I don’t remember much about the first few months of my son’s life. It’s a collection of tidbits—our doctor yelling “It’s a boy!,” the “dun-dun” of 4 a.m. Law & Order reruns, painful nipples. But I do remember five things that were, I think, largely responsible for the fact that I am now a parenting columnist and not a patient at the Kingsboro Psychiatric Center. These were pediatrician Harvey Karp’s famous Five S’s for calming fussy babies: swaddling, side/stomach position, swinging, shushing, and sucking.
So I was surprised when I learned a few weeks ago (from Karp, actually, while I was interviewing him for my last column) that swaddling—the act of wrapping babies snugly in cloths or blankets, which inhibits the startle-inducing Moro reflex and calms them—is now illegal in child care centers in Minnesota and strongly discouraged in centers in Pennsylvania and California. This has created a ripple effect that is scaring moms away from the practice nationwide. The bans stem from a 2011 decision by the National Resource Center on Child Health and Safety, a Colorado-based organization that provides health and safety guidelines for child care centers, to recommend against swaddling. The NRC cites “evidence that swaddling can increase the risk of serious health outcomes,” including Sudden Infant Death Syndrome (SIDS) and hip diseases. (The American Academy of Pediatrics has not taken an official stance on the safety of swaddling in child care settings but notes that swaddling “is an effective way to calm infants, especially in the newborn period, and is generally used in the first three months of life.”)
Karp is, of course, furious. (He called the recommendations against swaddling “crazy and unintelligent and unscientific.”) These moves make me mad, too, because they do seem scientifically unjustified—more on this below. Worse, Karp fears that if parents around the country stop swaddling, rates of postpartum depression and child abuse could increase. For my part, I can’t imagine parenting without swaddling, and I didn’t have a colicky baby. What will parents of difficult infants do if they feel they no longer have effective strategies for calming them?
Let’s start with the claim that swaddling increases SIDS risk. One British study does associate swaddling with an increased risk of death, but the researchers didn’t distinguish between swaddled babies who were left to sleep on their backs versus their stomachs. Yes, swaddled babies left on their stomachs are more likely to die—you, too, would have trouble catching your breath if someone wrapped you like a burrito and put you belly-down. But it turns out that swaddled babies are also more likely than unswaddled babies to be placed on their backs, which means that swaddlers are more likely to adhere to the American Academy of Pediatrics’ safe-sleeping recommendations. (The Back to Sleep campaign, now called Safe to Sleep, is believed to have cut SIDS rates in half since 1994.)
In a 2011 study of 103 inner-city U.S. parents, none reported putting their babies to sleep on their stomachs when they swaddled, whereas 9 percent of parents left unswaddled babies on their stomachs. (A few parents did leave their swaddled babies on their sides, though, which isn’t good because they could accidentally roll onto their stomachs.) When a 1994 New Zealand study tried to separate out all possible bedding-related factors that contribute to SIDS, it concluded that tight swaddling significantly decreases the risk of death.
Another concern voiced by the NRC is that swaddling might impair sleep arousal, indirectly putting babies at an increased risk for SIDS. While it’s true that arousal problems are considered a risk factor for SIDS, research on the swaddling aspect is conflicting. One 2010 Australian study found that babies who were regularly swaddled did not have any more trouble waking than did unswaddled babies. At the same time, it was slightly harder to wake swaddled 3-month-olds who were not used to being swaddled (though the effect didn’t exist among 3-to-4-week-old infants). A 2005 study conducted by French and Belgian researchers suggested that swaddled 10-week-olds were actually more easily awakened (but, paradoxically, sleep better) than unswaddled babies. Ultimately, it’s hard to say what swaddling does to arousal, but there’s little evidence that routine swaddling poses a problem.
The other big concern highlighted by the NRC—that swaddling could cause hip problems—is not particularly relevant to American babies. If parents swaddle so that their baby’s legs are bound together or tied to cradle boards, as is done in certain cultures for portability, then, yes, swaddling can damage the cartilage in the hip socket and loosen the hip joints. This increases the risk of hip dysplasia. But the type of swaddling taught in U.S. hospitals and recommended by Karp allows babies’ legs and hips to move freely. Plus, “for the past ten years, Americans have been swaddling a great deal, and we haven’t been seeing reports of more hip dysplasia,” says Bradley Thach, a pediatrician at Washington University in St. Louis. Even the International Hip Dysplasia Institute agrees that with proper technique, swaddling is perfectly safe.
So what happens if parents—particularly ones with fussy babies—stop swaddling after they hear about the child care swaddling bans? A 2005 study by researchers at Brown University found that 45 percent of parents of colicky babies were moderately to severely depressed, and that the more their babies cried and fussed, the worse their depression was. With one less technique available for soothing babies, mothers might be more at risk. Another 2006 study collected information from 720 mothers two to six weeks after they had given birth. The odds that the women had depressive symptoms increased by 79 percent if they had colicky babies. Fussy babies also don’t sleep as well, and a 2005 Ohio State study reported that the level of fatigue mothers experienced two weeks after birth predicted their risk for postpartum depression two weeks later.
Abuse is another potential issue. When pediatricians at the Albert Einstein School of Medicine in New York interviewed 23 mothers of colicky babies, they found that 70 percent had entertained aggressive fantasies about harming their infants by shaking them, dropping them, throttling them, or even stabbing them; more than a quarter of the mothers admitted to having thoughts about killing their infants. It would probably be smart not to scare desperate, exhausted parents away from a tool that could make their lives easier.
Of course swaddling can be risky, if you do it wrong. Make sure you can get a hand in between the blanket and your baby’s chest, because it’s dangerous to swaddle so tightly that your baby has trouble breathing. On the other hand, don’t swaddle so loosely that the blanket unravels and covers your baby’s face. Karp’s swaddling method helps to prevent such unraveling, and you could also opt for a swaddling sack if your baby is particularly adept at escaping. If it’s hot out, swaddle in a light blanket and keep your baby’s head uncovered. Finally, regardless of whether you swaddle or not, always put your baby on his or her back to sleep.
Just because there is a right and a wrong way to swaddle doesn’t mean that parents should be made to feel afraid of it. There are safe and unsafe ways to feed your kids, dress them, and discipline them, too—we just educate parents on how to do these things properly. And we can’t assume that if moms and dads become too scared to swaddle, there will be no negative consequences. No matter how cute their babies are, new parents need all the moments of peace they can get.
Update, March 13, 2013: In addition to the sources mentioned, The Kids would also like to thank Rachel Moon of Children's National Medical Center in Washington, D.C.