Musings on infant swaddling

June 2006

Swaddling during early infancy is an ancient practice, which was mentioned as early as the Bible for both babies Moses and Jesus (“baby Moses from the water and is asked by her maid if she knows what the Levite cloth swaddling the child signifies”; “And she wrapped [Jesus] in swaddling clothes”) as well as in texts on old Egyptian, Greek and Roman customs.

This technique of swaddling has lasted through the centuries and continued to be referenced in contemporary printed material (Harvey Karp, MD, — The Happiest Baby on the Block). Tight swaddling is said to be in widespread practice in Asian countries, including China, as well as in Turkey, the Middle East, central Asia, Russia and indigenous cultures in central, south and North America.

Swaddling and SIDS

Investigators at Washington University department of neonatology, lead by Bradley T. Thach, MD, are studying the practice of swaddling babies to learn if swaddling might have a role in further lowering of sudden infant death syndrome (SIDS) risk. Thach estimates that 25% of babies are fussy when they are forced to sleep in a supine position and swaddling improves the behavior and sleep of most of the babies who previously did not tolerate the supine sleeping position.

The insignia of the AAP, known as the “Della Robia” design modified from Della Robia’s original work, depicts a partially strip cloth swaddled older baby whose outstretched free arms could well signify breaking free of the constraints of infancy or illness, was adopted by the AAP in 1941 and became official in 1955. The original terra cotta bas-relief, created in 1477, 15 years before Columbus landed in the Americas, is one of 10 original bas-reliefs, which adorn the medieval Ospedale degli Innocenti (Foundling Hospital) located on the Piazza della SS. Annunziatia, in Florence, Italy. The hospital is considered to be the oldest known surviving institution continuously devoted to the welfare of children.

The stated purpose of swaddling was to reduce newborn fussiness and crying and to restrict random arm and hand movements that often awaken a sleeping baby during nocturnal sleep. Modern swaddling during early infancy is said to promote restful sleep in the supine position, is easily accepted by most babies, reduces frequency and intensity of brainstem arousals during deep nocturnal sleep, reduces scratching of the infant’s face during periods of hunger or irritability, diminishes frequency, intensity and duration of crying episodes, reduces accidental rolling over to the supine position, and has minimal physiological effects on respiratory and cardiac rate. It is also believed that swaddling can straighten out legs bowed from intrauterine constraints.

Swaddling often slows the babies’ heart rates. This was observed in the routine care for newborns with neonatal withdrawal from maternal opiate addiction or methadone maintenance as management for drug-addicted pregnant mothers. It also reduces the neonatal withdrawl symptoms of incessant scratching and digging at the face with fingernails, insomnia, and even vomiting.

The normative practice of tightly swaddling newborns in the hospital nursery is said to have begun its renaissance about 40 years ago when a medical study indicated that swaddled infants cried less than a comparative group of non-swaddled infants. Most normal newborns in the United States and Canada are swaddled tightly in receiving cotton blankets after initial suctioning, drying, and warming newborn care. There is a growing movement among the middle-class in the Netherlands, United States, Canada and Australia to continue the practice of swaddling during the first three months of life.

Karp estimates that 15% of the 4 million babies born in the United States each year are fussy and colicky for three hours a day. Tight or loose swaddling is one of the five cardinal S words of Karp’s popular book, The Happiest Baby on the Block. The others are: sucking, using the side/stomach position while holding the baby, swinging or rocking the baby vertically or laterally, and verbalizing shushing or humming noises near one of the baby’s ears when the baby is crying or fussy for no apparent reason.

Swaddling during the late evening and night and for prolonged daytime naps does not seem to be implicated in promoting SIDS, as long as the swaddled baby sleeps in the supine position and the swaddle cloths do not cover the baby’s face during sleep. Swaddling has not been implicated in promoting developmental hip dysplasia as long as the baby’s lower extremities are not constricted or all day and all night by tight swaddling techniques.

Finding the correct swaddling blanket, which is both easy to use and effective at preventing the infant from wiggling out of it, is essential. In addition to the common commercially-available 42 x 42 inch cotton flannelette infant receiving blanket, there are several commercially available swaddling restraints with Velcro tabs which are supposed to make it easier to swaddle the baby, such as the SwaddleMe adjustable smooth thin cotton or fleece Infant Wrap by Kiddopotamus and Co, (Leawood, KS), which is approximately $10.

According to a few comments from parents on the One Step Ahead Baby and the epinions.com Web sites, the blankets stretch too much; allowing a baby to easily wriggle out of the restraint that will cause the baby to wake itself up and also, the blanket can then cover the baby’s face.

Another variation is a cotton blanket with arm and feet flaps that wrap intricately around the entire baby from the shoulders down, called the Miracle Blanket, which retails for about $29 (Medford, OR). Four out of the five reviews posted on epinions.com written on the Miracle Blanket gave it very high remarks. There are numerous other swaddling blankets, including the Loving Baby Swaddle Blanket, the Cuddle Bug Cloverleaf Swaddling Blankets, and the Slumber Bug Swaddling Blanket, which are all available from Web sites.

Some babies do not take to swaddling easily. Have the parents practice on large dolls or stuffed toys during the learning curve for the swaddling procedure. It may be useful to suggest attempting to swaddle during a calm time and making shushing or humming noises or singing to the baby during the swaddling procedure. Sometimes the use of a hair dryer blowing warm, not hot, air over the baby at this time may help the baby adapt to the swaddling. Parents must be cautioned to not allow the blow dryer to get too close to the baby and to be observant of any metal the blow dryer may heat, such as a snap at the back of a bib. Another helpful technique is to allow one or both arms to be free, especially if the baby is able to self-sooth with his/her fingers/hands. This may, however, encourage the baby to touch or scratch his/her face during deep sleep and possibly self-awaken. Parents should also be aware that infants who are accustomed to being swaddled (and parents who are accustomed to their babies sleeping longer due to the swaddling), that their babies often develop sleep disturbances when the swaddling is abruptly discontinued (such as when the baby’s size and strength makes swaddling impossible).

Potential problems

There are some potential and real problems with swaddling. Overheating may occur if: 1) the baby is swaddled in several layers of flannelette; 2) the ambient room temperature is above 80°F; or 3) the baby has a high body temperature. If the baby overheats, the respiration rate and sweating increases to compensate for the increase in heat production. There is one reported case of swaddled Dutch twins who, after being kept in an overheated room in swaddling cloths for seven days, developed heat injury, dehydration, shock, and thereafter one of the twins had multisystem organ failure leading to death.

Another potential problem is suffocation if the baby’s arms free themselves from the swaddle blanket and pull the upper part of the blanket over the baby’s face; this concern has led to extensive discussion among SIDS experts in the AAP. As of the timing of this article, swaddling new babies is neither promoted nor rejected by the AAP. Many pediatric residents and pediatricians in clinical practice (including the first author of this article) were never taught the proper swaddling technique and are all thumbs when attempting to re-swaddle a newborn baby that they have just finished examining in the mother’s hospital room or in the newborn nursery. Many of us were also not taught how beneficial swaddling can be to calm a baby and thereafter allow him to sleep for longer periods.

For more information:

• Franco P, Seret N, Van Hees JN, et al. Influence of swaddling on sleep and arousal characteristics of healthy infants. Pediatrics. 2005;115:1307-1311.
• AAP. Symbolic Change: Academy’s Della Robbia insignia reflects changes. AAP News. November 2004.
• Von Gestel JP, L’Hoir MP, ten Berge M, et al. Risks of ancient practices in modern times. Pediatrics. 2002; 110:ppe78.
• Gerard CM, Harris KA, Thach BT. Physiologic studies on swaddling: an ancient child care practice , which may promote the supine position for infant sleep.Pediatrics.2002;141:398-403.
• Gerard CM, Harris KA, Thach BT. Spontaneous arousals in supine infants while swaddled and unswaddled during rapid eye movement and quiet sleep. Pediatrics. 2002;110:e70.
• Neu M, Browne JV. Infant physiologic and behavioral organization during swaddled and unswaddled weighing. J Perinatol. 1997;17:193-98.
• Caglayan S, Yaprak I, Seckin E, et al. A different approach to sleep problems of infancy: swaddling above the waist. Turk J Pediatr. 1991;33:117-20.
• Moss J, Solomons HC. Swaddling then, there and now: historical, anthropological and current practices. Matern Child Nurs J. 1979;8:137-51.
• Chisholm JS. Swaddling, cradleboards and the development of children. Early Hum Dev. 1978;2:255-75.