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Friday
Dec032010

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.

 

References

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.

 

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Reader Comments (38)

Thanks Nancy this is really great! I often think that as a hospital lactation consultant about 50% of my time is spent unswaddling and derobing babies and placing them on their mothers' bare chests. I often remark in the daily breastfeeding class that I think I get paid too much money per hour to be spending so much time on this(sort of as an off cuff remark to encourage them to do this at the beginning of class, if they don't do it themselves at some point usually I will do it so that I can more likely get the babies to feed during class.) Parents will marvel at how I supposedly got a baby to latch who wouldn't before when all I did was help or encourage mom to get the baby skin to skin!

December 3, 2010 | Unregistered CommenterBarbara Holmes

how interesting my son was swaddled from birth and woke every two to three hours for feeding day and night and never lost any weight still feeding at 3.5yrs and still regularly waking though no longer swaddled :)
my daughter not swaddled lost a bit of weight initially (6%) but soon regained and cos has access to her fingers slept through for 8 hours plus from 4 weeks old! now 3 mnths and goes 8-8 95%ile on bm alone

December 3, 2010 | Unregistered Commenterbabyboos

I guess my daughter was different than this article. My dauhgter is one, still nursing strong and was swaddled from birth to four months. We also had plenty skin to skin contact frequently everyday but at night, she was swaddled. She was quite colic and both helped her immensely. I could see how in the early days, skin to skin is much better and more effective. But once we were home and had breastfeedng established, she liked both. Both soothed her and got us through those very colic days. Every baby is different...different than the 176 babies tested

December 3, 2010 | Unregistered CommenterSarah

Interesting article! I used the swaddle but not for long and not all the time. My milk did come in quickest with the child I slept with on my chest instead of swaddled next to me. All of mine nursed well, didn't lose much, and did great overall. But, this makes so much sense. Swaddling is good, skin is better, a combination of the two must be ideal.

December 3, 2010 | Unregistered Commentermommytofour

This article seems full of haphazard assumptions to me. I agree that skin to skin in supreme in the early hours and days of welcoming a newborn, and certainly encourage parents to hold their babies as much as possible. However associating swaddling with hip displysia and prone position, although documented, has such rare instances. Overheating is also certainly possible, but parents are so careful about the temperature of their infant that I haven't seen this be an issue in working with over 800 babies so far. (Respiratory illness was new to me; I will have to look into that.)
I think we also need to look at the consequences of not swadling. We are not just replacing swaddling with skin to skin behavior (which would be ideal of course) but we would be seeing infants who are fussier, sleep less, and wear parents out more in the weeks following birth. Temptation will be put them onto their tummies to sleep, increasing their risk for SIDS significantly.
I don't think it is wise to dismiss an age old practice like swaddling in this manner. More evidence is needed before we leave behind something that has been recorded for centuries as a practice with breastfeeding infants.

December 3, 2010 | Unregistered CommenterABC Doula

I think you make some great points, however, my 8 month old has always needed to be swaddled to go to sleep. We are working on his falling asleep in his own crib at night these days, so he's not swaddled for bedtime, but when it comes to naps, he will not fall asleep if not swaddled, and on the off chance that miracle happens, he wakes up as soon as he's laid down. Sometimes, it's necessary to follow your child's clues and do for them what makes them most comfortable.

December 3, 2010 | Unregistered CommenterPhotoquilty

I'd like to add that my first son outgrew his swaddle blankets at 3 months and never seemed to mind. So it's not me that insists on the swaddle, but it really is my baby who wants it.

December 3, 2010 | Unregistered CommenterPhotoquilty

QUOTE my daughter not swaddled lost a bit of weight initially (6%) but soon regained and cos has access to her fingers slept through for 8 hours plus from 4 weeks old!

Yes I think unnaturally long sleep periods may also be a concern with swaddling (which may also be linked with SIDS) - plus encouraging finger sucking etc instead of the breast, which as Dr Palmer illustrates can impact negatively on the oral cavity. Some infants will gain with no nightfeeds, others wont and just as importantly a lot of mums wont be able to maintain supply.

It also seems to be about parental expectations: QUOTE I think we also need to look at the consequences of not swadling. We are not just replacing swaddling with skin to skin behavior (which would be ideal of course) but we would be seeing infants who are fussier, sleep less, and wear parents out more in the weeks following birth END

Babies are meant to be held close skin to skin or at least body to body. Instead of swaddling or not, why not support other practices eg stretchy wraps - which stop fussing and increase sleep? 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 (which may be ideal for parents in current society but is NOT best or natural for baby) they would cope much better. Not having a baby close is veering from the intended norm, so swaddling might help deal with the knock on effect of this separation ie distress, but with it the potential for lots of other negative implications.

I think the onus should be on proving it's safety (not just health wise but psychologically/emotionally ie what are brain patterns doing at this time)

December 4, 2010 | Unregistered CommenterCharlotte

I've had three babies, and all have been swaddled. I am a believer in in Dr.Harvey Karp (http://www.facebook.com/l.php?u=http%3A%2F%2Fwww.youtube.com%2Fwatch%3Fv%3DddRkI5wVIqQ%26feature%3Drelated&h=82fe1) AND I've never had any trouble at all getting my babies to feed , or producing milk . For sure they were not swaddled when I fed them, and those first hours after birth there was the skin to skin contact. I am expecting my fourth baby and would not change anything in what I did, meaning swaddling them.

December 4, 2010 | Unregistered CommenterDeb

I parented my first very much like the video, so I understand where people are coming from. On the other hand I parented my second and third children very differently and I felt quite sad watching the clip and just how detached it is. The baby is held away from the body, bound tight with no skin contact, movement and then loud noise thrown in too. I would like to see the readouts of blood pressure, brain patterns, heart rate, temperature etc during this. I don't really understand why the need to do all that ^ when you can offer the breast and/or use a stretchy wrap. Both calm baby far quicker, with far less crying, in a far more natural way. Humans are meant to be close to mum, not at arms length being shushed at. Why is skin contact only valued for a tiny period straight after birth? I thought this with my first, plus that you had to breastfeed every few hours and had never heard of wraps.

December 4, 2010 | Unregistered CommenterSally

All four of my children hated being the filling in burritos made of cotton "receiving blankets." I would make an obligatory attempt at swaddling them myself, but they fussed and fumed and struggled and eventually wiggled free of the wrappings, even when held in my arms. Also hated by my babies: those silly little caps nurses love to put on to "keep their heads warm." (I was not aware that I lived in Siberia. I stand corrected.) My two older babies were born in hospitals, so had to put up with this routine for days - my oldest because she was extracted via abdominal surgery, my second because she was eight weeks early and kept in a NICU for weeks.

I am not a big fan of swaddling or of keeping babies warm with hats. I have discovered that my babies preferred to get both tight cuddling and warmth from my holding them close, and that I prefer it as well.

I can see why maternity nurses LOVE swaddling, though. A tightly secured baby which does not rouse itself easily by making random or exploratory movements does not demand as much attention as a free baby, so requires far less maintenance when kept in a plastic box for "observation," routine, etc. Since swaddling blankets are not as warming as skin to skin or even clothing to clothing contact, the hats and, if necessary, warming lamps approximate the warmth of real cuddling.

And besides, it's traditional. Nurses like things like "traditions" and "routines."

December 4, 2010 | Unregistered CommenterSarah Dorrance-Minch

I would just like to let everyone know that some cultures don't and never really swaddle their babies, not this tightly and not like (I have seen) here in the west.
So, I don't see how "consequences of not swaddling" would be a great factor in everything. Each baby is different. My 2nd baby HATED being swaddled from very beginning. She prefered to sleep on me in the early days and weeks. Come to think of it, so did my first! But I was too stupid, naive and blindly followed my anglo partner and his family's practice of it.
Also, swaddling a colicy baby... I personally wouldn't do it. "Colic" frequently is tummy troubles and upsets (from my experience and readings), being restrained like in swaddling probably would not help, I would be more uncomforatble if forced into a certain position, frequently "straight" rather than curled up, fetal like ... but that is just me.
I personally see swaddling the mechanism used in the parenting practices which espoused babies being bottle fed on schedules, CIO techniques, sleeping in seperate rooms, etc...

December 4, 2010 | Unregistered Commenterxela

I always appreciate your thought process. And after reading this, see yet another reason why my early breastfeeding experience was diagnosed to fail. The very caretakers of my son followed an age-old tradition which even the hospital lactation consultant encouraged. I know that they were simply doing what they knew and that with the overwhelming amount of information, it is hard for them to make adjustments based on an individual child's needs. This is yet another reason why birth needs to be taken out of the hospital. Now that my son is 2 years old, I learn more everyday and realize that a first child is simply an experiment in motherhood. Thank you again for your constant reminder that we are caring for individuals and need to recognize that what they really need is the human touch and love that it shows.

December 5, 2010 | Unregistered CommenterCorryJ

My boys never did like being swaddled at all from birth. They loved being cuddled skin-to-skin.

December 5, 2010 | Unregistered CommenterJLW

I find it interesting to note that there is an assumption being made that swaddled babies are not being held, comforted or loved by their parents. My reality was different, our baby was swaddled while held and swaddling helped immensely with putting him down to sleep after his needs had been met. It seems to be too easy to say - just hold your baby, hold it lots and everything will be okay. More and more moms are not letting their babies cry it out anymore and are fairly responsive to their baby's needs. And the fact that the SIDS rate has improved immensely since moving children into the back-lying position has been entirely credited with SIDS rates falling throughout the world - the sleeping position has done this, not the absence of swaddling.

The articles you provide as proof are good in that they raise questions and learning and adapting are good, HOWEVER they do not prove that swaddling is bad for children. The articles you offer as proof even state quite explicitly, "There is still little known about which practice is potentially beneficial and which is potentially detrimental, although it is generally advised not to cover the head. It seems appropriate, therefore,that more epidemiologic studies be done on the effects of different swaddling practices before recommendations for clinical practice are made." The author is specifically recommending MORE studies, has stated the various differences in swaddling techniques around the world and so forth, whereas you've just made a blanket statement against swaddling.

I am in complete agreement that babies be held, that there is skin to skin contact after birth, breastfeeding, and all that. Kangaroo care has been proven extensively and I am a massive babywearing advocate and I really dislike it when it has to be an all or nothing, especially when the nothing is based on opinion and not actual facts. It harms and hurts the bwing movement...

December 5, 2010 | Unregistered CommenterDebora

I do find the idea of swaddling rather disturbing - rather like encasing a baby in a straightjacket. If the purpose is to re-create a womb-like environment, then holding a baby against the chest in order that he can share the mother's warmth and heartbeat is surely more biologically correct, and allows the child to play out the grasp reflex and feed on demand without distress.

December 6, 2010 | Unregistered CommenterAliD

It is important to note that Nancy's article and the research she refers to focuses particularly on the first few hours and days after birth.

In the journal articel, Nancy said: "Routinely swaddling babies during the first few days of life is associated with a delay in the first breastfeeding, less effective suckling at the breast, decreased intake of mother’s milk and greater infant weight loss."

Evidence-based research has shown that skin-to-skin contact is critical for optimal development in the baby's brain as well as facilitating extended breastfeeding and resulting in other benefits too, such as improved mother-baby interaction, reduced crying and better temperature control.

The first moments after birth have been described as "a sensitive period for programming future behavior."

Swaddling will definitely deprive a mother and baby dyad of all the benefits of skin-to-skin contact in that precious time just after birth!

December 7, 2010 | Unregistered CommenterShirley

Just want to clarify that I agree with Nancy's assesment of early newborn needs for skin to skin and to be able to breastfeed without the restriction of swaddling. But the article goes on to state that using swaddling after discharge can be harmful and that other techniques should be used instead. This assumes that parents are not already using 'other techniques' to soothe their fussy babies, and that they are not being held skin to skin as well as in baby carriers. This has not been my experience of the past 10 years, working closely with mothers and their (about 800) babies. Mothers are working tirelessly to do their best for their newborns; breastfeeding, holding, wearing, rocking, singing, patting, and on and on to soothe them. It is usually only after repeated attempts with these techniques that they reach out for something like swaddling. To make recommendations against swaddling is to take away a tool that many parents find so helpful and needed, even when they are successful breastfeeders, wear their baby regularly, and offer baby skin to skin time as well. I just don't see the research in the early moments (hours or days) relating to the following months (and subsequent struggles with 'back to sleep'), and I think we need to be careful not to limit tools that help babies and parents through that challenging 4th trimester.
The risks of swaddling are very obscure and I feel overstated in this article. (i.e. There are no swaddling techniques I know of that teach to swaddle an infant's hips to the point that dysplasia might be a concern. Parents who are taught to swaddle would also never be told to put them face down, and temperature is always a concern for new parents, as they are well aware of overheating and the relation to SIDS risks.)
Maybe I work in an area with well informed breastfeeding and baby wearing parents, but I assume that if they are learning a skill like swaddling, that they are being taught (since it is not an instinctive skill) about the nuances of how and when to use it. I think it is unhelpful in this manner to list swaddling as "risky" after discharge.

December 7, 2010 | Unregistered CommenterABC Doula

I agree that this topic warrants more investigation. Much as one would hope that all parents have a supportive health care professional to teach them proper swaddling techniques, the reality is that most people hear about it from a friend or relative who might not be so diligent in imparting critical information. I agree with the points Nancy brings up regarding the early days after birth. Skin to skin is imperative. Getting a newborn to sleep might sound like a great idea, but perhaps they are not meant to be anywhere but naked against their mothers naked chest, feeding frequently. We are hormonally primed after birth to tolerate that behavior.. lets take advantage of it... I think this is especially important with late preterm babies, as I observed with my grandson who would sleep when swaddled but would then sleep right through a feeding... my daughter did not get proper instructions from the pediatrician who gave it to her... imagine that! I would bet that any other mammal would have difficulty feeding their young if there was as much interference as there is in humans. (might be a great experiment to swaddle newborn puppies and kittens and see what happens, but probably animal rights activists would have my hide!) Swaddling newborns, I suspect, became even more popular in modern hospital nurseries when mothers had limited access to their babies who then had to be kept quiet or all hell would break loose.. all those babies screaming for their mothers..... Maybe a broad study of mothering and parenting behaviors (like the latest sleep survey by Kathy KT ) will reveal what really works and why. I keep thinking that we need to re-discover nature first before nurturing can be taught... hope that makes sense.

December 7, 2010 | Unregistered CommenterCelina Dykstra

some babies need swaddling to help organize their state control, and many cannot reach a quiet alert state without it so it concerns me to think of removing this entirely from the playing field. All of that aside, there is a building block issue at play here:
I agree after having been in hundreds of american homes where parents really do seem to try a wide variety of options on as they get to know their baby that swaddling is one of the tools they use. Even with those that love Dr. Karp's work, I have rarely seen a baby left swaddled for most of the hours of the day. We need to empower parents to read the research second, and to read their babies and their own intuition first. By combining the two with a heavy emphasis on the parents as the primary experts on their babies and helping to create space for the family to just be together and to get to know each other instead of jumping in with all of our solutions, they will find the right combination of tools to meet baby's needs and to gain confidence in their parenting abilities.

December 8, 2010 | Unregistered Commenterjlo
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