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Swaddling: benefits, risks and current advice

Key learning points:

 - History and current advice regarding swaddling

 - Methods of swaddling and risks

 - What health visitors should be advising parents

Swaddling means to wrap pieces of cloth around an infant's body. The technique varies from wrapping the infant in bands (the European way) to tightly folding blankets or sheets around the child as practiced in South America.1 Typically, the lower limbs will be extended (straightened) and the arms restrained. It is widely held that swaddling calms infants and induces sleep.2

Swaddling was an almost universal childcare practice before the 18th century.3 It is still traditional in certain parts of the Middle East and for many years was gaining popularity in the UK.4 In July 2013 many of us may have seen pictures or footage of the newborn Prince George leaving hospital with his parents, The Duke and Duchess of Cornwall, in which he appeared to be partly swaddled.

The Bible describes infants wrapped in cloths, and one of the earliest illustrations of swaddling is of the infant Jesus. History has also recorded that Alexander the Great, and Julius Caesar were both swaddled as babies.

Current advice regarding swaddling

Many parents prefer to swaddle their babies as they feel it makes the infant feel safe and secure similar, to the feeling of being in the mother's uterus. Being wrapped up can help prevent the infant from being disturbed by its own startle reflex, hypnagogic startles, which are completely normal.5 Understanding current advice is often confusing for parents, as so much has recently been reported in the media. In October 2013, Prof Nicholas Clarke, of Southampton University Hospital wrote in the peer-reviewed journal Archives of Disease in Childhood that “in order to allow for healthy hip development, legs should be able to bend up and out at the hips. This position allows for natural development of the hip joints. The babies legs should not be tightly wrapped in extension and pressed together.” The argument being that swaddling forces the hips into a straightened position where the legs are pressed together, which may lead to hip dysplasia. The Royal College of Midwives (RCM) were also advising parents to avoid swaddling a baby because of the added possibility of overheating the baby, and the increased risk of cot death.

Current advice from Jane Munro, quality and audit development advisor at the RCM, is for parents to avoid swaddling, but it is also crucial that professionals take into account each mother's cultural background, and to provide individualised advice to ensure she knows how to keep her baby safe, able to move and not to get over heated.

Methods of swaddling

There are three possible methods of swaddling a baby, which if done correctly can be considered healthy to a baby's hips. All three methods can be seen at www.nct.org.uk where the medical director of the International Hip Dysplasia Institute acts as narrator for a video showing the following methods:6

 - Diamond swaddle.

 - Square swaddle.

 - Sleep sack swaddle. 

The sleep sack can be obtained from many UK online retailers. They offer a safe alternative way of swaddling a baby. The sack consists of an adjustable swaddle wrap made of soft cotton, which provides a loose pouch for the legs and feet, allowing plenty of hip movement. The International Hip Dysplasia Institute approves the swaddle design as 'hip healthy'. They are also sleeveless to help reduce the risk of over heating.

When using the diamond and square method it is vitally important to ensure that the infant's natural hip position ('frog style'-with the legs drawn up and thighs roughly at right angles to the body) can be maintained.

Risks and benefits

Recently some experts have reviewed studies on swaddled infants, and it has been suggested that as well as causing increased incidences of developmental hip dysplasia, swaddling could have other implications including: 

 - Increased risk of cot death due to the possibility of overheating.

 - Reduced breastfeeding at birth.

 - Increased early weight loss.7

Heavily swaddling a baby in order to breastfeed may prevent the baby's natural freedom of movement with their hands. 

Babies naturally explore with their hands while breastfeeding, and when allowed will allow a more natural latch and successful feeding.

The benefits of swaddling a baby are that it can help them sleep for longer periods. Babies are used to being snuggled tight in the uterus.

As a baby's movements tend to be restricted when swaddled this causes them to startle less, which can prevent them from becoming upset which in turn can cause the infant to become over-stimulated. When this occurs, newborns cry in an attempt to block out the stimuli. When swaddled, the jerky arm and leg movements are kept to a minimum, resulting in less crying.

What health visitors should be advising parents

In summary, Professor Clarke's research into whether swaddling leads to hip dysplasia is not new but an othopaedic perspective based on previous research.8

While the decision to swaddle a baby may be influenced by parents' personal beliefs and cultural practices, it is vital that if a parent wishes to swaddle their baby then they are shown how to do so in a safe manner, while explaining the reasons why it is so important. 

The key message should be to use a thin cotton sheet and not to cover the baby's head or wrap the baby too tightly to prevent overheating and ensure the legs have enough room to bend the hips up and outwards to avoid increasing the possible risk of hip dysplasia. Parents should also be advised to check the baby's temperature to ensure they do not get too hot.

By three months most babies have probably outgrown being swaddled, but professional opinion about when the practice should be discontinued varies between one to three months of age.

 

References

1. van Sleuwen BE, Engelberts AC, Boere-Boonekamp MM, Kuis W, Schulpen TWJ, L'Hoir MP. Swaddling: A Systematic Review. Pediatrics 2007;120:4 e1097-e1106. 

2. Chisholm JS. Swaddling, cradleboards and the development of children. Early Hum Dev.1978;2:255-75.

3. Lipton EL, Steinschneider A, Richmond JB. Swaddling, a childcare practice: historical, cultural and experimental observations. Pediatrics. 1965;35(suppl):521-67.

4. Karp H. The Happiest Baby on the Block. London, United Kingdom: Penguin Group; 2002.

5. Dufficy E. I've heard of swaddling. But what does it mean? August 2011. Available at: www.babycentre.co.uk 

6. `How to Hip-Healthy Swaddle your baby - IHDI. Available at: www.nct.org.uk.

7. National Childbirth Trust. Arguments against swaddling. Available at: www.nct.org.uk

8. NHS Choices. Swaddling may damage babies' hips, expert warns. Available at: www.nhs.uk