Swaddling is an age-old practice ofwrapping infants in blankets or similar clothso that movement of the limbs is tightlyrestricted. Swaddling bands were oftenused to further restrict the infant. Swaddlingfell out of favor in the seventeenth century.
Some authors are of the opinion thatswaddling is becoming popular again,although the medical and psychologicaleffects of swaddling are in dispute. Somemodern medical studies indicate thatswaddling assists babies to sleep, and toremain asleep; and that supine sleep lowersthe risk of Sudden Infant Death Syndrome(SIDS).[1] However, one recent studyindicated that swaddling increased the riskof SIDS.[2] Additionally emerging evidenceis showing certain swaddling techniquesmay increase the risk of developmentaldysplasia of the hip.[3]
Origin and history
Several authors presume that swaddling was invented in the paleolithic.[4] In Europe theearliest depictions of swaddled babies are votive offerings and grave goods from Creteand Cyprus, 4000 to 4500 years old.
Votive statuettes have been found in thetombs of Ancient Greek and Romanwomen who died in childbirth, displayingbabies in swaddling clothes. In shrinesdedicated to Amphiaraus, modelsrepresenting babies wrapped in swaddlingclothes have been excavated. Apparently,these were frequently given as thank-offerings by anxious mothers when theirinfants had recovered from sickness.[5]
Probably the most famous record ofswaddling is found in the New Testamentconcerning the birth of Jesus in Luke 2:6-2:7:
| “ | And so it was, that, whilethey were there, the dayswere accomplished that sheshould be delivered. Andshe brought forth herfirstborn son, and wrappedhim in swaddling clothesand laid him in a manger;because there was no roomfor them in the inn. | ” |
Swaddling clothes described in the Bibleconsisted of a cloth tied together bybandage-like strips. After an infant wasborn, the umbilical cord was cut and tied,and then the baby was washed, rubbed withsalt and oil, and wrapped with strips of cloth.These strips kept the newborn child warmand also ensured that the child’s limbswould grow straight. Ezekiel 16:4 describesIsrael as unswaddled, a metaphor forabandonment. [6]
During Tudor times, swaddling involvedwrapping the new baby in linen bands fromhead to foot to ensure the baby would growup without physical deformity. A stay bandwould be attached to the forehead and theshoulders to secure the head. Babies wouldbe swaddled like this until about 8 or 9months.[7]
The Swiss surgeon Felix Würtz (approx.1500 to approx. 1598) was the first whocriticized aspects of swaddling openly.[8]
| “ | I also saw right and straightchildren created by Godand born into this world byhumans, who becamenevertheless bent and lamemen, who never got straightand healthy thighs. (…) Inaddition, I have for instancelet a child lay again downand tied up, so that I see, inwhich way he wasswaddled. There I thenreally saw, where it wasgone wrong (…). Bymisunderstanding howeverthe wanted to bind himstraight, but in fact they bindhim bent and tighten thebandages hard, so that thechild cannot have peace(….).[9] | ” |
In the seventeenth century the scientific opinion towards swaddling began to change.There was an association of neglect with swaddling, especially in regard to wetnurses whowould leave babies in their care swaddled for long periods without washing or comfortingthem.[10] More than hundred years after Würtz physicians and philosophers from Englandbegan to criticize the swaddling clearly and demanded finally its complete abolishment.The British philosopher John Locke (1632–1704) rejected swaddling in his 1693publication Some Thoughts Concerning Education, became a lobbyist for not bindingbabies at all.[11] This thought was very controversial during the time, but slowly gainedground, first in England and later elsewhere in Western Europe.
William Cadogan (1711–1797) seems to have been the first physician, who pleaded forcomplete abolishing of swaddling. In his “Essay upon Nursing” of 1748 he expressed hisview of contemporary child care, swaddling, the topic of too much clothing for infants andover feeding. He wrote:
| “ | But besides the Mischief arising from the Weight and Heat of theseSwaddling-cloaths, they are put on so tight, and the Child is so cramp’d bythem, that its Bowels have not room, nor the Limbs any Liberty, to act andexert themselves in the free easy Manner they ought. This is a very hurtfulCircumstance, for Limbs that are not used, will never be strong, and suchtender Bodies cannot bear much Pressure.[12] | ” |
Philosophers and physicians more and more began to reject swaddling in the 18th century.Jean Jacques Rousseau wrote in his book Emile: Or, On Education in 1762:
| “ | The child has hardly left the mother’s womb, it has hardly begun to moveand stretch its limbs, when it is given new bonds. It is wrapped inswaddling bands, laid down with its head fixed, its legs stretched out, andits arms by its sides; it is wound round with linen and bandages of all sortsso that it cannot move […]. Whence comes this unreasonable custom?From an unnatural practice. Since mothers despise their primary duty anddo not wish to nurse their own children, they have had to entrust them tomercenary women. These women thus become mothers to a stranger’schildren, who by nature mean so little to them that they seek only to sparethemselves trouble. A child unswaddled would need constant watching;well swaddled it is cast into a corner and its cries are ignored […]. It isclaimed that infants left free would assume faulty positions and makemovements which might injure the proper development of their limbs. Thisis one of the vain rationalizations of our false wisdom which experiencehas never confirmed. Out of the multitude of children who grow up with thefull use of their limbs among nations wiser than ourselves, you never findone who hurts himself or maims himself; their movements are too feebleto be dangerous, and when they assume an injurious position, pain warnsthem to change it. | ” |
Although this form of swaddling has fallen out of favour in the Western world, manyEastern cultures and tribal people still use it.[13]
Modern swaddling
The swaddling cloths of mediaevalMadonna and Child paintings are nowreplaced with cotton receiving blankets,cotton muslin wraps, or specialised “winged”baby swaddles. Modern swaddling isbecoming increasingly popular today as ameans of settling and soothing irritableinfants and helping babies sleep longer withfewer awakenings. Since the early 1990sthe medical community has recommendedplacing babies on their back to sleep toreduce the risk of SIDS. As studies provedswaddled babies sleep better in the backsleeping position, swaddling has becomeincreasingly popular and recommended soparents avoid the dangerous stomachsleeping position. Swaddling also preventsnewborns waking themselves with theirmoro reflex.[1]
Loose and ineffective swaddling techniques made while using an undersized blanket cangenerally be kicked off by a wakeful baby. It is important for caregivers to accomplish asecure swaddle to ensure the blanket does not become loose and the baby remainswrapped during the sleep period. The act of swaddling does carry a risk of the babyoverheating if the caregiver uses multiple blankets that are too thick or uses thick fluffyfabric that creates excessive thermal insulation.[14]
Modern specialized baby swaddles are designed to make it easier to swaddle a baby thanwith traditional square blanket. They are typically fabric blankets in a triangle, ‘T’ or ‘Y’shape, with ‘wings’ that fold around the baby’s torso or down over the baby’s shouldersand around underneath the infant. Some of these products employ Velcro patches or otherfasteners. Some parents prefer a specialized device because of the relative ease of use,and many parents prefer a large square receiving blanket or wrap because they can get atighter and custom fit and the baby will not outgrow the blanket.
By the time the baby is learning to roll over, often around 4–5 months, parents andcaregivers should transition the baby from swaddling to a less restrictive covering forsleep. If the baby is able to roll over, then it is important for the baby to have use of itshands and arms to adjust his or her head position after rolling over. The traditionalswaddling uses flat strings for babies to be tied, care is needed not to tie them too hard orbloodflow would be restricted.
Psychological and physiological effects of swaddling
Modern medical studies of swaddling use a form that is considerably shorter and lesssevere than the historical forms. The results of such studies are therefore to beunderstood only as assessments of historical practices. The classical study by Lipton et al.of 1965 dealt with a modern swaddling form. The researchers described the two maineffects of tightly wrapping babies: they are motorically calm and sleep much.[15] Theseeffects are detected by means of various psycho-physiological parameters, such as heartrate, sleep duration and duration of crying. The research group around the Dutch biologistvan Sleuwen in 2007 confirms this picture in their latest meta-analysis of medical studieson swaddling and its effects.[16] However, severe restrictions on the scope of these studiesshould be kept in mind, because most of the positive effects mentioned by van Sleuwen etal. are not related to normally developed newborns, but to impaired babies, namelypremature babies and cry babies with detectable organic brain damage.[17] Swaddlingenhances the REM sleep (quiet sleep) and also the whole sleep duration.[18] The effect ofswaddling on the regulatory disturbance excessive crying is not very convincing: Byadding the swaddling there is an immediate “calming” effect on children, but after a fewdays the effect of the introduction of regularity with swaddling is exactly the same as theregularity on its own.[19] In other words: after a few days swaddling is completelyunnecessary. It is therefore contraindicated to address the potential risk of swaddling,because the effect is only for a short term available, but after a little while is negligible.[20]
Swaddling and motor development
Two studies based on American indigenous cultures did not show a delay in the onset ofwalking caused by the restraint of the use of the cradleboard.[21] In other areas of themotor development clear delays of the development show up even when mild restrictionstake place.[22] Skepticism concerning the allegedly missing effect of swaddling on theonset of walking delivers a Japanese study: the application of the basket cradle (ejiko)leads to a retarded onset of walking.[23] An older Austrian study showed that swaddledAlbanian babies were retarded concerning crawling and their ability to reach things withtheir hands.[24] This shows the need for further substantial scientific clarifying regardingthe impairment of motor skills by swaddling.
Swaddling and Sudden Infant Death Syndrome
The effects of swaddling on the Sudden Infant Death Syndrome (SIDS) are discussedcontroversially. SIDS is the most common cause of death in babies after the newbornperiod.[25] It is a disorder with unknown causes. As it turned out statistically, that pronesleeping of babies is one risk factor for SIDS, it seemed appropriate to pediatricians tostart campaigns for supine sleeping.[26] Subsequently the number of SIDS declined.[27]Swaddling was supposed to keep the babies on their back, in order to prevent SIDS.Swaddling itself is not seen as a protective factor for SIDS. Swaddling even increases therisk when babies sleep in the prone position, it reduces the risk if they sleep in the supineposition.[28] A recent study demonstrated now, that swaddling is apparently a risk factor forSIDS, although the opposite was often previously assumed: Of the babies who died ofSIDS 24% were swaddled, in the control-groups only 6% were swaddled.[29] Other studiesshowed that “heavy wrapping” – a form of swaddling – in connection with infectiousdiseases also enhances the risk of SIDS.[30] Overall, therefore, several new studies showa significant risk potential of swaddling associated with SIDS.
Empirically proven negative effects of swaddling
There are several empirical studies that clearly demonstrate the negative effects ofswaddling.
- Traditional forms of swaddling increase the risk for hip dysplasia.[31]
- Tight swaddling, particularly where the head is covered, reduces the baby’s ability tocool its body temperature which can lead to hyperthermia .[32] In the scientificliterature, a tragic case is described in which a heavily wrapped child died ofhyperthermia.[33]
- In one study, the risk of developing respiratory infections increased fourfold byswaddling.[34]
- A pediatrician found in his sample the flattening of the occipital aspect of the head ofbabies, who were wrapped tightly and lay in their traditional cradles.[35]
- In the most important contemporary study on swaddling practices in maternity wards byBystrova et al., it is shown that swaddling in the hours after birth is linked with adelayed recovery from post-natal weight loss.[36] A positive effect on the recovery isgiven by direct skin-to-skin contact between mother and baby in the hours after birth.[37] Skin-to-skin contact was shown to reduce the impact of the stress of being born,with babies maintaining their body temperature to a greater degree than thoseswaddled in a nursery.[38]
- The recent results of an investigation of Bystrova et al. demonstrates that maternalbehavior develops weaker under swaddling conditions, reciprocity within the mother-child dyad is reduced.[39]
Tight swaddling today
Swaddling still is distributed worldwide.[40] In some countries swaddling is the standardtreatment of babies. In Turkey for instance 93.1% of all babies become swaddled in thetraditional way.[41] According to the Human Relations Area Files (HRAF) 39% of alldocumented contemporary non-industrialized cultures show swaddling practices; further19% use other methods of movement restriction for infants.[42] Some authors assume thatthe popularity of swaddling is growing in the U.S., Great Britain and the Netherlands.[43] ABritish sample showed up 19.4% of the babies are swaddled at night.[44] In Germanyswaddling is not used as routine care measure and experiences relatively littleacceptance, as the missing mentioning of this practice in the standard work on regulatorydisturbances of Papusek shows.[45] Swaddling as a medical intervention with a clearlylimited indication range is used in the care practices of premature babies or cry babieswith brain-organically provable damage.[46] Also for reducing pain in such care actions asfor instance the blood collecting at the heel, swaddling is used.[47] The swaddling of thesepremature babies (very low birth weight infants, VLBW infants) takes place only veryloosely. It is meant to hold the weak arms at the body and make certain movementspossible.[48] This “swaddling” is something completely different from traditional swaddlingin stretched position.
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