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Friday, April 5, 2013

Swaddling and SIDS

So, I was looking back at some of my old documents, and found an essay entitled, "Swaddling and SIDS." It was dated March 2012, before I started this blog. I wrote it to answer a question that was starting to pop up more and more - "Is swaddling safe?" The conclusions are directed to the Newborn Care Specialist community, but it applies to anyone caring for a newborn. I thought it had some valid points, and I would like to share it. Please keep in mind that my sources are simply links from a year ago - don't be upset if one or more no longer works.



Question: If a client told you not to swaddle because the hospital told them not to, what would you say?

 This is a fairly new recommendation employed in some, but not all, hospitals. My research on the subject seems to point to this recommendation being more prevalent in the UK than in the US. The reason that swaddling is being advised against appears to be because of a link to SIDS and hip dysplasia/stunted growth. The fear being that incorrect wrapping leads to loose bedding in the crib, overheating from over dressing, too deep of a sleep that baby is unable to awaken from, and wraps that are tied too tightly. Parents have other reasons for eschewing swaddling too. Some worry about baby rolling over in a swaddle and being unable to save themselves from suffocation. Others want their baby’s to be able to suck their thumbs while they sleep. 

Swaddling and SIDS
There have been conflicting studies in regards to how swaddling effects SIDS. Some studies have shown that babies whom are correctly swaddled show lower rates of SIDS, other studies say that swaddling can contribute to SIDS. The truth is hard to know, especially since the causes of SIDS are still unknown. We only have statistical evidence on what lowers the risk. Everything can be done right, and babies still die of SIDS.
One of the main reasons that swaddling has been linked to SIDS is the fear of loose bedding in the crib. However, swaddling done correctly leaves no loose bedding in the crib. A tight swaddle is the only swaddle that should be used. Teach the parents how to correctly do a tight swaddle to alleviate this fear. Hospitals have to play to the lowest denominator. They can not assume that a parent will try to learn how to correctly and safely swaddle a baby. Thus, they are forced to recommend no swaddling in case someone does it wrong. If their child is breaking out of the swaddle, recommend a ready made swaddler like a Woombie, Miracle Blanket, Loving Baby Swaddle, etc.
Overheating is another problem associated with swaddling and SIDS. The blanket is another layer. Keep the blanket in mind as baby is being dressed for sleep. According to the American Academy of Sleep Medicine, the optimal room temperature for sleep is a few degrees cooler than room temperature, somewhere around 65-70 degrees Fahrenheit. If you are not lowering the temperature or turning on a fan, than take a layer off before putting baby down. Babies can not control their own body temperatures anyway, and they certainly can’t take a blanket off if they get too hot. Using a breathable swaddle blanket like the ones made be Aiden & Anais that are made out of muslin or bamboo is a good way to keep baby from overheating. These blankets are exceptionally breathable, allowing for dissipation of heat near baby. As far as swaddlers go, Woombie is coming out with a breathable swaddler later this spring.
The lack of the ability to arouse from sleep when in respiratory or cardiovascular distress in some infants has been a factor in what many experts believe cause SIDS. The deeper a baby sleeps, the harder it is for them to wake up if in distress. Anyone who is familiar with swaddling knows that swaddling helps babies sleep better. Where though is the line drawn between helping a baby sleep better to promote growth and letting a baby try to sleep according to when they drop off to prevent too deep of a sleep? The job of the sleep trainer is to teach the infant how to self soothe to settle down after a natural arousal as happens in normal infant sleep patterns. If a baby is not showing signs of problems like sleep apnea, and is following the natural patterns of sleeping and feeding in an infant, than the addition  of a swaddle should not cause harm to the infant. However, according to a study published in the Journal of Pediatrics 2010, introducing a swaddle to an infant who was not routinely swaddled for the first few months has been shown to decrease arousability in infants, thus sleep trainers should avoid introducing a swaddle if a baby has not been routinely swaddled in the months since birth.

 Hip Dysplasia
Infant’s hip sockets are not fully developed at birth; much of the hip joint is made up of pliable cartilage that can be more easily forced out of place. Before birth, a hormone comes into play that makes mother’s ligaments stretchier to make it easier for baby to pass through the birth canal. Some babies are sensitive to this hormone, causing excessive stretchiness in their ligaments. In such cases, hip dysplasia becomes more prevalent. Hip dysplasia is also more likely in first born children (particularly girls), a baby born breech, and if there is a family history.
Incorrect swaddling can lead to hip dysplasia when the swaddle is too tight around the infant’s hips and thighs. While it is important to have a tight swaddle, tying a baby into a blanket is not recommended (Think of the Native Americans who tied their babies into papoose carriers. They had a 33% rate of hip dysplasia). The International Hip Dysplasia Institute teaches a method of swaddling that is hip-healthy (see hipdysplasia.org for more information). A swaddler like the Halo SleepSack, Woombie, and TrueWomb that allows for freedom of movement in the legs can help prevent hip dysplasia in infants. Also be aware of the effects that carriers like the Baby Bjorn have on infant hip health. If hip dysplasia is a worry for a family, than encouraging them to keep baby out of a swaddle during waking hours may be best.

Other Objections
I have heard before of parents who fear that their baby will roll over while in a swaddling blanket and be unable to roll back because their arms are strapped down. Newborns have no control over their muscles. If they were able to roll over even without a swaddle, they would not know how to roll back anyway. Once they are old enough to roll over, they will have more control of their muscles, and at that point it will probably be time to move them to a sleep sack or arms free swaddle anyway.
Some parents talk about how their baby prefers to have their hands nearby their face for comfort or sucking. In this case, suggest a one arm or arms free swaddle, but explain how the Moro (startle) reflex works to startle baby from sleep because of baby’s lack of muscle control. A swaddler like the Woombie or TrueWomb, that lets baby move their arms or have them across their chest rather than at their sides may be a better option here.

Conclusion
Swaddling done correctly is a safe practice. The risks associated with SIDS are circumvented by a correct swaddle, and hip safe swaddling can be done with infants who are at risk for hip dysplasia. A light breathable blanket that is tightly wrapped, or a ready made swaddler can be used to safely swaddle a baby. Keep in mind the risks associated with overdressing and do not start swaddling a baby who was not swaddled in the first few months of life.

Author: Katherine, Certified Newborn Care Specialist, Certified Professional Nanny.

Recommended for Safe Swaddling:
1.      Aiden & Anais Swaddle Blankets: large, breathable, light-weight, easy to get a tight swaddle with
2.      Woombie: Allows for freedom of movement, easy to use, breathable version available this spring, convertible version available for an arms free swaddle
3.      TrueWomb: A lot of Velcro makes this a noisier swaddler, but it allows for freedom of movement, especially when concerned with hip dysplasia
4.      Halo SleepSack: Freedom of movement, convertible to a regular sleep sack, allows for freedom of movement
5.      Loving Baby Swaddle: No Velcro, snaps, or zippers, this is a wrap and tie/tuck method that creates an easy tight swaddle
6.      Miracle Blanket: Similar to the Loving Baby, simply wrap around baby for an easy to use tight swaddle.

Sources:

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