Correct swaddling probably decreases SIDS risk
Supine swaddling decreases SIDS risks
van Sleuwen, et al1 are to be commended for their comprehensive review of swaddling. Particularly noteworthy is their mention of the potential value of supine swaddling in protecting babies from SIDS. The authors state, “Epidemiologic evidence clearly shows that being supine and swaddled decreases the SIDS risk more than being supine and unswaddled.” Yet, inexplicably, this important finding was omitted from the paper’s abstract, discussion and conclusion.
The authors cite three studies reporting lower SIDS incidence with supine swaddling 2 3 4 (two were large studies with adjusted odds ratio for SIDS risk of 0.64 and 0.69 in swaddled non-prone versus unswaddled non-prone babies).
In this systematic review, four possible mechanisms of swaddling’s protective effect are mentioned: 1) Physical inhibition of rolling to prone (routine prone sleeping doubles or triples SIDS rates, but for babies who routinely sleep nonprone and accidentally roll prone the SIDS rate rises 8-33 times 5 6 7); 2) Prevention of excessive cooling (the authors note that cooling stress is even more highly correlated with SIDS than over-heating 4 8 9 10); 3) Physical inhibition from accidentally moving into bulky bedding 4; 4) Increasing supine positioning. (Fifty percent of parents who place their babies to sleep prone do so because they sleep better in that position 1. Snug wrapping promotes parental compliance with “back to sleep” recommendation because it reduces sleep arousals thereby fostering better sleep 11 12 13).
An additional protective effect of swaddling, not included in the author’s’ discussion of SIDS, is an increase in a sleeping baby’s arouseability. 12 13 This important point is somewhat unclear in the article. The authors don’t adequately distinguish between arousals and arouseability. They state, “Theoretically, the decreased arousal associated with swaddling could also prevent arousal in life threatening situations.”
However, it must be noted that although swaddled babies have fewer arousals, swaddling actually increases arouseability. In other words, wrapped babies sleep longer, but rather than being in a “deep” sleep, from which they cannot easily be aroused, they are in a “lighter” sleep, from which they are more easily aroused (e.g. by noise). Increased arouseablity is believed to be protective from SIDS.
Over the past decade, the “Back to Sleep” campaign has made enormous progress in decreasing SIDS deaths. However, SIDS has not been fully eradicated and, as mentioned in the AAP Task Force report on SIDS 14, new prevention strategies are needed. Supine swaddling appears to offer significant promise in that regard and warrants further investigation.
1 van Sleuwen BE, Engelberts AC, Boere-Boonkamp MM Kuis W, Schilpen TW, L’Hoir MP. Swaddling: A Systematic Review. Pediatrics. 2007;120(4) :e1097-e1106
2 Wilson CA, Taylor BJ, Laing RM, Williams SM, Mitchell EA. Clothing and bedding and its relevance to sudden infant death syndrome. J Paediatr Child Health. 1994;30 :506 –512
3 Ponsonby AL, Dwyer T, Gibbons LE, Cochrane JA, Wang YG. Factors potentiating the risk of sudden infant death syndrome associated with the prone position. N Engl J Med. 1993;329 :377–382
4 Beal S, Porter C. Sudden infant death syndrome related to climate. Acta Paediatr Scand. 1991;80 :278 –287
5 De-Kun Li, Diana B. Petitti, Marian Willinger, Robin McMahon, Roxana Odouli, Hong Vu, and Howard J. Hoffman Infant sleeping position and the risk of sudden infant death syndrome in California, 1997–2000. Am J Epidemiol. 2003;157 :446–455
6 Mitchell EA, Thach,BT, Thompson JM, Williams S. Changing Infants’ Sleep Position Increases Risk of Sudden Infant Death Syndrome. Arch Pediatr Adolesc Med. 1999;153 :1136-1141
7 L’Hoir MP, Engelberts AC, van Well GTJ, et al. Risk and preventive factors for cot death in the Netherlands, a low-incidence country. Eur J Pediatr. 1998;157 :681 –688
8 Nelson EAS, Schiefenhoevel W, Haimerl F. Child care practices in nonindustrialized societies. Pediatrics. 2000;105(6)
9 Bacon CJ, Bell SA, Clulow EE, Beattie AB. How mothers keep their babies warm. Arch Dis Child. 1991;66 :627–632
10 Williams SM, Taylor BJ, Mitchell EA. Sudden infant death syndrome: insulation from bedding and clothing and its effect modifiers. The National Cot Death Study Group. Int J Epidemiol. 1996;25 :366–375
11 Gerard CM, Harris KA, Thach BT. Spontaneous arousals in supine infants Pediatrics. 2002;110 : e70
12 Franco P, Scaillet S, Groswasser J, Kahn A. Increased cardiac autonomic responses to auditory challenges in swaddled infants. Sleep. 2004;27 :1527 -1532
13 Franco P, Seret N, van Hees JN, Scaillet S, Groswasser J, Kahn A. Influence of swaddling on sleep and arousal characteristics of healthy infants. Pediatrics. 2005;115 :1307 –1311
14 AAP Task Force on SIDS – The Changing Concept of Sudden Infant Death Syndrome. Pediatrics. 2005;116 :1245-1255