COMMENTARY

Death From Swaddling

Can Swaddling Be Made Safer?

Laura A. Stokowski, RN, MS

Disclosures

March 14, 2014

In This Article

Safe Swaddled Sleep

The study by McDonnell and Moon illustrates a couple of very important points. First, it shows how very far we are from achieving the kind of consistent, safe sleep environments for infants that we hoped would exist by now in homes across the country, with or without swaddling. Second, it shows that swaddling has introduced another variable to this environment that poses risks for at least some infants, although we might not yet have a handle on who those infants are. Despite criticism from those who believe that swaddling is no riskier than hugging and singing lullabies, we have to treat swaddling with the caution that it has shown it deserves, as another element in the already overcrowded message about safe sleep that healthcare providers must repeat to all new parents before they leave the hospital and again at every well-baby visit.

Considering the resurging popularity of swaddling, we will best serve parents by making sure that they use swaddling as safely as we know how, within the context of a safe sleep environment. This includes the following:

Talk about swaddling and the alternatives to swaddling (eg, standard infant sleepers/clothing of appropriate weight for the ambient temperature that can be worn without the need for additional wrapping).

Teach appropriate layering and thermoregulation; some parents believe that infants need more layers than they really do. Although we don't generally recommend taking an axillary temperature unless the baby appears ill, it might not be a bad idea if you are concerned that the family has a tendency to overbundle the infant.

Have parents bring in what they plan to use at home for swaddling, and teach them how to swaddle properly to prevent damage to hips.

Discuss when to discontinue swaddling. Although some physicians disagree about how long swaddling can safely continue, Dr. Rachel Moon, who is also lead author of the American Academy of Pediatrics Safe Sleep guidelines[1] and chair of the Task Force on SIDS, believes that babies should not be swaddled past 2 months of age.[5]

If parents are taking their infant to day care or a babysitter, they need to ensure that these caregivers know how to swaddle properly (if swaddling is permitted at all) and follow all other rules of safe sleep. If parents have stopped swaddling their infant, caregivers should be instructed to stop swaddling as well.

If parents continue to use a wearable blanket or wrap beyond the recommended age, they must carefully watch for signs that the infant is close to being able to roll over, in either direction. They should observe the infant's movements during supine and prone play; an infant who seems close to rolling in either direction (a "partial roll") or who can roll from prone to supine should no longer be swaddled using any method. Even if the infant can't accomplish a roll by him- or herself, the movements that the infant makes in attempting to roll could unravel the swaddling wrap or blanket.

Reinforce the other elements of the safe sleep environment.

Parents should be aware that injuries, including deaths, have occurred with swaddling, including some incidents where no improper use of swaddling or unsafe sleep practice could be identified. An insecurely applied swaddle wrap or wearable blanket can unravel during sleep, and (as demonstrated by the infant deaths in this study), can end up obstructing the infant's airway or even strangling the infant. The plain truth is that the safety of these products, even when used as correctly as humanly possible, has not been established, and people who use them do so at their own risk.

Abstract

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