The Question of Routine Swaddling
By Gussie Fauntleroy
Nov 09, 2011
Please see the Special Report: Swaddling Reconsidered for more information and resources on routine swaddling.
Remember the bumper sticker, “What Would Jesus Do?” Here’s a variation on that query: What would Jesus’ mommy do? We are told his mother wrapped her newborn in swaddling clothes. So if it’s good enough for baby Jesus…?
Yet simply because a practice has been widespread in various cultures and time periods doesn’t mean it is best for babies.
Likewise, even though routine swaddling may have popular authority on its side at the moment—through bestselling books, advertising, parent education organizations, and even the apparent evidence of first-hand experience—this does not in itself mean its benefits outweigh potential disadvantages in the light of current research and intuitive common sense.
The obvious and well-promoted benefits of swaddling, of course, are a calmer baby who fusses less and sleeps more. Parents are given a chance to rest, relieved of the stress of an “excessively crying” infant. The swaddled baby appears calm and content.
Other advantages often mentioned include preventing baby from scratching her face with her fingernails, and keeping her from startling herself awake with her own movements. In addition, proponents claim swaddling reduces the risk of sudden infant death syndrome (SIDS) in babies placed on their backs to sleep, since with confined limbs they are less able to turn over into a prone position.
Why Even Question It?
For millions of new parents, the ubiquitous presence of pro-swaddling messages creates a reassuring sense of caring both for their baby’s needs and their own. For most, there seems no reason to question the practice. The idea that it elicits controversy may be surprising. Yet hidden behind this friendly face is a growing body of research from around the world that calls into question the benign, warm-and-cozy nature of routine swaddling of newborns and older infants.
It should be noted that the term swaddling means different things to different people. For some parents, loose wrapping with arms free is considered swaddling, while others use roomy sleep sacks that allow for movement within the bag. Here, however, we are referring to tight or constrictive wrapping using a swaddling blanket or cloth that holds the baby’s arms and legs straight. The blanket’s snugness is seen as providing a sense of comfort and security, and ensures the infant won’t pull it loose.
Wrapped in History
It was not only Jesus’ mother who wrapped her baby in swaddling clothes, which likely was cloth held in place by bandage-like strips of cloth wound around the infant. Some version of the practice of wrapping babies has taken place in many cultures worldwide and across time. Among the earliest evidence of swaddling, dating back several thousand years and perhaps originating in what is now central China, were various forms of the cradleboard.
As with American Indians and other later cultures, the cradleboard contained and protected babies during nomadic travels. Some current-day North American tribes continue to use cradleboards. In the Southwestern United States, for example, a Navajo mother may secure her baby in a cradleboard and prop it close to her while she works at her weaving loom.
Over the centuries, stated benefits of swaddling have included producing straight limbs and proper physical development, making babies stronger, preventing self-injury, allowing both parents to work in the fields, and providing babies with warmth and comfort. In 17th and 18th-century Europe the employment of swaddling by wet-nurses was often associated with neglect, with wet-nurses known to leave tightly wrapped babies unattended for hours.
Eighteenth-century philosopher Jean-Jacque Rousseau warned against some motivations for swaddling in his novel Emile: or, On Education: “A child unswaddled would need constant watching; well swaddled it is cast into a corner and its cries are ignored […]. It is claimed that infants left free would assume faulty positions and make movements, which might injure the proper development of their limbs.
“This is one of the vain rationalizations of our false wisdom which experience has never confirmed. Out of the multitude of children who grow up with the full use of their limbs among nations wiser than ourselves, you never find one who hurts himself or maims himself; their movements are too feeble to be dangerous, and when they assume an injurious position, pain warns them to change it.” 1
In 19th and 20th-century Europe, England, and America, sedatives such as paregoric (camphorated tincture of opium), alcohol, antihistamines, or children’s cold medicines were sometimes used instead of swaddling to calm and quiet fussy babies.
By the mid-20th century, American hospital maternity wards were turning to swaddling newborns as a means of relieving overwhelmed nurses when babies began being separated from their mothers and placed in the hospital nursery after birth.
Respected Los Angeles-based pediatrician Dr. Paul Fleiss invokes “disturbing mid-20th century photographs taken in factory-style maternity hospitals…(with) tightly swaddled newborn babies precision packed into orderly rows of sterile plastic bins. In these pictures, the babies are unmoving and still...like termite larvae in their egg cases.” Although many hospitals now embrace rooming-in, others continue to separate mother and infant and continue to rely on—and teach new parents—swaddling to quiet crying babies.
In recent years, routine swaddling by parents has grown increasingly popular, in large part as a result of the efforts of California-based pediatrician Dr. Harvey Karp. Dr. Karp’s best selling book, The Happiest Baby on the Block, and related DVDs have reached millions of parents in search of an easy way to quiet a crying baby. Numerous online chat rooms and parenting sites also attest to the mother-to-mother spread of “success stories” involving swaddling. As emphasized in Dr. Karp’s writings and educational programs, one significant attraction of swaddling is that fathers, as well as mothers, can have hands-on involvement in quieting baby.
Crying for a Reason
With all this in mind and assuming that modern parents don’t leave wrapped babies unattended for hours on end, what could be the downside of swaddling?
One core concern on the part of pediatricians, breastfeeding advocates, and others is that routine swaddling interferes with a mother’s intuitive response to her baby’s needs. “Crying is the baby’s language, his voice; it’s the only way he has to tell you he needs something,” stresses internationally-known breastfeeding advocate, pediatric nurse practitioner, and educator Kittie Franz. “Newborns are about need, not want. Before you use this tool (of swaddling), find out what he needs—don’t just shut him up.”
Dr. Fleiss goes even farther, suggesting that when an infant with unmet needs is swaddled and separated from his mother, the message he receives is: Give up. No one cares, no one is going to help you; solve it yourself.
“You can say swaddling works; it stops the baby from crying. But because something works doesn’t mean it’s a good thing to do,” Fleiss argues. “I tell parents not to swaddle, ever. When a baby is crying he’s saying where’s my mommy? He’s not saying wrap me up real tightly. He should be put to the breast, he should be talked to, sung to, held, loved.”
Comforted, or Shut Down?
In fact, many researchers and infant advocates now believe the apparent contentment of a swaddled baby may in fact be a sign of listlessness and shutting down, rather than of feeling comforted. Franz tells of a new product introduced some years ago at a medical conference. Plugged into a crib, the device vibrated its springs while emitting “white noise.” Fussy babies were believed to be calmed by the rhythmic movement and sounds. But photographs of the babies’ faces told another story.
“In the before photos the eyes were open, hands fisted, there was tightness around the nose and mouth, and the babies were crying,” Franz says. In photos taken as babies experienced the crib device, the hands were still fisted, there was the same furrowed brow and tightness around the eyes and mouth—but the babies were silent. Franz has observed a similar response among swaddled babies. “The baby is staying quiet but is not relaxed or happy. That led me to conclude the baby is shutting down,” she says.
More Sleep, Less Nursing
Breastfeeding advocates note a related and worrying aspect of swaddling, especially during a baby’s first days and weeks. Newborns who are routinely swaddled have been found to feed less frequently, suckle less effectively, and have greater weight loss than those left unswaddled with access to the breast. 2
One reason is that swaddled babies awaken less frequently and less fully, often falling asleep again while feeding. The American Academy of Pediatrics suggests that breastfed newborns need to feed eight to twelve times every 24 hours. Swaddled babies, however, often feed no more than six or seven times in a 24-hour period. 3 This is related to the natural progression of sleep states in infants. As a baby begins moving through the sleep stages from deep to light, her eyes move a little under closed lids and her mouth moves. As she rises into even lighter sleep, her arms begin to wave, or “cycle.” 4, 5 This arm movement serves as a natural cue to help wake baby for her feeding. If the arms are bound by swaddling, the baby may sink back into a deep sleep and miss a feeding.
Some years ago Franz, while working as a pediatric nurse practitioner in Santa Monica, California, noticed that breastfed babies often lost as much as 10 percent of their birth weight in the first week when they were swaddled. This is a higher than normal weight loss that calls for supplemental feeding to avoid rapid escalation downward into dangerous dehydration.
Franz began telling the parents of these swaddled babies to keep their babies un-swaddled for 24 hours, and in most cases the infants quickly began regaining weight. “Babies need to feed around the clock and when they’re kept swaddled they sleep through their cues. They don’t wake up to feed,” she explains. She adds that she noticed that the mothers who stopped swaddling were happy with the weight gain, but the fathers tended to be not so sure they wanted their babies “so awake” all the time.
There are circumstances in which it may be appropriate to swaddle an infant as a temporary short-term intervention. One is the case of a baby—born to a drug-addicted mother, for example—whose central nervous system is immature, resulting in jitteriness or excessive erratic limb movement. Another is when an infant has too much muscle tone and her limbs remain stiffly extended or too tight. Both situations can negatively affect breastfeeding and swaddling can be helpful, Franz observes. However, she stresses that whenever she recommends swaddling it is always with room for the arms and legs to flex, rather than held straight at the baby’s sides.
Among the most commonly stated benefits of swaddling is the calming of babies who cry inconsolably from the pain and discomfort of colic. Yet a mother may not know whether her child has colic or is crying for other reasons, Franz notes. In such cases she recommends applying the “rule of threes”: If the infant is over three weeks and under three months old (the age range in which colic occurs), with bouts of crying for three hours a day, three times a week, he very well may be suffering from colic. But even a truly colicky baby may be helped more by being carried than by swaddling, since motion helps relieve colic symptoms by encouraging bowel movements and the passing of gas, Franz points out.
While swaddling would appear to be a good way to keep a newborn warm and cozy, especially in cool climates, research indicates skin-to-skin contact with mother is the best way to regulate an infant’s temperature. In a study of 176 mothers and babies conducted in a Russian hospital, a team of Swedish, Russian, and Canadian researchers found that swaddled newborns placed in the hospital nursery were colder—as measured by foot temperatures—and consumed less mother’s milk than those not swaddled. 6
Bundled babies not only miss out on their mother’s physical warmth and comfort in cool environments; in overly warm circumstances swaddled babies can become dangerously overheated, leading to brain damage or even death. This is especially crucial among ethnic or cultural groups with a traditional belief that mother and her newborn should be kept very warm, or in cases where families have recently moved from a cold to a hot climate, Franz notes. “If a baby is swaddled and his onesie is damp from sweat, then he is at great risk of over heating,” she says.
It is important to note that most studies on swaddling compare swaddled and un-swaddled babies who in both cases are separated from their mothers, rather than looking at babies in skin-to-skin contact with mother. When skin-to-skin contact is introduced into the equation, the purported advantages of swaddling dramatically diminish in comparison.
South African researcher Dr. Nils Bergman suggests that through skin-to-skin contact, mother helps her baby “regulate,” or find the optimal set-points for future control of physiological functions including temperature, heart rate, breathing, and hormone levels. This results in thermal and behavioral synchrony between mother and baby.7, 8, 21
Bergman also notes that newborns are able to “self-regulate” by reaching their arms out to cool themselves down. “Keeping temperature in homeostasis requires freedom of movement,” he believes.
Babies are natural wigglers. Flexing and extending arms and legs, wiggling fingers, and moving around to whatever degree they can is one way of refining muscular control and assisting in the development of the nervous system, observes Dr. Fleiss. “Humans need total freedom of movement, not only so that blood can properly circulate to all the extremities, but for critically important neurological reasons that science is just now beginning to document,” he maintains.
Others point to the fact that flexion is the baby’s natural position. In the womb, a fetus’s arms are flexed with hands at the mouth. Tight swaddling with straight limbs not only forces an infant into an unnatural position, it prevents her from the self-soothing that comes from putting her hands to her mouth.
As swaddling has grown in popularity, so has concern about the potential for developmental dysplasia of the hip (DDH) in tightly swaddled newborns. 9,10,11 Hip dysplasia is a deformation or misalignment of the hip joint, which can lead later in life to premature degenerative joint disease and chronic pain, including early arthritis of the hip. The often-congenital condition can be exacerbated in a baby’s first days and weeks by forcing the legs to remain in extension through tight swaddling. In a technical report released Nov. 1, 2011, the American Academy of Pediatrics recommends against tight swaddling for this reason. The authors state: “This is particularly important, because some have advocated that the calming effects of swaddling are related to the “tightness” of the swaddling.”23
A more commonly noted risk is that of sudden infant death syndrome, which has been linked to babies sleeping prone (face down). In this sense, swaddling may offer some protection for young babies who are placed face up to sleep, since without the use of arms and legs they are unable to turn themselves over. However, in one study, some swaddled babies were able to turn themselves over onto a prone position by three months of age, suggesting that older swaddled babies may be at greater risk of SIDS even when placed supine, or face up, to sleep.12
In addition, an Australian case-control study found that among babies laid face down, those who were swaddled were at greater risk of SIDS than those (also face down) who were left un-swaddled. 13 “These results suggest that if infants have to sleep in the prone position for a specific medical reason, they should be placed on a firm mattress and not swaddled,” the researchers conclude. (According to the American Academy of Pediatrics, one medical reason for placing a baby prone to sleep is infant gastroesophageal reflux.) Franz reminds us that even when sleeping prone, babies reflexively use their hands to push against the mattress to be able to lift and turn their heads, which helps protect the airway.
Whether sleeping prone or supine, swaddled babies in life-threatening situations may be subject to an added level of danger because swaddling inhibits arousal, according to a 2007 review of the research in the Journal of the American Academy of Pediatrics. 14 In addition, a too-high body temperature—resulting from swaddling in combination with an overly warm environment—is believed to be a possible contributory factor in SIDS.
Another potential health risk associated with tight swaddling is pneumonia and upper respiratory infections. One reason may be that a tightly wrapped chest restricts expansion of the lungs, which can increase susceptibility to infection. 15, 16
Officials Weigh In
While the American Academy of Pediatrics mentions swaddling as a possible aid in “prevention and management of pain and stress in the neonate,” 17 the AAP has no official policy on the practice. (Significant research suggests breastfeeding and skin-to-skin contact is an effective analgesic and is preferable to swaddling in this function. 181920) The American SIDS Institute discourages the use of routine swaddling because of its potential to increase the risk of SIDS, according to Executive Director Betty McEntire. McEntire cites the risk factors of overheating, turning over to face-down position while swaddled, or pulling swaddling fabric loose. “Unless a baby needs swaddling, why take the chance?” she asks.
Attachment Parenting International also has no official policy on swaddling. However, because of the API’s focus on helping parents become more sensitive to their baby’s cues, co-founder Barbara Nicholson expresses concern that routine swaddling can mean parents become less closely attuned to their infant’s needs.
What Baby Really Needs
Nicholson and others note that other tools for soothing a baby can work at least as well as swaddling and have additional benefits. For example, carrying baby in a fabric baby carrier provides a similar sense of comfort but with the added stimulation of the mother’s movement and closeness to her body and the rhythm of her heartbeat. “What I love about a baby carrier is that the baby is up seeing the world. Babies are very observant, and they really love that motion,” she says. Other excellent tools for calming a fussy baby include skin-to-skin contact and gentle infant massage. “We (at API) talk a lot about the importance of touch,” Nicholson says.
Studies show that separation from mother creates stress in young babies. When babies in a 2006 study were held by their mothers much of the time in the early weeks after birth, crying was found to be significantly less than among those not held. 22 Dr. Fleiss agrees. “The best way to prevent crying is to keep your baby in your arms and be attentive to his beautifully subtle and effective communication efforts,” he believes. “Yes, this is a lot of work. Caring for babies is the hardest work there is, but it is also the most rewarding,” he stresses. “I guarantee that you will look back upon the physical closeness you experienced with your child during his babyhood as the most meaningful and cherished moments of your entire life.”
Franz offers parents a simple way to sort out conflicting advice. “See which basket the advice fits into: the good-for-the-parent basket or the good-for-the-baby basket,” she suggests. “Remember: You’re not managing an inconvenience; you’re raising a human being.”
Gussie Fauntleroy is a Crestone, Colorado-based writer whose work has appeared in national magazines including Orion, Arts & Antiques, Southwest Art, American Craft and Native Peoples. She is the author of three books about visual artists, and has written on a variety of topics for local and regional publications.