A blog by Dr Lin Day



Safe Swaddling

Baby swaddling is a controversial subject. Read on to find out how to keep your baby safe. Peer reviewed article published in the Journal of Health Visiting (April 2015). 


Archaeological records show that babies have been swaddled since 4000 BC. Swaddling involved wrapping pieces of cloth and a band tightly around the baby’s body from the shoulders to the feet to in the belief that it helped them to develop a strong, straight back before they were able to walk. The swaddled baby was then placed horizontally in a cradle or cot, or strapped firmly vertically to a cradleboard to support the spine.
 
Due to the effect of tight swaddling on limb restriction, the practice fell out of favour in the mid-1960s, as new theories in baby development took hold. However, following the ‘Back to Sleep’ campaign in the 1990s, and popularisation in parenting guides, swaddling has made a comeback.
 
Some healthcare professionals recommend swaddling while others speak out against it. Advocates believe that swaddling replicates the confined conditions of the womb, and helps the newborn adjust to life in the outside world. Some studies (Gerard et al. 2002; Thach 2009) have shown that swaddled babies startle less, have a lower heart rate, sleep more deeply, and wake less spontaneously than when not swaddled. Swaddling also prevents babies from rolling over on to their tummies, which is a risk factor for Sudden Infant Death Syndrome (SIDS) (Gerard et al. 2002).
 
Work by Blair et al. (2009) has linked swaddling to respiratory complications, prolonged deep sleep, and overheating, which are risk factors for SIDS. Other concerns include tight swaddling of the legs, which can lead to developmental dysplasia of the hip. There is also disagreement among healthcare professionals about the benefits of restricting the protective startle reflex in newborns. When the limbs are confined, babies are unable to startle themselves awake.
 
The effects of swaddling on SIDS are controversial. Until there is conclusive evidence that swaddling is unsafe, the practice is unlikely to become less common.
 
History of swaddling
 
Egyptian tomb reliefs from 2500 BC show babies swaddled with cloths and tied to the mother's back or hip. Sacred statuettes of infants in swaddling clothes have also been found in Ancient Greek and Roman tombs. History shows that Alexander the Great and Julius Caesar were all swaddled as babies. The practice of swaddling has been known for centuries over most of Europe, Asia, Canada, South and North America.
 
The most famous record of swaddling is found in the New Testament concerning the birth of Jesus.
  
And she brought forth her firstborn son, and wrapped him in swaddling clothes, and laid him in a manger; because there was no room for them in the inn." (Luke 2:7).
 
After the birth, the newborn was washed, rubbed with salt and oil to thicken and firm the skin. To prevent cold air from touching the skin and to ensure that the limbs grew straight, the baby was wrapped in linen or cotton and over-wrapped with six metre long bandage-like strips or bands. Swaddling and salting became the model of infant care practice for some 1,500 years or more.
 
During the Tudor period (1485 to 1603), newborns were ‘salted’ and wrapped in linen bands from head to foot for up to nine months to ensure that they grew up without physical deformity. The legs were placed closely together, the arms were placed at the sides, and the swaddling cloth was then folded over the baby’s body, feet and arms. A swaddle band was wrapped under the baby's chin and over the forehead to secure the head, and then around the body all the way down to the ankles. The weight and heat of the swaddle wrap and band restricted movement, cramped the bowels, and increased body temperature.
 
In Medieval times, it was traditional practice to immobilise babies for up to nine months without washing or regular human contact. They were unable to reach out for objects or suck their fingers or toes for comfort. Infants were also left in their own excrement for days on end. Crawling, an important developmental milestone was often delayed or absent (Frenken 2011).
 
In parts of Canada, North America, and South America, babies were traditionally swaddled and attached to portable cradleboards constructed of dogwood or willow sticks, which supported the spine and constricted movement. However, studies (Chisholm & Cary 2009) demonstrated a very high prevalence of hip dysplasia. The frequency of hip dislocation decreased dramatically when cloth nappies, which slightly flexed and abducted the hips, were introduced in the 1950s (American Academy of Pediatrics (AAP) 2011a).
 
In the 1800s, the medical profession recommended a less containing form of swaddling, which kept the arms and legs free. Nevertheless, most mothers continued to use traditional swaddling bands until the early 1930s. Swaddling eventually fell out of favour following concerns that it could overheat the baby, restrict growth, and displace the hips.
In recent years, swaddling has become increasingly popular as a settling technique in the Netherlands, some parts of the United States, and the United Kingdom (Frenken 2011). In the UK, about 19 percent of babies are swaddled in the first four weeks of life (Clarke 2013). However, modern swaddling allows ample room for hip and knee flexion.
 
Benefits of swaddling
 
Many parents say that swaddling provides comfort and security, limits the startle reflex, and helps their babies get to sleep and stay asleep. Gerard et al. (2002) found that babies were just as likely to startle when swaddled as when unswaddled, but returned to sleep more quickly. Longer sleep duration in swaddled infants is believed to be important for brain development.
 
Additional benefits include:
 
·         Helps babies to stay on their backs, which reduces the risk of SIDS.
·         Prevents the baby moving into dangerous situations.
·         Helps to settle an overstimulated or distressed baby.
·         Makes the baby feel secure.
·         Prevents uncontrollable flailing of the baby’s arms and legs.
·         Reduces crying, fussiness, and distress.
·         Helps babies sleep more deeply.
·         Promotes brain development by reducing stress.
 
When the baby sleeps better in the supine position, parents are less likely to use the prone position for sleep. Improved sleep means that mother is less likely to suffer from exhaustion, postpartum depression or stress.
 
 
Safe swaddling
 
Swaddling is standard practice in many neonatal intensive care units for premature and/or low birth weight infants. However, swaddling takes place very loosely. The arms and legs are held weakly against the baby’s body so that movement is possible. This form of swaddling is very different to traditional tight swaddling in the stretched position.
 
The American Academy of Pediatrics (AAP 2011b) recommends swaddling, when done correctly, to be an effective technique to help calm infants, promote sleep, and reduce SIDS. Mothers who swaddle are twice as likely to put their babies in the supine position, which reduces the likelihood of SIDS. Safe swaddling also prevents the baby rolling into the prone position or moving into a dangerous situation (Gerard et al. 2002). Additionally, swaddling reduces the chances of bedding covering the baby’s face and head, which can cause overheating or asphyxia. The baby’s hands can also be left free to self-comfort by sucking on the fingers or hand.
 
Most modern swaddle wraps are produced in a triangular, ‘T’ or ‘Y’ shape, which may include ‘wings’ that fold around the baby's body and arms, and a pouch that allows the baby’s hips to move and the legs to spread apart naturally. Swaddle wraps are made from cotton, muslin, silk or a lightweight breathable fabric to prevent overheating. Some swaddle wraps are made from cotton spandex to reduce the risk of chest wall compression.
 
Swaddling should be stopped at three months-old (the peak age of SIDS risk) or when the baby shows signs of rolling over. Older babies may use a baby sleeping bag, which is less restrictive than a swaddle wrap. The sleeping bag keeps the baby warm, and it offers plenty of room for the legs and feet to move freely during the night. It is also sleeveless and without a hood to prevent overheating or asphyxiation.
 
Potential risks of swaddling:
 
·         Placing the swaddled baby in the prone position.
·         Reduced ability to arouse from deep sleep.
·         Overheating, if a heavy blanket is used.
·         Suffocation if the swaddle wrap covers the baby’s face.
·         Inhibited breathing if the wrap is too tight across the chest.
·         Developmental dysplasia of the hip if movement of the hips or knees is restricted.
·         Increased risk of SIDS if continued over the age of 3 months-old.
 
Blair et al. (2009) found that one in 4 SIDS babies had been swaddled. However, the sample used for the study was small and the risk was branded 'unreliable' by the National Health Service. Other studies (e.g. Thach 2009) have shown that swaddling increased the risk of SIDS when babies slept in the prone position, but not when they slept on their backs. 
 
Some studies (Thach 2009; Clarke 2013) found that swaddling babies slept more soundly. However this may not be a desirable outcome, as the pathogenesis of SIDS is thought to involve an impaired ability to arouse from sleep in response to a life threatening respiratory or cardiovascular challenge. Although newborns have an inborn survival mechanism, which enables them to wake up if the airway is obstructed; in deep sleep their well-being could be threatened.
 
The Royal College of Midwives (Clark 2013) advised against tight swaddling and heavy blankets in fear of overheating the newborn. Other concerns included restriction of the chest wall resulting in breathing difficulties or secondary complications such as pneumonia.
 
Hip dysplasia
 
If the baby is swaddled too tightly, developmental dysplasia of the hip (DDH) may occur (Mahan & Kasser 2008; Chisholm & Cary 2009; AAP 2011a). The risk is elevated in babies with:
 
·         A family history of DDH.
·         Breech positioning.
·         Congenital foot deformity.
·         Torticollis (asymmetrical head or neck position).
 
DDH occurs in about 1 in 1,000 babies. About 80 percent of cases are female. This is due to oestrogen produced by the female foetus, which increases elasticity of ligaments and causes the femoral head to move out of position. Treatment, which involves fitting a harness to keep the legs in a flexed, widespread position day and night for six weeks, is successful in about 85 percent of cases.
 
About 17 percent of newborns have some degree of hip dysplasia. Although the condition resolves untreated by 2 to 3 months-old, traditional tight swaddling may lead to late onset hip dysplasia and early arthritis (Clark 2013).
 
Conclusion
 
There is a significant difference between traditional tight wrapping and safe swaddling. If babies are placed on their backs to sleep, and they are loosely wrapped without hip or limb constriction, swaddling may be safe. However, swaddling could become a safety issue if blankets are used or when the baby becomes mobile. Care should be taken to ensure that the swaddle wrap does not restrict blood flow or breathing, or cover the baby’s face or head.
 
The association between swaddling and SIDS has been mainly limited to babies lying in the prone position. The risk of SIDS in supine swaddled babies needs more in-depth research.
 
Further information
 
Information covering all aspects of baby care, health and safety can be found in our Baby Sensory new baby course ‘Baby Foundations’. Please visit www.babyfoundations.com
 
By Dr. Lin Day (www.babysensory.com)
 

 
This article appeared in the Journal of Health Visiting April 2015 Volume 3 Issue 4 and has been subject to peer review.
 
 
References
 
American Academy of Pediatrics (2011a) Improper swaddling a risk factor for developmental dysplasia of hip. Available from http://aapnews.aappublications.org/content/32/9/11.1 [Accessed 11 October 2014]
 
American Academy of Pediatrics (2011b) Practice safe swaddling to protect baby’s hips. Available from http://aapnews.aappublications.org/content/32/9/11.2 [Accessed 11 October 2014]
 
Blair PS, Sidebotham P, Evason-Coombe C, Edmonds M, Heckstall-Smith EM and Fleming P (2009) Hazardous cosleeping environments and risk factors amenable to change: case-control study of SIDS in south west England. BMJ 339: b3666
 
Chisholm JS and Cary MC (2009) Navajo Infancy: An Ethological Study of Child Development. New Jersey: Transaction Publishers. p.187
 
Clarke NMP (2013) Swaddling and hip dysplasia: an orthopaedic perspective. Archives of Disease in Childhood 99 (1): 5-6
 
Frenken R (2011) Psychology and history of swaddling: Part two - The abolishment of swaddling from the 16th century until today. The Journal of Psychohistory 39 (3): 219-245
 
Gerard CM, Harris KA and Thach BT (2002) During rapid eye movement and quiet sleep spontaneous arousals in supine infants while swaddled and unswaddled. Pediatrics 110: e70
 
Mahan ST and Kasser JR (2008) Does swaddling influence developmental dysplasia of the hip? Pediatrics 121: 177-178
 
Thach BT (2009) Does swaddling decrease or increase the risk for sudden infant death syndrome?  The Journal of Pediatrics 155: 461-462
 
 

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