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A binding issue

18 July, 2012

A binding issue

The age-old practice of swaddling babies has come back in vogue in recent years, but is it a method that midwives should be encouraging? Infant-feeding consultant Dr Val Finigan investigates.
Midwives magazine: Issue 4 :: 2012

The age-old practice of swaddling babies has come back in vogue in recent years, but is it a method that midwives should be encouraging? Infant-feeding consultant Dr Val Finigan investigates.

Swaddling feature Issue 4 2012

Swaddling, the ancient practice that had an almost universal use in child care before the 18th century, has regained its popularity. The practice continues to be widely used within the UK today in order to curb crying in unsettled infants and around one fifth of the world’s babies are swaddled (van Sleuwen et al, 2007).

Research in experimental situations has shown that swaddling can affect the baby’s wake and sleep pathways, hence its wide use to encourage babies to sleep for longer periods of time (van Sleuwen et al, 2007). However, it is important to understand what the benefits, risks and consequences of swaddling are. If the consequences of this practice outweigh the benefits then it should not be reintroduced as a mechanism to settle babies, particularly when there are other ways to achieve this.

Reduced crying
Leaving babies to cry not only denies them nourishment they need, but also risks the potential consequences of leaving them exposed to high cortisol levels (stress hormone) in infancy. Some professionals recommend that babies should be left to cry to teach them how to settle themselves (Flemming et al, 1996). However, caution must be aired as ‘crying’ is a baby’s language; its way of telling us what it needs. Routine swaddling may suppress the baby’s voice and delay the mother’s intuitive responses.

The kindest response to a baby’s crying is to pick it up, touch and respond gently to it and to offer it a feed or love (Gerhart, 2004). Gerhart also suggests that this type of response stimulates the development of the baby’s emotional brain, which leads to emotional stability in later life.

There are circumstances in which it may be appropriate to swaddle an infant, such as a temporary short-term intervention where a baby is born to a drug-addicted mother and is withdrawing from the drugs in her system. Infants with cerebral brain damage who cry excessively have significantly reduced episodes of crying if they are swaddled in comparison to being massaged (Ohgi et al, 2004). In such cases, a decrease in maternal anxiety and increased parental satisfaction were also noted after swaddling episodes, probably due to the reduction in crying.

Breastfeeding and growth
Newborn babies who are routinely swaddled have been found to feed less frequently, suckle less effectively, and have greater weight loss than those left un-swaddled (Bystrova et al, 2007). It is likely that swaddling inhibits the infant’s arousal pathways due to the inhibited arm movement (Gerard et al, 2002). As a baby begins moving through the sleep stages from deeper to lighter sleep, eye movement is seen, and the baby begins to move its mouth. During lighter sleep, its arms begin to wave, which serves as a natural cue to help wake a baby for feeding and to draw its mother’s attention to its needs. If the arms cannot freely move, because they are bound by swaddling; the baby may sink back into a deep sleep and miss a feed (Gerard et al, 2002; Richardson, 2010). Rather than feeding eight to 12 times in 24 hours, a swaddled baby may only feed six to seven times in this same time period. 

Bystrova et al (2007) hypothesised that swaddling may reduce touch, and that touch has been shown to influence infant growth by stimulating the release of gastrointestinal hormones. If this holds true, different techniques to reduce episodes of infant crying such as carrying, using a sling, or skin-to-skin contact may lead to more positive outcomes.

Temperature control
Some studies suggest that swaddling can be favourable for pre-term, incubator cared-for infants by raising their core temperature slightly by 0.2˚C during swaddling episodes (Short, 1998).

A negative consequence can be the risk of hyperthermia if swaddling is not controlled. This risk is especially crucial among ethnic or cultural groups that believe mothers and babies need to be kept very warm. Anecdotal reports suggest that fleece blankets are more likely to be used rather than cellular or cotton blankets, which further increase the risk of hyperthermia.

It is also a common practice in some UK communities to cover the baby’s head during sleep periods. Yet the head is the site of 40% of infant heat production and for infants almost 85% of heat loss takes place through their head and face, so it is crucial that heat dissipation can occur through this surface (Blair et al, 2006).

L’Hoir et al (1998) looked at the preventive factors for sudden unexpected death in infancy (SUDI) in the Netherlands. The study focused on the use of lightweight cotton sleeping sacks for infant sleep periods to reduce SUDI. The mechanism of the sack is similar to the concept of swaddling in that it prevents the baby from turning from a supine to a prone position during sleep episodes and avoids head covering.

While the findings suggest this mechanism is preventive, caution should be aired; the SUDI rates in the Netherlands are comparatively low to those of the UK and further studies are needed to confirm or refute the findings of the L’Hoir et al paper (1998).

Hip dysplasia
Clarke (2012) and Mahan and Kasser (2008) have raised concerns about the links between developmental dysplasia of the hip and tight swaddling of newborns. Hip dysplasia is a deformation or misalignment of the hip joint, which can lead to premature degenerative joint disease and chronic pain later in life, including early arthritis of the hip. It has been postulated that the condition can be exacerbated in a baby’s first days and weeks of life by forcing the legs to remain in extension through tight swaddling periods. Clarke (2012) has warned that the trend in swaddling babies is leading to more cases of hip dysplasia, where the infants’ hips are loosened by the mothers’ hormones, which relax ligaments during birth. Forcibly straightening the legs within the first three to four months of life means babies who would otherwise recover naturally are unable to freely flex and strengthen weakened joints, making surgery more likely to be needed.

SUDI risk
A study in Bristol found that one in four babies who died of cot death had been swaddled (Flemming et al, 1996). A total of 80 cases of infant deaths and almost 170 babies in a control group who were at risk were examined. While swaddling may prevent babies from turning from a supine to a face-down position, thus potentially being protected from SUDI, evidence suggests that swaddled babies are able to turn themselves over by three months of age (van Sleuwen et al, 2007). Head lifting and turning is crucial to avoid asphyxia environments and this ability is impeded where a baby’s arms are restrained by its sides. Therefore, babies older than three months may be at greater risk of SUDI even when placed supine or face up to sleep (Beltman, 2000).

Swaddling is an issue; research suggests this practice is potentially unsafe and it may lead to overheating, increased risks of SUDI and tight swaddling may affect the baby’s natural posture and increase the risks of hip dysplasia.
Midwives have a responsibility to ensure that they take into account each mother’s cultural background and are supportive of traditional practices within the realms of safety. It is important that midwives provide individualised care and advice to make sure that mothers and fathers can keep their babies safe, and enable them to develop well.

Dr Val Finigan
Consultant midwife for infant feeding, Pennine Acute Hospitals NHS Trust

RCM Communities
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