Is Swaddling Safe?

by Dr. Gregory Gordon

Dr. Gregory Gordon

Prior to the “Back to Sleep” program popularized in the 1990s, most infants in the United States slept on their tummies (prone). I know my parents placed me on my stomach for sleep. Back then, experts thought prone sleeping was safer, as it was believed to protect infants from choking if they spit up. Parents did not question this advice as prone sleeping infants slept better. Unfortunately, children placed prone to sleep are at a much higher risk for SIDS (Sudden Infant Death Syndrome). Once research revealed this startlingly finding, child advocates responded. The United States’ “Back to Sleep” program was launched to educate the public and protect children from SIDS through promoting back (supine) sleeping.

As a medical student in the late 1990s, our professors taught us the merits of supine sleep. Our job was to educate new parents – not an easy task! Parents easily understood the theoretical advantage of lowering the risk of SIDS, but their children did not sleep well. Children placed on their backs did not settle down as easily or sleep as well as those placed on their tummies. Pediatricians and parents quickly adopted the technique of swaddling to comfort these children when placed on their backs for sleep. However, as the popularity of swaddling increased, so have concerns about its practice. Some experts today believe that swaddling could increase the risk of SIDS or increase a child’s risk of hip problems.

In the first two months of life, swaddling clearly reduces crying, as well as the risk of SIDS. The swaddling/SIDS controversy surrounds swaddling children two months and older. Some experts theorize that after two months, a swaddled child could increase their risk of SIDS by rolling over or covering their head with the blanket. While these are valid concerns, there is insufficient evidence to support them. In fact, current evidence shows that swaddling and placing a baby on their back reduces the risk of SIDS. Yes, it is true that swaddled children placed on their tummies are at an increased risk of SIDS. While this seems obvious, the one study often quoted to say “swaddling increases the risk of SIDS” did not differentiate between swaddled tummy verses swaddled back sleepers. Those studies that look exclusively at swaddling with back sleeping reveal a decrease in SIDS.

Swaddling and Hip Dysplasia
Swaddling techniques and practices vary by culture. Swaddling techniques that strap an infant to a rigid board are clearly shown to increase an individual’s risk of developmental dysplasia of the hips (DDH). The Navajo Indian “cradle board” and the Japanese “swathing diaper” are notorious for causing DDH, as they do not allow the baby to flex their hips. Both of these populations had excessively high incidences of DDH until their swaddling practices were reformed.

To date, modern American swaddling techniques have not been directly shown to cause DDH. However, there is significant evidence to warrant caution when swaddling. Dr. Charles Price, a local Orlando pediatric orthopedist and the Director of the International Hip Dysplasia Institute said this about the link between swaddling and developmental dysplasia of the hips: Data from several other countries and an on-going United States study “suggests a mild increase in the number of late presenting cases. A slight increase has been documented and parallels the increasing popularity of swaddling.” It seems that tight swaddling that does not allow for flexion of the hips increases a child’s risk of DDH.

As a pediatrician and a father, I cannot imagine raising children without swaddling. Swaddling is an effective way to reduce crying, reduce the risk of SIDS and promote good sleep habits. Parents can continue to swaddle their babies, but it should be done in a safe manner.

Place your infant on a rectangular blanket with his shoulders even with the top edge of the blanket.
While holding his hands together and down with your right hand, fold the left corner across his left shoulder.

Roll your son on his side and tuck the left corner of the blanket behind the child’s shoulder.

Fold the right corner of the blanket across his left shoulder. Tuck the right corner of the blanket behind the child’s shoulder.

Fold the bottom flap up and wrap the flaps around the infant’s back.

A snug swaddle with free hip movement.

Here is the final result!

 
To reduce the risk of SIDS:
– Place infants swaddled on their back to sleep.
– Stop swaddling your child when they turn over and sleep prone.
– Choose a swaddling method where it is unlikely that a loose fold could cover a child’s face.

To protect your child’s hips:
– Swaddle them in a manner that allows maximal flexion of their hips.
– Swaddling can be snug but never tight.

These goals are best accomplished with the swaddling technique where the last fold is up. In this technique, the arms are folded in and in the final fold (up from the bottom), the hips are flexed. This method promotes hip flexion and loose folds that are closer to the feet than face.

For more information on “hip safe swaddling”, visit www.hipdysplasia.org.

Greg & eight!

Dr. Gregory Gordon grew up in Gainesville, Florida. He attended the University of Florida for both his undergraduate and medical degrees. After he completed his pediatric residency at the University of Alabama at Birmingham, he joined Pediatric Associates of Orlando. Dr. Gordon is the proud father of eight children. He is the Vice President of “The Gift of Swimming” (a local charity that provides swim lessons to Orlando’s needy children). In early 2010 Dr. Gordon started gregorygordonmd.com to share his pediatric and parenting experience.