This guest was written by Sheena Hill. We encourage mothers to express themselves and make their own educated choices. The views and opinions expressed here may or may not be the opinions of “I Am Not the Babysitter”.
Section II
What is the point of swaddling?
Swaddling is the ancient art of wrapping a baby snugly with a blanket to restrict involuntary movement. Swaddling techniques vary from European-based wrapping in bands to a South American method of tightly folding blankets or sheets around the child. Though swaddling variations persist–depending on the period in history, culture and the perceived needs to be addressed–the common thread of the practice is to achieve infant motor restraint. Methodology aside, swaddling was consistently used to keep infants warm1, 11-14, to immobilize them and to help prepare their bodies for the lives that awaited them. Historically, swaddling has been used in most societies in northern, temperate and subarctic regions, including those in Asia, South America, and the Mediterranean as well as throughout the Middle East. For societies in Africa and other humid or high temperature locations, the traditional practice of wearing children in a sling (often nearly naked) remains a reputable alternative to swaddling10. In other words, evidence for swaddling throughout history and cultures is pervasive.
Cultural and Historical Use of Swaddling:
Swaddling was discussed in the Bible, both in Ezekiel and Luke, the latter specifically identified swaddling as a component of the care for baby Jesus. Swaddling was likely a staple of infant care in the ancient world, a theory supported with art and literature, which provide countless examples of swaddling by Greeks, Romans, Jews and Christians alike (swaddling and infant salting–in Greek and Roman style–was intended to prepare the skin for the harsh environment and this practice served as the model of infant care for more than 1,500 years). The countless artistic depictions throughout history confirm its widespread use and acceptability. Variations on swaddling included swaddling materials, start time, duration and the overall intention1.
One of the key variations I discovered in my research for this post is the purpose of swaddling across cultures and history. While some believed swaddling was necessary because infants were weak and would otherwise fall apart, others viewed the practice as a method of creating cooperative children or preparing them for the restrictions and suffering of life. By many cultures at various points in history, swaddling was even considered a means to prevent masturbation in infants or to prevent babies from groping their mother’s breasts while nursing. For most cultures throughout history, swaddling was used as a general technique for quieting and containing infants1. In the late 1770’s, doctors advised mothers to swaddle on alternating sides so that infants would grow straight. In some cultures, swaddling kept infants occupied while mothers worked[1], either domestically or outside the home. Culture and historical context aside, for most parents who have employed the technique, swaddling was intended to help babies retain warmth and comfort.
Swaddling continued through the Middle Ages and early modern period. However, once medical professionals lost confidence in the ability of mothers to swaddle correctly1, they began to warn against the practice. It initially came into question late in the eighteenth century after physicians, such as William Cadogan, claimed swaddling was harmful to children and advocated for social reform in England and France. During this time, several cases of infants being swaddled too tightly and suffering circulatory restrictions from being worn on a back board while swaddled created hysteria. Convinced that no mother was capable of understanding the safe way to swaddle, doctors began to strongly advise against swaddling1. Swaddling began to disappear more widely in Europe in the era of industrialization, as it became viewed as a “primitive” practice, used by rural populations (much like breastfeeding is promoted as a primitive or impoverished infant care choice). In 20th century Europe, swaddling was seen as a practice which denoted inferior social status. However, swaddling has persisted into the twenty-first century, particularly in Eastern Europe and the Middle East. Many mothers from South and North America rely on swaddling to pacifying the infant and preventing his waking himself by sudden movements1. Even in societies where swaddling traditions were nearly lost, the custom has seen recent resurgence in popularity, due to its effectiveness at soothing infants15, 16. For example, in the Netherlands over the past decade, swaddling has made a prominent comeback, which is a frequently recommended intervention due to its dependability in calming crying babies18.
Now, I hope that seeing swaddling through the lens of culture and history can help you identify the roots of the anti-swaddling standpoint. From this perspective, it is clear that swaddling has been extensively used across the planet and for a variety of reasons throughout most of history. The only reasons it initially received criticism was for signifying lower social status and a fear that parents would not be competent to swaddle in the safest manner. These are not good reasons to direct parents away from a respected and effective practice! As a car seat technician, I am aware that misuse rates are currently over 75% nationwide, which means that most kids on the road right now are not as safe as you think they are. Yet, I don’t instruct parents to stop using car seats, simply because they are not using them correctly! Instead, I focus on education campaigns to help parents learn the importance of safety; swaddling belongs in this category. Rather than make a decree that swaddling is unsafe, let’s ensure that people know how to swaddle safely. Furthermore, I imagine that you are as outraged as I am that Nestle and formula companies make new mothers believe that breastfeeding is for ‘poor people’ or would fail their children in some other obscure way. Swaddling belongs in this category. Women are told that swaddling is for uneducated mothers1 so they don’t try it. Please don’t allow swaddling be used as one more tool in the indoctrination of fear-based parenting, which insists on amnesia and abandonment of what has evolutionarily worked for parents for the duration of our species.
Swaddling has really gotten an unfair rap as a top safety hazard; what makes it worse is that its trashy reputation is allegedly backed by research. In fact, research conducted over more than 100 years has shown quite positive results regarding the benefits of swaddling. I want to examine some of the basic research on the topic and then specifically address the three main safety concerns that people reference when they claim swaddling is unsafe: hip dysplasia, SIDS and breastfeeding.
Research
Given its consistent impact on infant care, a decent amount of research on swaddling exists. Initial research on swaddling occurred in the late 1800’s. Interestingly, some of the early research on swaddling actually focused on swaddling for animals and found results applicable to human infants as well. In the early 20th century, researchers made correlations between immobilization and effective sleep induction in a variety of species. They also asserted that these animals seemed to adapt easily to motor restriction and subsequently had an easier time going to sleep without restraint in future incidents22, 23.
Infants were a popular research interest during the first half of the 20th century, with research conducted on swaddling and related topics with relative consistency from the 1920’s through the 1960’s and again in the past twenty years. Several full scale empirical studies of swaddling practices have been conducted, as well as a systematic study, which reviewed 82 sources which examined swaddling. Evidence supports that it increases sleep and sleep efficiency19, reduces levels of motor activity1 and spontaneous waking4 and allows for fewer startles when compared directly to responses from non-swaddled infants. Moreover, research indicates that there was no decrease in a swaddled baby’s capacity to respond to stimulation and continue to interact with their environments1, 10. Through studying a variety of swaddling forms and cultures, researchers discovered that the mere process of restraining the infant produced a tranquil, cooperative state; finding that almost all the children studied responded well and benefited greatly from being swaddled. Recent research asserts that swaddling also addresses excessive crying and, in response to pain, has a similar calming effect as a pacifier 20. Swaddling appears to have immediate results in comforting distressed babies, even before they struggle to the point of clear muscular fatigue. In other words, simply the act of being swaddled comforts them1. In a randomized study of Mongolian babies, there was no evidence that swaddling impacted mental and psychomotor development21. Clearly, descriptive and controlled studies confirm that swaddling enhances sleep continuity and can be trusted to calms babies, who must adjust to the chaotic world beyond the womb.
Now that we have looked at some of the highlights from the prominent research on swaddling, I want to take the time to refute each of the common misconceptions regarding research on specific dangers of swaddling. The three most commonly cited dangers of swaddling include causing hip dysplasia, increased SIDS risk, and interferes with breastfeeding.
Swaddling and Hip Dysplasia (DDH))
First, let’s talk about hip dysplasia (DDH). It is true that swaddling too tightly in the hips and legs can cause hip problems since the hips are still growing and tight restriction limits the natural movement of hips in their sockets. However, too tight swaddling includes swaddling so tightly that all movement is prohibited for the infant or placing baby’s legs straight down. The hysteria over swaddling leading to hip dysplasia is so odd to me because hip dysplasia is actually a relatively common occurrence in newborns, since stronger indicators of developing DDH include genetics and breech delivery. Furthermore, the real parenting practice which puts infants at higher risk for DDH is unsafe baby-wearing (like using ‘crotch dangler’ carriers, wearing baby facing outward, or wearing babies so that their legs hang straight down–instead of going out to the sides at the hips and only hanging down from the knees, as is natural and safest for all children!). To prevent swaddling-related hip dysplasia, swaddle so that there is enough room at the midsection and the bottom of the blanket so that baby can bend their legs up and out from their body. Swaddling is intended to limit involuntary movement, not completely restrict the child24-26.
Swaddling and SIDS
Yes, swaddling does help babies stay warm, because their body heat is contained. For this reason, swaddling can put an infant at a higher risk of overheating. This concern can be easily addressed by removing a layer (or all) of the baby’s clothing while swaddling and placing a fan in the room where they sleep. It’s also true that placing a swaddled baby in the prone position (on their belly) to sleep puts them at direct risk for suffocation because they are unable to roll over or push themselves up. Since this reason is also a general risk factor for SIDS, it is imperative that infants are placed on their backs to sleep (whether they are swaddled or not). However, several studies demonstrate that safe swaddling actually reduces the risk of SIDS and encourages parents to place babies to sleep on their backs. Researchers conclude that the advantages of swaddling outweigh any risks as long as the infants are placed in the supine position for sleeping27. The best way to utilize swaddling while continuing to minimize SIDS risk is to always keep baby’s head and face exposed (yes, this needs to be stated, as this was one of the risk factors the anti-swaddling camp has mentioned), place babies to sleep on their backs and cease swaddling as soon as an infant can roll over. Additionally, refrain from overdressing babies and remember that a swaddled baby does not need any extra blankets. Furthermore, swaddling in a way which maintains access to the hands allows infants to suck as needed, which ensures accessible breathing and is an added SIDS reduction faction.
Swaddling and Breastfeeding
Though only one study specifically examined the effect of swaddling on breastfeeding, it has been cited widely as a major reason why swaddling should be reconsidered and used minimally. The research suggests that swaddling immediately after birth impedes breastfeeding. This should not be surprising, because we know that skin-to-skin contact following birth is crucial to nursing. Of course babies should not be swaddled immediately after birth! As standard practice, newborns should always be placed on their mother—either at her breast or simply skin to skin–within 1 hour of birth and if she is not available, dad should employ kangaroo care. No reputable research suggests that swaddling interferes with breastfeeding at any other time during a baby’s life10, 29.
Indeed, amidst all the positive research on swaddling, there are studies that call attention to potential risk factors as well as research which is flawed or inconclusive. Some research has indicated that swaddling constricts breathing when it’s too tight. Ok, I think it’s clear: don’t swaddle too tightly! There is certainly room for more empirical studies which can examine things absolutely, providing us with more information or definitive answers. For the time being, however, I hope that the wealth of research (along with the historical and cultural significance) can put your mind at ease regarding the incendiary claims of anti-swaddlers. While, of course I do not believe people in this camp are ill-intentioned (because we all care about the safety of babies), I do feel strongly that they are misinformed, having grossly misinterpreted the research presented. I encourage you to look at the original sources, look at the variation among the research and trust the fact that it has been a traditional practice for literally centuries. But, I don’t want you to make your final conclusions just yet. Though it may seem like I could not possibly say anything else about swaddling, I want to address swaddling best practice and parental preference.
Read more…
Sheena M. Hill is a single mom who understands the stresses of balancing parenthood with all the other responsibilities in life. She is an educator who specializes in parenting and family life. Its easy to be an expert, but in order to truly serve families, you must also be an excellent teacher who can respond to the complex needs of adult learners. She developed the Purposeful Parenting Philosophy, which helps parents make the most of parenthood. Read more at ParentingWorks.org.
References
1 Lipton EL, Steinschneider A, Richmond JB. (1965). Swaddling, a child care practice: Historical, cultural and experimental observations. Pediatrics, 35: 521– 567.
10 van Sleuwen, BE, Engelberts, AC, Boere-Boonekamp, MM, Kuis, W, Schulpen, TWJ, L’Hoir, MP. Swaddling: A Systematic Review. Pediatrics, 120: 1097-1106.
11 Tsogt B, Maniseki-Holland S, Pollock J, Blair P, Fleming P. Can traditional care influence thermoregulation? A prospective controlled study of the effects of swaddling on infants’ thermal balance in a Mongolian winter. Presented at: 9th SIDS Conference; June 1–4,2006; Yokohama, Japan
12 Li Y, Liu J, Liu F, Guo G, Anme T, Ushijima H. Maternal child-rearing behaviors and correlates in rural minority areas of Yunnan, China. J Dev Behav Pediatr.2000;21 :114– 122
13 Tronick EZ, Thomas RB, Daltabuit M. The Quechua Manta Pouch: a caretaking practice for buffering the Peruvian infant against the multiple stressors of high altitude. Child Dev.1994;65 :1005– 1013
14 Manaseki S. Mongolia: a health system in transition. BMJ.1993;307:1609– 1611
15 Karp H. The Happiest Baby on the Block. London, United Kingdom: Penguin Group; 2002
16 Blom MA. Crying and Restlessness in Babies: A Parent’s Guide to Natural Sleeping. Edinburgh, Scotland: Floris; 2005
17 Masataka, N. (1996). On the function of swaddling as traditional infant-care practiced by Native South Americans. Shinrigaku Kenkyu, Volume 67, Issue 4, Pages 285-291. Primate Research Institute, Kyoto University, Kanrin, Inuyama 484, Japan
18 van Schaijk M, Lanting CI, van Wouwe JP, Engelberts AC, L’Hoir MP. (2006). Survey risk factors for cot death, 2002–2003 [in Dutch]. In: Van Schaijk M, Lanting CI, van Wouwe JP, Engelberts AC, L’Hoir MP, eds. TNO: Quality of Life. Leiden, Netherlands
19 Meyer, L. E. and Erler, T. (2011). Swaddling: A traditional care method rediscovered. World Journal of Pediatrics, Volume 7, Issue 2, May 2011, Pages 155-160
20 Ohgi S, Akiyama T, Arisawa K, Shigermori K. Randomised controlled trial of swaddling versus massage in the management of excessive crying in infants with cerebral injuries. Arch Dis Child.2004;89 :212– 216
21 Semira Manaseki-Holland, Elizabeth Spier, Bayasgalantai Bavuusuren, Tsogzolma Bayandorj, Susan Sprachman, Tom Marshall (2010). Effects of Traditional Swaddling on Development: A Randomized Controlled Trial. Pediatrics, 26: 1485-1492.
22 Sidis, B.: An experimental study of sleep. J. Abnorni. Psvchol., 3: 1, 63, 1908.
23. Coriat, I. H. : The nature of sleep. J. Abnorm. Psychol., 6:329, 1912.
24 http://www.hipdysplasia.org/developmental-dysplasia-of-the-hip/hip-healthy-swaddling/
25 http://www.webmd.com/parenting/baby/tc/developmental-dysplasia-of-the-hip-topic-overview
27. Jobe, A. H (2009). Swaddling and SIDS – not simple. The Journal of Pediatrics. October 2009 Volume 155 Number 4
28. Karp H. The ‘fourth trimester’: a framework and strategy for understanding and
resolving colic. Contemp Pediatr 2004;21:94.
29 Bystrova K, Matthiesen AS, Widström AM, 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 :29– 39
[1] Even where swaddling enabled field work for mothers, swaddled babies were nursed on demand and were actively attended to by other family members17.
