Swaddling is not contraindicated in the newborn period
Venue: Journal of Perinatology

Congratulations to Dr Varghese et al. on their contribution to the literature on the persistent issue of knowledge and behavior deficiencies amongst new parents regarding safe sleep recommendations at hospital discharge, as described in their manuscript, 'An analysis of attitude toward infant sleep safety and SIDS risk reduction behavior among caregivers of newborns and infants. However, as members of the American Academy of Pediatrics (AAP) Task Force on SIDS, we must express our concern regarding the discussion about swaddling. The article states that there is an 'AAP recommendation to avoid swaddling infants at sleep time. This statement misinterprets the current recommendations. The 2011 AAP SIDS Task Force Technical Report states: 'Although swaddling may be used as a strategy to calm the infant and encourage use of supine position, there is not enough evidence to recommend it as a strategy for reducing the risk of SIDS. Parents often swaddle infants to promote sleep and minimize the number of awakenings. However, there is some concern, because decreased arousability (that is, the infant does not awaken as easily) may increase SIDS risk. Physiologic data about the effects on arousability to an external stimulus when infants are swaddled are conflicting, and there may be minimal effects of routine swaddling on arousal. Epidemiological data directly linking swaddling with SIDS or problems with arousability are lacking. Additional potential disadvantages to swaddling include increased respiratory rate and reduced functional residual lung capacity, exacerbation of hip dysplasia if the hips are kept in extension and adduction, 'loose' swaddling becoming loose bedding, and overheating, especially if the head is covered or the infant has an infection. The Technical Report concludes: 'Swaddling must be correctly applied to avoid the possible hazards. Swaddling does not reduce the necessity to follow recommended safe sleep practices. The authors also misinterpret the study by McDonnell and Moon that reviewed CPSC reported injuries and deaths involving swaddling devices. Varghese states: 'It is crucial that caregivers of infants are educated on the dangers of swaddling and the products designed to encourage it. However this statement is not consistent with McDonnell's and Moon's conclusions: 'Reports of sudden unexpected death in swaddled infants are rare. Risks can be reduced by placing infants supine, and discontinuing swaddling as soon as an infant's earliest attempts to roll are observed. Risks can be further reduced by removing soft bedding and bumper pads from the sleep environment. In McDonnell and Moon's study, the vast majority of the cases were attributed to positional asphyxia, with prone positioning and other risk factors, most commonly soft bedding, often present. We wholeheartedly agree with Varghese et al. that it is important for health care providers to be educated about how best to model recommended behaviors to parents. It is unfortunate that this article overstates the risks of swaddling. Although swaddling has not been shown to be a SIDS risk reduction tool, there is no current evidence that suggests it should be contraindicated. Contrary to the implications in this article, when done properly, swaddling is still an important and appropriate tool in the care of the newborn. Health care providers should be aware of the pros and cons of swaddling and share this knowledge with new families in the hospital setting. Parents must also be educated to stop swaddling when the potential risks outweigh the potential benefits, that is, as soon as the infant's earliest attempts to roll are observed.