To swaddle or not to swaddle? What the current guidance is for newborns

Anyone who has seen inside a hospital's newborn nursery is probably familiar with the sight of rows of sleeping babies swaddled in clean blankets.

Swaddling is an age-old practice that has long been bound in controversy, falling in and out of style several times in the past century. But experts say it can offer benefits when done correctly.

Here are the current best practices around swaddling, according to health-care professionals and public health agencies.

WHAT IS SWADDLING?

Swaddling involves wrapping an infant securely in a light, breathable blanket to restrict their movement.

The Public Health Agency of Canada (PHAC) and the Canadian Pediatric Society (CPS) say the practice can calm infants and help them sleep. Dr. Jessica Duby, neonatologist at the Montreal Children's Hospital, agrees.

"It sort of mimics how they were in the mother's belly," she said in a telephone interview with CTVNews.ca on Friday. "They feel a bit more contained, a bit more secure when their arms and legs are swaddled."

SO, WHY IS IT CONTROVERSIAL?

Swaddling can be safe and beneficial when done properly. However, when done improperly, it can pose a number of threats to infants.

According to the Registered Nurses' Association of Ontario (RNAO), if a blanket used for swaddling becomes unwrapped, it can pose a face-covering risk and potentially raise the risk of Sudden Infant Death Syndrome (SIDS).

"Swaddling may also lead to overheating, depending on the type of blanket used," RNAO's clinical best practice guidelines for infants under 12 months reads.

There is also evidence that babies whose legs are swaddled too tightly may be at risk of developing hip dysplasia. According to the CPS, dysplasia is a developmental abnormality of the hip joint where the socket doesn’t fully cover the ball portion. Dysplasia can increase the risk for dislocation.

Duby said swaddling was once promoted as a way to prevent SIDS when, in fact, "there's no evidence that it helps." Further, RNAO warns swaddling can potentially increase the risk of SIDS if a swaddled infant is placed in the prone position – on their stomach – for sleep.

"Hence, caution regarding swaddling should be expressed with parents/caregivers," the organization's clinical best practices guidelines read.

Any answer to the question of whether or not parents should swaddle newborns is going to come with caveats. That's why some institutions have moved away from encouraging expectant parents to swaddle, according to Susan Georgoussis.

Georgoussis is a registered nurse and prenatal education co-ordinator at Toronto's Mount Sinai Hospital. She said in situations where the nuances of how to swaddle safely might be lost, the simplest answer might be the safest.

"If you're in public health and you want to give directions to parents, you have to think about how many different kinds of parents and backgrounds and literacy levels you're dealing with," she said. "You want simple messages, so in some ways it's easier to say, 'Don't swaddle.'"

However, when the risks and best practices surrounding swaddling can be properly communicated and families' unique situations and challenges considered, she said the practice can be beneficial, in moderation.

"I don't see this as something that is a yes or no, I think parents need to know that," she said. "It shouldn't be their go to, but… some babies are colicky, some babies are hard to settle and it can be very helpful."

WHAT IS THE OFFICIAL GUIDANCE?

The benefits of proper swaddling are still recognized by PHAC, CPS and the American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome, and all three agencies offer guidelines for doing it safely. Duby said it's still a common practice in many hospitals, and that it shouldn't contribute to the risk of SIDS when done properly.

"I think the big message is swaddling is not going to be the make-or-break for Sudden Infant Death Syndrome," Duby said. "The thing that has been shown to have the most impact on reducing Sudden Infant Death Syndrome is putting the baby to sleep on their back."

According to PHAC and CPS, swaddled infants should always be placed on their backs to sleep, on bedding that isn't too soft, with their nose and mouth uncovered. As soon as a baby begins trying to roll over, around three to four months, parents should stop swaddling.

"The risk becomes that the baby will roll on to their belly and get stuck in that position and, unfortunately, suffocate and die," Duby said.

Because restricting leg movement can lead to an increased risk of hip dysplasia, parents and caretakers should make sure swaddled babies can still freely move their legs and hips. Swaddled babies can also overheat under too many layers, so parents and caretakers should use light blankets and avoid over-dressing. Duby said they should also stay away from weighted blankets.

"There's always new products popping up and one of the sort of cool new fads are these weighted swaddlers and those have been shown to also not be safe," she said. "And so a swaddle should just be done with a blanket."

When the time comes to stop swaddling, Duby said products like appropriately-sized sleep sacks can help ease the transition into regular sleepwear, as long as they're used properly.

"You have to just make sure that it's completely well fastened," she said, "So do every snap that comes with it, every zipper, don't leave anything loose and lying around."