Swaddling is a traditional practice of wrapping infants to promote calming and sleep. Although the benefits and risks of swaddling in general have been studied, the practice in relation to sudden infant death syndrome remains unclear.
The goal of this study was to conduct an individual-level meta-analysis of sudden infant death syndrome risk for infants swaddled for sleep.
Additional data on sleeping position and age were provided by authors of included studies.
Observational studies that measured swaddling for the last or reference sleep were included.
Of 283 articles screened, 4 studies met the inclusion criteria.
There was significant heterogeneity among studies (I2 = 65.5%; P = .03), and a random effects model was therefore used for analysis. The overall age-adjusted pooled odds ratio (OR) for swaddling in all 4 studies was 1.58 (95% confidence interval [CI], 0.97–2.58). Removing the most recent study conducted in the United Kingdom reduced the heterogeneity (I2 = 28.2%; P = .25) and provided a pooled OR (using a fixed effects model) of 1.38 (95% CI, 1.05–1.80). Swaddling risk varied according to position placed for sleep; the risk was highest for prone sleeping (OR, 12.99 [95% CI, 4.14–40.77]), followed by side sleeping (OR, 3.16 [95% CI, 2.08–4.81]) and supine sleeping (OR, 1.93 [95% CI, 1.27–2.93]). Limited evidence suggested swaddling risk increased with infant age and was associated with a twofold risk for infants aged >6 months.
Heterogeneity among the few studies available, imprecise definitions of swaddling, and difficulties controlling for further known risks make interpretation difficult.
Current advice to avoid front or side positions for sleep especially applies to infants who are swaddled. Consideration should be given to an age after which swaddling should be discouraged.
Comments
A letter to the editor in reply to Swaddling and the Risk for Sudden Infant Death Syndrome: A Meta-Analysis (Pease et al., 2016).
As noted by the authors, this meta-analysis of four studies on the relationship between Sudden Infant Death Syndrome (SIDS) and swaddling has multiple limitations (e.g., unclear definitions of swaddling and SIDS; varied methods of swaddling in different counties occurring over a span of 30 years). The study reinforces the previous published finding that prone and side sleeping are SIDS risk factors, especially for swaddled infants,1 and reiterates the AAP’s strong recommendation that infants should only sleep on the back (whether swaddled or not).2
A slightly increased risk of SIDS among supine swaddled infants appeared, but the authors cautioned that methodological limitations made drawing conclusions from that modest finding unreliable: “further studies are needed to quantify whether this practice [swaddling of back sleeping infants] poses any risk” (p. 7). However, not considered was the issue that is arguably the most pertinent to parents and practitioners: do the benefits of supine swaddling outweigh the risks?
We believe three significant topics were omitted from the discussion that would have given a fuller perspective on the interpretation of the findings. First, not mentioned was a recent study of the deaths of swaddled babies reported to the US Consumer Product Safety Commission (CSPC) between 2004 and 2012, when millions of swaddle wraps and blankets were sold.3 This study noted 22 deaths; Ten deaths were associated with wearable blankets and swaddle wraps and 12 with ordinary blankets. One swaddled infant died without other risk factors reported; most fatalities were associated with risks, such as loose bulky bedding and prone position. This study offers better insight into current swaddling practices and suggests a rather low risk of infant death in the context of swaddling.
Second, although the authors note swaddling’s ability to reduce crying and improve sleep, it would have been useful for the small, questionable risk of supine swaddling to be compared to the risk of injury, dysfunction, and death associated with infant crying and parental exhaustion, such as postpartum depression, child abuse, unsafe sleeping practices, and cigarette smoking.4 For this reason, the AAP recommends swaddling as an integral part of its Shaken Baby Syndrome prevention program.2
Third, the tentative findings indicate that older babies are at a higher risk for infant death. Given that different appropriate age limits have been recommended and discussed in the literature,5 referring to this discussion this would have been of benefit for the conclusions, stating that “professionals and current guidelines should consider an appropriate age limit”.
These omissions may lead professionals, parents, regulators, and the press to discourage correctly practiced, supine swaddling, which may inadvertently lead to greater infant morbidity and mortality caused by increased crying and reduced sleep. We support the authors’ call for prospective studies with meticulously defined risk factors to clarify the optimal use of swaddling. In the meantime, the evidence supports the continued education of parents about the potential benefits of correct swaddling and safe sleep practices.
References
1 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.
2 American Academy of Pediatrics, Task Force on Infant Positioning and SIDS. Positioning and SIDS. Pediatrics. 1992;89:1120-1126.
3 McDonnell E, Moon RY. Infant deaths and injuries associated with wearable blankets, swaddle wraps, and swaddling. J Pediatr. 2014;164(5):1152-1156.
4 Colvin JD, Collie-Akers V, Schunn C, Moon RY. Sleep environment risks for younger and older infants. Pediatrics. 2014;134(2):e406–12.
5 Kennedy K. Unwrapping the controversy over swaddling. AAP News. 2013;34.6:34.
RE: http://pediatrics.aappublications.org/content/120/4/e1097.comments
31 October 2007
Limit swaddling and massage to colicky babes
Edward J. O'Hagan, Retired
Dr. Patricia Franco (1) and her co-authors reported in Pediatrics in May of 2005 that their study on swaddling of infants revealed that it was associated with increases in the infants' sleep efficiency and in the time spent in non–rapid eye-movement(NREM) sleep . When swaddled, the infants awakened spontaneously less often.
Both swaddling and prone placement have traditionally been employed in countering the effects of infant colic. Additionally, childcare advocates are currently being quoted widely in the various news media and on Internet websites in regard to the many benefits of employing infant massage techniques ... and not alone in regard to bringing relief to colicky infants, but also as being beneficial to all infants in general. The claimed benefits are widespread and comprised in a lengthy list of well researched and worthwhile outcomes; included are claims of massaged infants experiencing improved sleep efficiency and sleeping more 'soundly'. In short, there is no reason to suspect that the claims being made concerning the benefits of infant massage are other than being entirely valid.
Nevertheless , while all three approaches, namely prone placement, swaddling, and massage, may be employed beneficially in treating infant colic, it should be understood that the infants are to be fully awake and crying, and when sleep eventually initiates they should be placed in the supine position.
Prone sleeping is recognized as being contributory to the overall incidence of SIDS fatalities, and since we do not know which infants may be individually vulnerable, it becomes necessary to recommend that all infants be placed to sleep in the supine position.That being the case ( vis-à-vis prone placement during sleep increasing the possibilities of SIDS outcomes) and since both infant massage and swaddling have been recognized as 'improving' the duration and depth of sleep, the following observations may merit consideration:
There appears to be the assumption that if massage brings relief to victims of infant colic, and has all kinds of benefits for infants generally, not least of which is that sleep becomes longer and deeper, then it should be employed 'holus bolously' with all infants without exception. Therein, may rest a danger paralleling that of prone placement during sleep, inasmuch as increasing the duration and depth of sleep may likewise possibly result in the elevation of the overall incidence of SIDS.
Possible vulnerability to SIDS once again has to be considered, and unless infants have been diagnosed professionaly as experiencing colic, or until such time as research data and/or study outcomes tell us otherwise, namely that infant massage is not contributory to increasing hazard of SIDS, it might be useful to weigh claimed benefits against the possibilty of tipping the scales in the directly opposite direction. Similarly the above considerations can be also applicable to swaddling, and, therefore, consideration once again might be given to restricting its use solely to professionally diagnosed cases of colic.
A search of the Internet will reveal that there are numerous unsupported claims being published concerning the effectiveness of swaddling in reducing the incidence of SIDS. It did not take too long before Franco's and her colleagues' study was being cited on the websites as being supportive of these purely speculative claims, despite the fact that the authors were careful to avoid making any such conclusions.
Dr. G. Manci (2) in an editorial in the New England Journal of Medicine back in February,1993 wrote : "....assuming that the adverse consequences of sleep are limited to the REM phase and considering slow- wave sleep to be invariably beneficial may be unwise. ..."
The bottom line? Swaddling and massage should not be employed with infants under the age of 6 months,unless in cases of professionally diagnosed colic.
(1) Pediatrics. 2005 May;115(5):1307-11. Influence of swaddling on sleep and arousal characteristics of healthy infants. Franco P, Seret N, Van Hees JN, Scaillet S, Groswasser J, Kahn A. Pediatric Sleep Unit, University Children's Hospital, Free University of Brussels, Brussels, Belgium.
(2) Autonomic Modulation of the Cardiovascular System during Sleep; NEJM, Volume 328: 347- 349,February 4,1993; Number 5
Conflict of Interest:
None declared
Show Less
Conflict of Interest:
None declared.
.
PreviousNext
RE: Swaddling may Reduce DHEA which may Increase SIDS
I suggest the connection of swaddling with SIDS is low DHEA. Following a high level of DHEA at birth, DHEA levels decline sharply during the first year.
It is my hypothesis of 1985 that low DHEA during sleep produces SIDS because of lack of stimulation of the brainstem. (Very briefly, it is my hypothesis that the function of sleep is to produce DHEA which stimulates consciousness when DHEA levels increase sufficiently during sleep. My mechanism suggests that the light-dark cycle is involved in stimulating DHEA. This requires melatonin production during the dark phase which then results in the production of DHEA. Sleep occurs as DHEA levels decline at the end of the day. Throughout sleep, periodic stimulations of DHEA occur in order to maintain brainstem function. As these stimulations occur, a point is reached which produces sufficient DHEA to induce consciousness.; the cycle then begins again. The function of sleep / circadian rhythm is production of DHEA.)
In 2002, regarding "Spontaneous Arousals in Supine Infants While Swaddled and Unswaddled During Rapid Eye Movement and Quiet Sleep," Pediatrics, December 2002, VOLUME 110 / ISSUE 6, Gerard, et al., I posted a comment in which I suggested that reduced arousal in swaddled infants is caused by low DHEA and that low DHEA in infants can produce SIDS.
At birth, DHEA levels are very high but decline during the first year to very low levels (chart). Again, I suggest that the connection of swaddling with SIDS is low DHEA."
RE: Swaddling may Reduce DHEA which may Cause SIDS
I suggest the connection of swaddling with SIDS is low DHEA. Following a high level of DHEA at birth, DHEA levels decline sharply during the first year.
It is my hypothesis of 1985 that low DHEA during sleep produces SIDS because of lack of stimulation of the brainstem. (Very briefly, it is my hypothesis that the function of sleep is to produce DHEA which stimulates consciousness (http://anthropogeny.com/Sleep%20and%20SIDS.htm ). My mechanism suggests that the light-dark cycle is involved in stimulating DHEA. This requires melatonin production during the dark phase which then results in the production of DHEA. Sleep occurs as DHEA levels decline at the end of the day. Throughout sleep, periodic stimulations of DHEA occur in order to maintain brainstem function. As these stimulations occur, a point is reached which produces sufficient DHEA to induce consciousness.; the cycle then begins again. The function of sleep / circadian rhythm is production of DHEA.
In 2002, regarding "Spontaneous Arousals in Supine Infants While Swaddled and Unswaddled During Rapid Eye Movement and Quiet Sleep," Pediatrics, December 2002, VOLUME 110 / ISSUE 6, Gerard, et al., I posted a comment in which I suggested that reduced arousal in swaddled infants is caused by low DHEA and that low DHEA in infants can produce SIDS.
Again, I suggest that the connection of swaddling with SIDS is low DHEA.
James Michael Howard
Fayetteville, Arkansas