Rethinking Swaddling

There’s no doubt that babies seem calmer and sleep more when swaddled.  But is this a positive or a negative?  The research provides some surprising answers, starting with the first days after birth.

Swaddled babies arouse less and sleep longer.1 That may sound good, but in the early hours and days after birth this can lead to less breastfeeding, which is associated with greater weight loss, more jaundice, and a delay in milk production.2

When swaddling is added to other newborn stressors, it appears to worsen their negative effects.  Researchers compared outcomes among 176 mothers and babies, who were divided into 4 groups:

1. Kept in skin-to-skin contact with mother for 30 to 120 minutes after birth
2. Held in mother’s arms wearing clothes
3. Separated from mother at birth and returned to her after two hours
4. Taken to the hospital nursery at birth and returned to mother for breastfeeding seven times each day at regular intervals

In each group, some babies were swaddled and some wore clothes.  The researchers reported that skin-to-skin contact reduced “the stress of being born” and found the babies kept skin-to-skin after birth had the highest body temperatures.4

Swaddled babies separated during their first two hours lost more weight.  Among the babies in Group 3 above, the swaddled babies had a significantly greater weight loss on their third and fifth days.5

Swaddled babies kept in the nursery were colder and consumed less milk.  Among the babies in Group 4 above, those who were swaddled had the lowest foot temperature of any of the babies in any of the study groups.  Newborns who were both separated and swaddled consumed less mother’s milk overall than those who were separated but not swaddled.  Their mothers also produced less milk on the fourth day and they had a shorter duration of breastfeeding overall.5

Swaddled babies in the nursery lost more weight despite consuming more formula.5  Possible reasons for this that the researchers suggested include:

• Severely limiting baby’s movements is stressful, which burns more calories.
• Swaddled babies receive less touch, which can compromise growth in preterm babies.6

If there are reasons to be concerned about a newborn’s temperature, a more effective strategy than either swaddling or using an infant warmer is to keep baby on mother’s body, putting blankets over both mother and baby.7,8,9 If the mother can’t provide skin-to-skin contact, the father is an excellent second choice.

But what about after hospital discharge?  Once a baby is breastfeeding well, is there any reason to avoid swaddling?  While swaddling may be helpful when used occasionally, routine swaddling during the first months associated with greater risk of:

• Respiratory illness10
• Hip dysplasia11
• SIDS in prone sleeping positions12
• Overheating13

Evidence is also growing that babies’ hand movements aid them in finding the breast and latching. 14 Swaddling during breastfeeding to restrict babies’ hands may contribute to breastfeeding problems.

After reading the research, my own opinion of swaddling has changed.  In most cases a mother’s body is her newborn’s best “baby warmer.”  When babies get fussy, it may be best to limit swaddling and suggest instead parents consider alternatives, such as skin-to-skin contact and baby carriers.

For a more detailed look at this subject, click here to read “Rethinking Swaddling,” my lead article in the September 2010 issue of the International Journal of Childbirth Education.

References

1Franco, P., et al. Influence of swaddling on sleep and arousal characteristics of healthy infants. Pediatrics 2005;115(5):1307-11. 

2Yamauchi, Y., & Yamanouchi, I. Breast-feeding frequency during the first 24 hours after birth in full-term neonates. Pediatrics 1990; 86(2):171-75. 

3Moore, E. R., & Anderson, G. C. Randomized controlled trial of very early mother-infant skin-to-skin contact and breastfeeding status. J Midwifery Womens Health 2007; 52(2):116-25.

4Bystrova, K., et al. Skin-to-skin contact may reduce negative consequences of "the stress of being born": a study on temperature in newborn infants, subjected to different ward routines in St. Petersburg.Acta Paediatr 2003; 92(3):320-26. 

5Bystrova, K., 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(1):29-39. 

6Ferber, S. G., et al. Massage therapy by mothers and trained professionals enhances weight gain in preterm infants.Early Hum Dev 2002; 67(1-2):37-45. 

7Galligan, M. Proposed guidelines for skin-to-skin treatment of neonatal hypothermia. MCN; Amer J Matern Child Nurs 2006; 31(5):298-304; quiz 305-296. 

8Ludington-Hoe, S. M., et al. Safe criteria and procedure for kangaroo care with intubated preterm infants.JOGNN 2003; 32(5):579-588.

9World Health Organization. Integrated management of pregnancy and childbirth: Pregnancy, childbirth, postpartum & newborn care. Geneva, Switzerland: WHO, 2003.

10Yurdakok, K., et al. Swaddling and acute respiratory infections.Amer J Pub Health 1990; 80(7):873-75. 

11Sahin, F. et al.  Screening for developmental dysplasia of the hip: Results of a 7-year follow-up study.  Pediatr Int 2004; 46(2):162-66. 

12Ponsonby, A. L., Dwyer, T., Gibbons, L. E., Cochrane, J. A., & Wang, Y. G. (1993). Factors potentiating the risk of sudden infant death syndrome associated with the prone position. New Eng J Med 1993; 329(6):377-82. 

13van Gestel, J. P., et al. Risks of ancient practices in modern times. Pediatrics 2002; 110(6): e78.

14Genna, C.W. & Barak, D.  Facilitating autonomous infant hand use during breastfeeding.Clin Lact 2010; 1(1):15-20.