Swaddling

Question: Please could you inform me re safe wrapping of a baby. Your SUDI presentation talks about unsafe wrapping.Would be good to advise re safe wrapping. (November, 2009)

Response (updated Sep 2012): Thanks for the question. Swaddling has documented benefits and harms1,2. It can reduce crying, improve sleep and help babies settle as well as suppress arousal, influence mobility and effect thermal control. It can also increase the risk of developmental displasia of the hips (DDH) and this is becoming increasingly common due to inappropriate swaddling (with the legs together). How people swaddle makes it a safe or unsafe practice. Depending on how it is practiced, swaddling can either increase or reduce sudden infant death rates and healthy hip development.

Better infant sleep and healthy infant arousal seem to work against each other. Yet helping babies settle is a driving concern for parents and coroner reports too often describe parents resorting to unsafe practices in order to achieve this. If parents choose to swaddle their babies what is paramount is that the baby is sleeping face-up (on the back) and with a clear face that will stay clear throughout the sleep. These safe sleep principles support people to make a safety assessment whatever the situation. The protective effect of face-up sleeping on healthy arousal appears to override the risk effect of swaddling, in relation to prevention from sudden infant death.

If swaddling leads to a changed position (no longer on the back) or a covered face it becomes dangerous. More specifically, if the swaddling material is bulky and leads to overheating, the wrapping too loose and covers the face, or too tight and the baby cannot breathe against the tightness; if the baby is swaddled and on the side, propped on pillows, the bed is sloping or mattress tipping; if the baby is also already more vulnerable e.g. due to smoking in pregnancy, or is not used to being swaddled; if the baby is still swaddled at a stage in their development where they can get into situations but not out of them - then these factors, in isolation or in combination, can make swaddling dangerous. 

Yet swaddling, when applied with regard for safety of hips, airways and positioning, has important sleep and settling benefits for babies and parents alike. Balance is needed in our advice giving. We offer guidelines below to support healthcare professionals in tehir discussions with families.

Safe Swaddling (or Wrapping) guidelines for sleeping babies (developed by Change for our Children)

  • Position: only for babies lying flat and on their backs. Can beangerous if babies are in any other position.
  • Clothing: dress baby in light clothing (eg singlet and grow suit) and avoid over-dressing babies who are also swaddled
  • Wrap Size: a 120 cm x 120 cm muslin or light cotton square is ideal. Avoid undersized wraps from which babies can break free and risk a covered face.
  • Wrap Material: choose wrapping material that is light weight. Wrapping with heavier materials needs to be considered bedding and care is needed to prevent babies from overheating.
  • Method: end result of wrapping is : firm around the shoulders, loose around the hips, clear of the face. (Baby must be able to move their hips freely, make easy breathing movements and maintain a clear face)
  • Frequency: If swaddling is to be practiced, it needs to be a applied routinely from birth as 'naive to swaddling'. that is 'unaccustomed', increases SUDI risk.
  • Co-sleeping: only swaddle babies when sleeping in own 'baby bed. Avoid swaddling in any shared sleeping situation as this combination increases SUDI risk.
  • Developmental stage: use a wrapping method that is appropriate to a baby's developmental stage. Either stop swaddling when a baby attempts to turn,  or wrap using an arms free method.
  • Specialised wraps: if using specialised wraps ensure they enable you to achieve the same end result: firm across the shoulders, loose around the hips, clear of the face.
  • Older babies: once babies can roll, they need their arms free to enable some protection against a covered face. If wrapping is to continue, it needs to be 'arms free' where the lower body is wrapped from under the arms.
  • Demonstration video (via Dropbox) of the Flexible Frog safe swaddling method for young babies
References
1 van Sleuwen BE et al. Swaddling: A Systematic Review. Pediatrics 2007;120(4);e1097-e1106
2 Richardson HL et al. Minimizing the Risks of Sudden Infant Death Syndrome: To Swaddle or Not to Swaddle? J Pediatr. 2009 Oct;155(4):475-81.