The Swaddling Controversy Continues

You may have read my two previous posts in this blog's "Swaddling" section, which sparked a huge controvery among my readers.  My original post was an abridged version of the lead article I wrote for the September 2010 issue of the International Journal of Childbirth Education

After my article appeared, the editor received a letter from Dr. Harvey Karp, author of the popular book The Happiest Baby on the Block and its companion DVDNot surprisingly, Karp disagreed with many of my conclusions, as swaddling is the first "S" in his "5 S's" approach to calming fussy babies.  The journal editor kindly asked me if I would like to respond to Karp's letter, which I did.  You can read both Karp's letter and my response on page 26 of the Summer 2011 issue of the International Journal of Childbirth Education.

Responses to 'Rethinking Swaddling'

My December 3 post, “Rethinking Swaddling,” attracted more than 7,000 hits—a new record—and triggered many strong reactions.  For some, this post met a need; for others, it struck a nerve.  After reviewing the research, its central question was:  Does swaddling really calm babies, or does it stress them to the point of shutting down?

Readers responded with more than 50 comments here and on Facebook.  One wrote: “My paradigms are shifting at an alarming rate!”  Many understood the concern: “As a hospital lactation consultant, about 50% of my time is spent unswaddling and derobing babies and placing them on their mothers’ bare chests…Parents marvel at how I supposedly got a baby to latch who wouldn’t before.”  “I would like to see the readouts of blood pressure, brain patterns, heart rate, temperature, etc.” And: “I remember a professor telling me she used a certain DVD to teach what ‘shut down’ looked like in a newborn.”

Many disagreed strongly.  Some believed—despite the research findings—that because swaddling appears to calm babies that babies “like” or “prefer” it.  “It’s not me who insists on the swaddle, but it is really my baby who wants it.”  “Some [babies] prefer swaddling, others prefer to be free to move.” Many referred to swaddling as a way to “make babies happy.”  But returning to the question: Are swaddled babies really “happy” or are they shut down?  One thoughtful writer suggested: “it might be a great experiment to swaddle newborn puppies and kittens and see what happens, but probably animal rights activists would have my hide!”

Although avoiding swaddling right after birth made sense to most, some discounted the findings that swaddled newborns lost more weight and had lower temperatures.  They believed that because their swaddled newborns breastfed without problems or because the baby they didn’t swaddle lost more weight initially than the one they did swaddle, the research must be “wrong.”  Of course, there are many factors at work, and swaddling is just one of them.  It takes many more than one or two babies to accurately measure the effects of any practice.

Some were concerned about “the consequences of not swaddling.”  Without it, one wrote, “we would be seeing infants who are fussier, sleep less, and wear parents out more in the weeks following birth.  Temptation will be to put them onto their tummies to sleep, increasing their risk for SIDS significantly.”  Another wrote:  “My guess is that swaddling has saved many infants from shaken baby syndrome (after extended crying bouts) and also allowed babies who have never been willing to sleep on their backs before to accept this practice (if they are not co-sleeping and bedsharing families).”

Swaddling and sleep was the subject of many comments.  Several who were not bedsharing said their babies “needed to be swaddled to go to sleep.” One wrote that the biggest benefit of swaddling was “to encourage a baby to sleep on their back as per the AAP’s recommendation.  It is unfair to me to give parents a recommendation for safety, and then not offer them tools to help them follow those instructions.” Another wrote: “If parents didn’t have unreal expectations or believe infants are meant to sleep all night in their own space at a few weeks old…they would cope much better.” 

One wrote: “Swaddling helped immensely with putting him down to sleep after his needs had been met.”  Biologically speaking, though, body contact is not just an optional “nice to have.” Like milk, it is one of a baby’s needs.  Breastfeeding Made Simple explains that of the four categories of mammals, humans are considered “carry mammals.”  Like the other carry mammals—such as the great apes and marsupials—constant holding and feeding during the early months are the biological expectations of our young.  Has swaddling become a culturally acceptable substitute for the body contact our babies expect?  One writer suggested that swaddling can be okay if parents are alert to their baby’s cues, but another responded: “Swaddling suppresses the baby’s no amount of responsive monitoring can see cues that aren’t there.”  Or as one so succinctly put it:  “Humans are meant to be close to mum, not at arms length being shushed at.”

One considered the article a “blanket statement against swaddling” and an “all or nothing” approach “based on opinion and not actual facts.”  Another thought the post attempted to “take away a tool that many parents find so helpful and needed.” She contended that most parents only use swaddling as last resort after trying many other things first.  However, more than a few popular books and DVDs suggest swaddling as a first strategy to calm a fussy baby. 

Most would agree with the comment “We need to empower parents to read the research second and to read their babies and their own intuition first.”  However, if parents are told repeatedly that swaddling makes their baby “happy,” this colors their interpretation of their baby’s response.  Shouldn’t parents know that swaddling may be stressful for their baby?  Anything less than full disclosure is patronizing.  Only by hearing both sides can they make informed choices about this practice.

Another writer defended the post, noting “I don’t think the purpose of the article was to say swaddling should be thrown out altogether….It reads, ‘when babies get fussy, it may be best to limit swaddling and suggest instead parents consider alternatives, such as skin-to-skin contact and baby carriers.’”  This seems like a logical approach until we learn more about swaddling’s effects on babies.

Finally, a writer cautioned against limiting swaddling because it is an “age-old practice” that has been “used for centuries.”  However, the same could be said of discarding colostrum as “dirty,” an age-old practice in many cultures. We have since learned better.  And if we discover with further research that rather than calming babies, swaddling actually does stress them, we may need to rethink this practice as well as many of our own assumptions about it. 


Rethinking Swaddling

There’s no doubt that babies seem calmer and sleep more when swaddled.  But is this a positive or a negative?  The research provides some surprising answers, starting with the first days after birth.

Swaddled babies arouse less and sleep longer.1 That may sound good, but in the early hours and days after birth this can lead to less breastfeeding, which is associated with greater weight loss, more jaundice, and a delay in milk production.2

Swaddling delays the first breastfeeding and leads to less effective suckling.  In a study of 21 babies after a vaginal birth,3 researchers divided them into two groups.  One group was laid skin-to-skin on mother’s body, examined briefly, then returned to skin-to-skin contact for two hours.  The other group was shown to the mother, examined, and swaddled with hands free and then returned to mother.  The swaddled group showed delayed feeding behaviors, suckled less competently at their first breastfeeding, and established effective breastfeeding later.

When swaddling is added to other newborn stressors, it appears to worsen their negative effects.  Researchers compared outcomes among 176 mothers and babies, who were divided into 4 groups: 

  1. Kept in skin-to-skin contact with mother for 30 to 120 minutes after birth

  2. Held in mother’s arms wearing clothes

  3. Separated from mother at birth and returned to her after two hours

  4. Taken to the hospital nursery at birth and returned to mother for breastfeeding seven times each day at regular intervals

In each group, some babies were swaddled and some wore clothes.  The researchers reported that skin-to-skin contact reduced “the stress of being born” and found the babies kept skin-to-skin after birth had the highest body temperatures.4

Swaddled babies separated during their first two hours lost more weight.  Among the babies in Group 3 above, the swaddled babies had a significantly greater weight loss on their third and fifth days.5

Swaddled babies kept in the nursery were colder and consumed less milk.  Among the babies in Group 4 above, those who were swaddled had the lowest foot temperature of any of the babies in any of the study groups.  Newborns who were both separated and swaddled consumed less mother’s milk overall than those who were separated but not swaddled.  Their mothers also produced less milk on the fourth day and they had a shorter duration of breastfeeding overall.5

Swaddled babies in the nursery lost more weight despite consuming more formula.5  Possible reasons for this that the researchers suggested include:

  • Severely limiting baby’s movements is stressful, which burns more calories.

  • Swaddled babies receive less touch, which can compromise growth in preterm babies.6

If there are reasons to be concerned about a newborn’s temperature, a more effective strategy than either swaddling or using an infant warmer is to keep baby on mother’s body, putting blankets over both mother and baby.7,8,9 If the mother can’t provide skin-to-skin contact, the father is an excellent second choice.

But what about after hospital discharge?  Once a baby is breastfeeding well, is there any reason to avoid swaddling?  While swaddling may be helpful when used occasionally, routine swaddling during the first months associated with greater risk of: 

  • Respiratory illness10

  • Hip dysplasia11

  • SIDS in prone sleeping positions12

  • Overheating13

Evidence is also growing that babies’ hand movements aid them in finding the breast and latching. 14 Swaddling during breastfeeding to restrict babies’ hands may contribute to breastfeeding problems.

After reading the research, my own opinion of swaddling has changed.  In most cases a mother’s body is her newborn’s best “baby warmer.”  When babies get fussy, it may be best to limit swaddling and suggest instead parents consider alternatives, such as skin-to-skin contact and baby carriers.

For a more detailed look at this subject, click here to read “Rethinking Swaddling,” my lead article in the September 2010 issue of the International Journal of Childbirth Education.


1Franco, P., et al. Influence of swaddling on sleep and arousal characteristics of healthy infants. Pediatrics 2005;115(5):1307-11. 

2Yamauchi, Y., & Yamanouchi, I. Breast-feeding frequency during the first 24 hours after birth in full-term neonates. Pediatrics 1990; 86(2):171-75. 

3Moore, E. R., & Anderson, G. C. Randomized controlled trial of very early mother-infant skin-to-skin contact and breastfeeding status. J Midwifery Womens Health 2007; 52(2):116-25.

4Bystrova, K., et al. Skin-to-skin contact may reduce negative consequences of "the stress of being born": a study on temperature in newborn infants, subjected to different ward routines in St. Petersburg.Acta Paediatr 2003; 92(3):320-26. 

5Bystrova, K., et al. The effect of Russian Maternity Home routines on breastfeeding and neonatal weight loss with special reference to swaddling. Early Hum Dev 2007; 83(1):29-39. 

6Ferber, S. G., et al. Massage therapy by mothers and trained professionals enhances weight gain in preterm infants.Early Hum Dev 2002; 67(1-2):37-45. 

7Galligan, M. Proposed guidelines for skin-to-skin treatment of neonatal hypothermia. MCN; Amer J Matern Child Nurs 2006; 31(5):298-304; quiz 305-296. 

8Ludington-Hoe, S. M., et al. Safe criteria and procedure for kangaroo care with intubated preterm infants.JOGNN 2003; 32(5):579-588.

9World Health Organization. Integrated management of pregnancy and childbirth: Pregnancy, childbirth, postpartum & newborn care. Geneva, Switzerland: WHO, 2003.

10Yurdakok, K., et al. Swaddling and acute respiratory infections.Amer J Pub Health 1990; 80(7):873-75. 

11Sahin, F. et al.  Screening for developmental dysplasia of the hip: Results of a 7-year follow-up studyPediatr Int 2004; 46(2):162-66. 

12Ponsonby, A. L., Dwyer, T., Gibbons, L. E., Cochrane, J. A., & Wang, Y. G. (1993). Factors potentiating the risk of sudden infant death syndrome associated with the prone position. New Eng J Med 1993; 329(6):377-82. 

13van Gestel, J. P., et al. Risks of ancient practices in modern times. Pediatrics 2002; 110(6): e78.

14Genna, C.W. & Barak, D.  Facilitating autonomous infant hand use during breastfeeding.Clin Lact 2010; 1(1):15-20.