Published online May 1, 2008
PEDIATRICS Vol. 121 No. 5 May 2008, pp. 1075-1076 (doi:10.1542/peds.2008-0299)
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LETTER TO THE EDITOR

Safe Swaddling and Healthy Hips: Don't Toss the Baby out With the Bathwater

Harvey Neil Karp, MD
Department of Pediatrics,
UCLA School of Medicine,
Los Angeles, CA 90025

To the Editor.—

Swaddling has made a comeback over the past several years, thanks in part to its popularization in modern parenting guides.1–3

In their commentary on this ancient practice, Mahan and Kasser4 succinctly summarized numerous reports that associated swaddling with developmental dysplasia of the hip (DDH). They noted, however, that it is unclear whether DDH is promoted by all forms of swaddling or only with "traditional" infant-wrapping techniques practiced by certain ethnic groups. This possibility was also raised in a recent systematic review of swaddling,5 and this distinction is of paramount importance.

The studies cited by Mahan and Kasser correlating DDH and swaddling described populations in Japan, Saudi Arabia, Turkey, and certain Native American tribes that use an antiquated traditional method of wrapping with which the hips are fully extended and adducted and the legs are snugly bound together with blankets, cloths, or ropes. Oftentimes, the bundled infants are also rigidly tied to cradle boards, which holds the hips immobilized in hyperextension.

It is believed6 that traditional swaddling promotes DDH by displacing the femoral head anterolaterally in infants with congenital laxity of the hip capsule and ligamentum teres. The risk is elevated for infants who have a family history of DDH, are born breech, or have congenital foot deformity or torticollis. (Of historical interest, the original American Academy of Pediatrics insignia, which showed a swaddled infant with tightly bound legs, was changed to one with unfettered legs in 1955.7)

Contemporary swaddling techniques, however, permit infants to be snugly wrapped with their hips being safely flexed and abducted. As Mahan and Kasser stated, "[a]llowing even tightly swaddled infants to still have this flexion and abduction in their hips would allow for safe development of their hips." They also noted 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 stress,14 early breastfeeding termination,15,16 postpartum depression,17–20 shaken-baby syndrome,21,22 unnecessary treatment for gastroesophageal reflux disease,23 postpartum resumption of cigarette smoking,24 and sudden infant death syndrome25–27 (repeated studies have shown that supine swaddling reduces the sudden infant death syndrome risk ratio to 0.64–0.69, and swaddling's sleep-promoting benefit may dissuade parents from intentionally placing their infants prone for sleep5).

It is worth noting that other infant care practices also require proper technique to avoid unintended deleterious effects. Infant car restraints, for example, can potentially cause injury if not installed correctly. Similarly, the proper swaddling technique must be taught to avoid overheating, head covering, hip extension/adduction, etc. To that end, over the past 4 years I have helped train >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

REFERENCES

  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, NY: 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[Free Full Text]
  5. van Sleuwen BE, Engelberts AC, Boere-Boonkamp MM, Kuis W, Schilpen TW, L'Hoir MP. Swaddling: a systematic review. Pediatrics. 2007;120 (4). Available at: www.pediatrics.org/cgi/content/full/120/4/e1097
  6. Salter RB. Etiology, pathogenesis and possible prevention of congenital dislocation of the hip. Can Med Assoc J. 1968;98 (20):933 –945[Medline]
  7. Symbolic change: Academy's Della Robbia insignia reflects changes. AAP News. 2004:25 (5):244[Free Full Text]
  8. Giacoman SL. Hunger and motor restraint on arousal and visual attention in the infant. Child Dev. 1971;42 (2):605 –614[CrossRef][Web of Science][Medline]
  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; August 28, 2007; Denver, CO
  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 (5):1307 –1311[Abstract/Free Full Text]
  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 (6). Available at: www.pediatrics.org/cgi/content/full/110/6/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 (4):222 –232[Web of Science][Medline]
  13. Neu M, Browne JV. Infant physiologic and behavioral organization during swaddled versus unswaddled weighing. J Perinatol. 1997;17 (3):193 –198[Medline]
  14. Levitzky S, Cooper R. Infant colic syndrome: maternal fantasies of aggression and infanticide. Clin Pediatr (Phila). 2000;39 :395 –400[Abstract/Free Full Text]
  15. Bernal J. Crying during the first ten days of life. Dev Med Child Neurol. 1972;14 (3):362 –372[Web of Science][Medline]
  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 (4):312 –317[Abstract/Free Full Text]
  17. Murray L, Cooper P. The impact of irritable infant behavior on maternal mental state: a longitudinal study and a treatment trial. In: Barr R, St James-Roberts I, Keefe M, eds. New Evidence on Unexplained Early Infant Crying: Its Origins, Nature and Management. Skillman, NJ: Johnson & Johnson Pediatric Institute; 2001:149 –164
  18. Maxted AE, Dickstein S, Miller-Loncar C, et al. Infant colic and maternal depression. Infant Ment Health J. 2005;26 :56 –68[CrossRef][Web of Science]
  19. Corwin EJ, Brownstead J, Barton N, Heckard S, Morin K. The impact of fatigue on the development of postpartum depression. J Obstet Gynecol Neonatal Nurs. 2005;34 :577 –586[CrossRef][Web of Science][Medline]
  20. Howell EA, Mora P, Leventhal H. Correlates of early postpartum depressive symptoms. Matern Child Health J. 2006;10 (2):149 –157[Web of Science][Medline]
  21. Theodore AD, Chang JJ, Runyan DK, Hunter WM, Bangdiwala SI, Agans R. Epidemiologic features of the physical and sexual maltreatment of children in the Carolinas. Pediatrics. 2005;115 (3). Available at: www.pediatrics.org/cgi/content/full/115/3/e331
  22. Sandberg M, Barr R. The National Center on Shaken Baby Syndrome research on victim and perpetrator profiles. Presented at: the 4th National Conference on Shaken Baby Syndrome; September 12, 2002; Salt Lake City, UT
  23. Sutphen J. Is it colic or is it gastroesophageal reflux? J Pediatr Gastroenterol Nutr. 2001;33 (2):110 –111[CrossRef][Web of Science][Medline]
  24. Gaffney KF, Henry LL. Identifying risk factors for postpartum tobacco use. J Nurs Scholarsh. 2007;39 (2):126 –132[CrossRef][Web of Science][Medline]
  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 (6):506 –512[Web of Science][Medline]
  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 (6):377 –382[Abstract/Free Full Text]
  27. Beal S, Porter C. Sudden infant death syndrome related to climate. Acta Paediatr Scand. 1991;80 (3):278 –287[Web of Science][Medline]
  28. Pennsylvania Department of Health. Cries to Smiles. Harrisburg, PA: Pennsylvania Department of Health, Breastfeeding Awareness and Support Group; 2007
  29. National Association of Children's Hospitals and Related Institutions. Children's Hospitals at the Frontlines: The Prevention of Child Abuse and Neglect. Alexandria, VA: National Association of Children's Hospitals and Related Institutions; 2007:9 –10
PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics

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This Article
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