Correct swaddling is fine for a baby’s hips
Safe swaddling and healthy hips: Don’t toss the baby with the bath water
Swaddling has made a comeback over the past several years, thanks in part to its popularization in modern parenting guides.1 2 3
In their commentary on this ancient practice, Mahan and Kasser 4 succinctly summarize numerous reports associating swaddling with developmental dysplasia of the hip (DDH). They note, however, that it is unclear whether DDH is promoted by all forms of swaddling or only with “traditional” baby wrapping techniques practiced by certain ethnic groups. This possibility was also raised in a recent systematic review of swaddling5 and this distinction is of paramount importance.
The studies cited by Mahan and Kasser correlating DDH and swaddling describe populations in Japan, Saudi Arabia, Turkey and certain Native American tribes using an antiquated traditional method of wrapping where the hips are fully extended and adducted and the legs are snugly bound together with blankets, cloths or ropes. Oftentimes, the bundled babies were also rigidly tied to cradle boards, which held the hips immobilized in hyperextension.
It is believed6 that traditional swaddling promotes DDH by displacing the femoral head antero-laterally in babies with congenital laxity of the hip capsule and ligamentum teres. The risk is elevated in babies with a family history of DDH; born breech; or with congenital foot deformity or torticollis. (Of historical interest, the original AAP insignia showing a swaddled baby with tightly bound legs was changed to one with unfettered legs in 1955.7)
Contemporary swaddling techniques, however, permit babies to be snugly wrapped with their hips being safely flexed and abducted. As Mahan and Kasser state, “Allowing even tightly swaddled infants to still have this flexion and abduction in their hips would allow for safe development of their hips.” They further note that the swaddling method encouraged in my work calls for this safe hip positioning.
There is a compelling reason for making the distinction between the hazardous traditional style of wrapping and safe swaddling. Swaddling performed correctly is beneficial to young infants because it reduces crying,8 9 improves sleep10 11 and shortens periods of distress. 12 13
Reduction of fussing and improvement of sleep are not trivial goals. Colicky crying and maternal fatigue are serious public health concerns associated with significant morbidity and mortality, including: Marital stress14, early breastfeeding termination15 16, postpartum depression17 18 19 20, Shaken Baby Syndrome21 22, unnecessary treatment for GERD23, postpartum resumption of cigarette smoking24 and SIDS25 26 27 (repeated studies have shown supine swaddling reduces the SIDS risk ratio to 0.64-0.69 and swaddling’s sleep promoting benefit may dissuade parents from intentionally placing their babies prone for sleep5).
It is worth noting that other infant care practices also require properly technique to avoid unintended deleterious effects. Infant car restraints, for example, can potentially cause injury if not correctly installed. Similarly, proper swaddling technique must be taught to avoid overheating, head covering, hip extension/adduction, etc. To that end, over the past four years, I have helped train more than 1500 educators to correctly teach the modern version of this ancient practice to new parents in hospitals, clinics and military bases across the country.9 28 29
1 Jana LA, Shu J. Heading Home with Your Newborn. New York, NY: American Academy of Pediatrics; 2005
2 Karp HN. The Happiest Baby on the Block. New York: Bantam Dell; 2002
3 Karp HN. The Happiest Baby on the Block. DVD. Los Angeles, CA: Trinity Home Entertainment; 2003
4 Mahan ST, Kasser JR. Does Swaddling Influence Developmental Dysplasia of the Hip? Pediatrics. 2008: 121(1) : 177-178
5 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
6 Salter RB. Etiology, pathogenesis and possible prevention of congenital dislocation of the hip. Can Med Assoc J. 1968;98 :933 –945
7 Symbolic change: Academy’s Della Robbia insignia reflects changes. AAP News, 2004: Vol. 25 No. 5 : 244
8 Giacoman SL. Hunger and motor restraint on arousal and visual attention in the infant. Child Dev 1971; 42: 605-614.
9 Adler M. Promoting Maternal Child Health by Teaching Parents to Calm Fussy Infants at the Boulder Colorado Department of Health. Presented at the CDC CityMatCH Urban MCH Leadership Conference. Denver, CO, August 28, 2007
10 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; 115:1307-11
11 Gerard CM, Harris KA, Thach BT. Spontaneous Arousals in Supine Infants While Swaddled and Unswaddled During Rapid Eye Movement and Quiet Sleep, Pediatrics 2002 110: e70
12 Fearon I, Kisilevsky BS, Hains SMJ, Muir DW, Tranmer J. Swaddling after heel lance: age-specific effects on behavioral recovery in preterm infants. J Dev Behav Pediatr. 1997;18 :222 –232
13 Neu M, Browne JV. Infant physiologic and behavioral organization during swaddled versus unswaddled weighing. J Perinatol. 1997;17 :193 –198
14 Levitzky S, Cooper R. Infant colic syndrome: Maternal fantasies of aggression and infanticide. Clin Peds 2000;39 :395-400
15 Bernal J: Crying during the first ten days of life. Dev Med Child Neurol 1972:14:362-372
16 van der Wal, MF, van den Boom DC, Pauw-Plomp H, de Jonge GA, Mothers’ reports of infant crying and soothing in a multicultural population. Arch Dis Child 1998;79:312-317
17 Murray L, Cooper P, The impact of irritable infant behavior on maternal mental state: A longitudinal study and a treatment trial, Barr R, St. James-Roberts I, Keefe M (eds): New Evidence on Unexplained Early Infant Crying: Its Origins, Nature and Management, pp 149-164. Johnson and Johnson Pediatric Institute, Pediatric Round Table, 2001
18 Maxted AE, Dickstein S, Miller-Loncar C, High P, Spritz B, Liu J, Lester BM, Infant colic and maternal depression, Infant Ment Health Journal. 2005; 26; 56-68
19 Corwin EJ, Brownstead J, Barton N, Heckard S, Morin K, The Impact of Fatigue on the Development of Postpartum Depression. Journal of Ob Gyn and NN Nursing. 2005; 34:577-86
20 Howell EA, Mora P, Leventhal H. Correlates of early postpartum depressive symptoms. Maternal and Child Health Journal. 2006;10:149-57
21 Theodore AD, Chang JJ, Runyan DK, Hunter WM, Bangdiwala SI, Agans R, Epidemiological features of the physical and sexual maltreatment of children in Carolinas. Pediatrics. 2005;115: 331-7
22 Sandberg M, Barr R. The national center on shaken baby syndrome research on victim and perpetrator profiles. Presented to the 4th National Conference on Shaken Baby Syndrome. Salt Lake City, UT, September 12, 2002
23 Sutphen J: Is it colic or is it gastroesophageal reflux? J Pediatr Gastroenterol Nutr 2001;33:110-11
24 Gaffney KF, Henry LL. Identifying risk factors for postpartum tobacco use. J Nursing Scholarship. 2007:39 :126-132
25 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
26 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
27 Beal S, Porter C. Sudden infant death syndrome related to climate. Acta Paediatr Scand. 1991;80 :278 –287
28 Cries to Smiles. Pennsylvania Department of Health. Breastfeeding Awareness and Support Group. 2007
29 Children’s Hospitals at the Frontlines: The Prevention of Child Abuse and Neglect. NACHRI Profile Series: pp 9-10, Alexandria, VA: National Association of Children’s Hospitals and Related Institutions; 2007