difficulty breathing - Numerous studies show that swaddled babies have perfectly normal and safe breathing. (A few studies have found tightly swaddled babies take 2-3 breaths/minute more, but they have totally normal respiratory health.)

3) SIDS/suffocation - Evidence shows that swaddling may well reduce infant sleep deaths. By reducing crying and boosting sleep, swaddling lessens a parent's temptation to bring the baby into bed with them or to put the baby to sleep on the stomach (both serious SIDS/suffocation risks).

Some studies show babies who sleep swaddled and on the back have a lower SIDS risk. It is believed that wrapping protects babies by making it harder for them to accidentally roll over. (Two-month olds who routinely back sleep - but then roll to the stomach - have a much higher risk of SIDS.) Reduced crying also has may reduce other SIDS triggers, like maternal smoking and breastfeeding failure. 

Swaddling is used by millions of parents, yet reports of deaths of swaddled babies are quite uncommon. On the other hand, our newspapers report deaths of bed sharing and prone babies on a daily basis. For these reasons, the Australian SIDS prevention program - SIDS and Kids -  recommends swaddling for up to 6 months.  

However, if a baby can roll to the stomach while swaddled, the parents should speak to their doctor about stopping the swaddling...or allowing the swaddled baby to sleep safely buckled into a fully reclined (flat) infant seat or swing.

Snug, safe swaddling (plus the use of a rough, rumbly white noise for all naps and nights) are invaluable parenting tools. When done correctly they significantly reduce infant fussing and improve a baby's sleep.

-----

Response from Dr. Emmett:

I think that Dr. Karp's ideas are basically correct, although he does have a financial interest in selling books and CDs. People learn infant skills from those around them including their parents, their friends, and media, and definitely the least, from doctors and nurses.

I am always surprised by the seemingly odd slants on what I say or have written that parents sometimes absorb.  I have learned that the only safe way to figure out what a parent or patient has understood or misunderstood is to have them "teach back."

After a medical practitioner has given instructions, he or she should ask the parent to tell them back what the instructions were. In this way, errors can be fixed before they hurt the patients. Hand outs and CDs cannot "teach back" and sometimes practitioners are rushed and do not ask either.

Unfortunately, I can only communicate on this blog in writing and will say again: Swaddling calms babies. To be safe and effective it must be done properly. The swaddle should be firm and difficult for the baby to open, but not so tight - the swaddler should be able to slip their hand between the blanket and the child's chest.  The feet should be against the blanket but able to move slightly. Babies should be place on their back for sleep.

To specifically address one of Dr. Karp's corrections, the National Resource Center for Health and Safety in Child Care and Early Education said in its report that swaddling is "not necessary and recommended" on page seven of the report. Perhaps it would have been better to say the report decided to not make a decision, but some might interpret that as not recommending swaddling.

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