Health Professionals Need to Talk to Families About Swaddling

Swaddling babies snuggly in a blanket mimics the confines of the womb and can comfort babies and promote sleep. That’s why swaddling has been a popular practice for generations and is commonplace in hospitals and homes across the country. But in recent years, health professionals have questioned how safe swaddling is for babies while sleeping.

According to the Centers for Disease Control and Prevention, there are approximately 3,500 infant sleep-related deaths every year. And despite infant mortality rates decreasing in the past decade, accidental strangulation or suffocation in bed has continued to rise. Initiatives like the National Action Partnership to Promote Safe Sleep (NAPPSS-IIN) and the Safe Sleep CoIIN to Reduce Infant Mortality, both funded by the Health Resources and Services Administration Maternal and Child Health Bureau, are currently working with states and communities to change these numbers.  

“Identifying safe sleep practices and helping families adopt them can help more babies reach their first birthday,” says Pat Heinrich, RN, MSN, CLE, NICHQ Executive Project Director for NAPPSS-IIN. “The confusion about swaddling means that we need to make an extra effort to advise families about what’s safe and help them follow the most recent safe sleep recommendations from the American Academy of Pediatrics (AAP).”

According to the AAP, swaddling is safe when used correctly. Moreover, it really can help babies sleep, which is no small success—better sleep for babies often means better sleep for mothers, which may help decrease the chance of accidental bed-sharing, a risk factor for sleep-related infant deaths. However, when families don’t swaddle properly it has the potential to become risky and result in injury and possible death.

So, what should health professionals do to reduce risks while acknowledging that swaddling can comfort babies and relieve tired parents? NAPPSS-IIN faculty expert, Michael Goodstein, MD, a neonatologist and safe sleep expert, says the answers start with improving conversations with caregivers.

“We’re doing a lot to help families learn about safe sleep recommendations, which is really important. We need to do more though to make sure parents are receiving evidence-based advice about swaddling, specifically. Aiming some of our efforts on filling that educational gap can help keep more babies safe.”

Below, Goodstein offers advice on some of the key points health professionals should cover when discussing swaddling with mothers, fathers, and any potential caregivers.  

Milestones matter

According to the AAP, swaddling stops being safe once babies can roll over. When babies roll on their stomach while swaddled, they may not be able to return to the back position and the airway can become obstructed, leading to suffocation. Talking about these risks with families while still in the hospital is important for infant safety, says Goodstein. Specifically, health professionals should explain that since babies roll over at different ages (some as early as the first month), parents should be observant of their baby’s motor development, and stop swaddling if their baby begins to exhibit signals that suggest they’re ready to roll over. Room-sharing with a baby during the first year of life can help parents monitor their baby’s habits, and is recommended for all babies, whether swaddled or not.

Practice makes perfect

“Swaddling is really an art form,” says Goodstein. “And if a parent hasn’t been taught how to do it, their baby can get out of the swaddle. This leaves a loose blanket in the crib, which is a big risk factor for sleep-related deaths.”

Too-tight swaddles can also be harmful and must be prevented. When babies’ legs are too restricted, they can’t bend their legs up and out at the hips. These tight swaddles can exacerbate the risk of developmental dysplasia of the hip, which may require surgery and cause lifelong difficulties when walking. Goodstein recommends always giving families time to practice swaddling before they leave the hospital, checking that their swaddle is safe, and answering any questions.

Talk about technique

Swaddling isn’t one size fits all, explains Goodstein. For example, fussy babies often benefit from a swaddle with their arms straight at their side; otherwise, they can break free and end up sleeping with a loose blanket. In contrast, premature babies should be swaddled with their arms flexed, allowing the hands to be positioned midline for developmentally appropriate care, avoiding musculoskeletal and neurodevelopmental abnormalities. Talking to families about which swaddling technique is right for their baby, making sure to model it, and watching families practice can help ensure safer swaddles.

Address overheating

Since overheating is a risk factor for Sudden Infant Death Syndrome (SIDS), health professionals should also talk to families about overheating when advising them on swaddling. Explain that since swaddling is an added layer, families should monitor their baby for signs of overheating. Goodstein recommends telling families to check their baby by touching the core of the baby’s body (either the chest or back of neck), and remove a layer if their baby feels warm or sweaty. Discuss the benefits of using light, breathable materials for a baby’s swaddle and show examples of more risky materials, such as overly fluffy blankets and swaddle products that include head coverings (another risk factor for infant death).

Finally, says Goodstein, remember to always talk about swaddling within the context of all AAP safe sleep guidelines, reiterating that families should always place babies to sleep on their back, in their own sleeping space, and in a crib with a fitted sheet and no loose blankets, pillows, or toys. These recommendations should guide all conversation with parents, whether they do or do not choose to swaddle.