Controversies: Is Swaddling Dangerous?

For the most recent Carnival of Evidence Based Parenting, Melinda Moyer discussed the recent debate over swaddling.  Swaddling has been on my list of controversies to address, but I believe Melinda covers the research very effectively. So, instead of my reinventing the wheel completely, I suggest you hightail it over to her column on Slate to read her conclusions.

Melinda brings up six arguments against swaddling and then the rebuttals. I’ll excerpt from her article here.

1.) Sleep Positioning

As Melinda points out, one concern of the National Resource Center on Child Health and Safety is the possibility of swaddled babies being put to sleep on their stomachs. However, as she says,

Yes, swaddled babies left on their stomachs are more likely to die—you, too, would have trouble catching your breath if someone wrapped you like a burrito and put you belly-down. But it turns out that swaddled babies are also more likely than unswaddled babies to be placed on their backs, which means that swaddlers are more likely to adhere to the American Academy of Pediatrics’ safe-sleeping recommendation

2.) Rousing from deep sleep

While it’s true that arousal problems are considered a risk factor for SIDS, research on the swaddling aspect is conflicting. One 2010 Australian study found that babies who were regularly swaddled did not have any more trouble waking than did unswaddled babies. At the same time, it was slightly harder to wake swaddled 3-month-olds who were not used to being swaddled (though the effect didn’t exist among 3-to-4-week-old infants). A 2005 study conducted by French and Belgian researchers suggested that swaddled 10-week-olds were actually more easily awakened (but, paradoxically, sleep better) than unswaddled babies. Ultimately, it’s hard to say what swaddling does to arousal, but there’s little evidence that routine swaddling poses a problem.

3.) Hip displaysia

But the type of swaddling taught in U.S. hospitals and recommended by Karp allows babies’ legs and hips to move freely. Plus, “for the past ten years, Americans have been swaddling a great deal, and we haven’t been seeing reports of more hip dysplasia,” says Bradley Thach, a pediatrician at Washington University in St. Louis. Even the International Hip Dysplasia Institute agrees that with proper technique, swaddling is perfectly safe.

In addition to Melinda’s points above, I want to bring up three more concerns regarding swaddling.

4.) Neurological organization and soothing

Arms up or arms down? That, if you believe it, is a common debate on the baby boards.  Some parents think that swaddling babies’ arms down by their side is cruel and ‘mummifying’ and that arms crossed over the chest is more comfortable. Other parents point out that children seem much more calm if their arms are all the way down. There’s also a variation on the debate: whether the child’s hands should be accessible for self-soothing.

This is especially relevant when dealing with premature infants. A common medical concern regarding swaddling preemies’ arms tight by their side is that it restricts them from bringing their arms midline.  The midline position is the more natural position for babies in the womb.  As one neonatal nurse points out, everything happens at midline – rolling over, crawling, pulling up, etc.  The concern is that by restricting that positioning, we train babies to keep their arms by their sides as opposed to midline, creating a ‘flying W’.

Another common concern is that wrapping the arms tight by the side fail to promote neurological organization. Touch is very important to neurological organization, especially for preemies. Skin-to-skin kangaroo care is now well-regarded as critical to helping premature infants’ developments, and when swaddling, allowing a preemie’s hands to touch each other allows for that sense to develop.

For infants with hypotonia, doing what is called a developmental swaddle (a swaddle that promotes the midline position as opposed to an arms-down position), may even help promote development by keeping a baby’s arms midline and hands touching.

However, as swaddling-promotor Harvey Karp points out, what is true for preemies isn’t always true for full-term infants.  Neurological development and motors skills unfold more naturally for a full-term infant, and therefore a few hours of arms-down swaddling per day shouldn’t affect development.  In addition, full-term infants experience more intense and active bouts of crying, thereby leading to flailing arms, further distressing the infant. Arms-down swaddling can help prevent that.

Dr. Karp also takes on the idea of arms-down swaddling affecting self-soothing, pointing out that very young infants often are unable to self-soothe using their fingers. Therefore, they get even more frustrated when their hands hit their mouth and they try to suck but are unable to coordinate the whole shebang.

Others, however, point out that many infants suck their fingers in utero, and also that since thumb sucking is an early sign of hunger, allowing an infant access to fingers helps promote on-demand breastfeeding.

Unfortunately, without great research, both ends of this debate may just have to agree to disagree. However, the relevant point here is that if you are against arms down swaddling, you can always wrap a child with arms completely out or with arms flexed on the stomach. Anecdotally, I’ve found wrapping a child with arms completely out works only when the child is older. Wrapping with arms flexed on the stomach seems to work, but one has to be a pretty good swaddler to do it right (I have never been able to do it right  – every time I try to wrap a child with arms up on the chest, the child escapes the swaddle.)

If you are interested in trying to wrap a child with the arms in a more ‘natural’ position, I suggest trying the Australian swaddling technique.

5.) Motor development and 6.) Overheating and respiration

These are two areas I haven’t delved into deeply, but  Pediatrics review of all studies to date regarding swaddling has shown that motor development (including the age an infant begins to walk) and overheating are not issues when swaddling is done in an optimal manner.

 

What other information do you have on swaddling? Let me know in the comments! I’m especially interested in the idea of swaddling and rolling over; common wisdom is to stop swaddling before a child begins to roll, but some parents continue to swaddling into the 9th and 10th month of life.

Controversies: To Cry It Out or Not? There Might Not Be Much Research Either Way.

Look at this face. Could you let her cry?

Look at this face. Could you let her cry?

Few things elicit more controversy, advice, commiseration, and myths than infant sleep. Parents are asked early on if their babies have ‘slept through the night’ yet. Debates rage on regarding what exactly IS sleeping through the night and what we can expect at which age.  But by far the most controversial aspect of infant sleep is the concept of crying it out.

Let Me Sing You the Song of My People
First, what is crying it out? I will get into the how and when in the Basics portion of the site, but in general, it involves leaving a baby in the crib to put him or herself to sleep, after checking that they are clean, dry, healthy, and full.  For most people, crying it out involves a process of checking on the baby at intervals, to reassure him or her, and then leaving again, allowing the baby to ‘work it out’. Crying-it-out, especially in this form, is also referred to as ‘Feberizing’, after the work of Dr. Richard Ferber, who published his book, Solve Your Child’s Sleep Problems, in 1985. Some parents also refer to crying-it-out with the generic term “sleep training” although that of course can encompass no-cry methods as well.

Varieties abound. Intervals for checking on the baby can be shortened or lengthened. Some methods involve just a brief 30 second visit to the baby’s room with verbal reassurances, and some advocate picking the baby up until he or she is completely calm. There is also Attended CIO, which involve the parents staying by the baby’s crib until asleep, picking him or her up if hysterical crying ensues.  There are differences in opinion regarding what age to let a baby cry (Babywise by Gary Enzo seems to advocate it sooner than most).  Finally, there is the extinction method, best described by Dr. Marc Weissbluth in Healthy Sleep Habits, Happy Child, in which, in “extreme” cases, one just lets the baby cry to sleep, with no checks or reassurances.

As you can imagine, this is a deeply personal topic for many parents.  The attachment parenting philosophy, of course, is 100% against any sort of cry-to-sleep.  Dr. William Sears, the current guru of Attachment Parenting, states, “Baby loses trust in the signal value of his cry – and perhaps baby also loses trust in the responsiveness of his caregivers. Not only does something vital go “out” of baby, an important ingredient in the parent- child relationship goes “out” of parents: sensitivity. “  An essay I see commonly bandied about parenting forums is “Just Let Her Cry”, giving cry-it-out an adult perspective (“Sometimes,” she writes, “I’d be having a day where I felt I may be able to eat or drink something, and I would call out to him, asking for something.  Again, he would ignore me.  Sometimes he would poke his head in, but it was only to tell me that I needed to go to sleep and I was “fine”.  I had times where I grew very depressed.  On top of being sick and miserable, I missed my husband’s loving arms.  Sometimes I just needed to be held and comforted.  Still, he would ignore me.”).

On the other end, of course, are parents who state, first, that there was no other way to get the baby to sleep, that months of sleep deprivation were wearing on them, that this was as much for the baby’s health as theirs – babies need to sleep. “Walk a mile in my shoes,” they state.  The retort from the other side is often a mix of, “I did it, so can you,” “What did you expect? This is motherhood. Your baby needs you,” and “Your expectations were too high -babies are supposed to wake in the middle of the night, and we are supposed to comfort them.”

The fact that babies need sleep and the fact that babies do wake up at night are both valid, and I can get into that in more detail in the Basics section.  As you can see, just like with formula feeding vs. breastfeeding vs. who cares, there are so many variables in this discussion. Personal philosophy of the parent, disposition of the child, disposition of the parent, parental expectations, advice and comments from social circle, pediatrician advice, mental state of the parent, the extent of the child’s sleep issues (and related to expectations, whether or not the parent sees it as an issue), cosleep vs. not, nightwean vs. not, how much the parent thinks a child needing sleep trumps a child needing to not cry (and vice versa…), and on and on.

On the disposition of the child front, the concept of the tension releaser vs. the tension escalator is relevant, as well as the concept of fuss-it-out vs. full blown CRY it out.  As Moxie points out, some children, the tension-releasers, need to exert energy by fussing or crying a bit before sleeping.  If those parents let the child fuss or cry to sleep, it’s considered cry-it-out – but it’s quite different than the experience of a parent with a very sensitive child, who may scream his or her head off the minute when placed in the crib. Those parents look at CIO parents completely askance.

…. Of course, with the fuss it out part, Mothering.com, known for its strict forum guidelines regarding certain positions contrary to peaceful parenting, takes issue even with discussion of a child fussing in his or her crib.

However, instead of the dramatics of this particular Mommy War, what I’m interested is is what the research shows.  Can cry it out damage a child? Conversely, can the lack of sleep training actually harm a child’s ability to sleep well (and all that comes with it – learning and development) down the road?

This Psychology Today article seems to give the ultimate verdict – crying it out damages the neurons in a child’s brains, leaving to a lifelong feeling of neglect.  But where are the studies that actually say that? Every study cited in this article talks about the effects of emotional distress, significant stress, and low-nurturing parents. We have here a common conflation – cry it out = emotional abuse, a child ‘left to cry’ in his or her bed is exhibiting significant distress.

We return back to Moxie’s “tension releasers” vs “tension increasers”, and the fact that most parents likely can tell when a baby is crying out of anger vs when a baby is truly distressed.

Now, in one of the first articles she writes, talks about a Harvard study that shows that CIO changes the baby’s nervous system, making the baby sensitive to future trauma.  So a smoking gun, correct?

Perhaps not.

It seems as though the Harvard study cited everywhere as showing for a fact that CIO causes long-term harm to babies is…just the personal opinion of the researchers?

There goes one of the major ‘evidence-based’ arguments against cry-it-out, one that I see over and over again.

So I’m for crying-it-out, right? Not necessarily. I try not to take a stand on either side of these types of arguments. If I seem pro-CIO here, it is simply because I just want to dissect the claims of anti-CIO people I see, and unfortunately, most of what I see doesn’t hold water.

Wait, there’s a new study that shows CIO has absolutely no ill effect?

Not exactly.   Major news organizations implied the study showed that a group of children who were subjected to CIO and a group of children that were not showed absolutely no difference years later.  But as AP champion Annie at PHD in Parenting points out:

“The only difference between the intervention group and the control group is that the nurses that in the intervention group were given formal training on sleep interventions. From what I can the parents were never asked which sleep interventions they used (if any).”

So, again, I’m not here to tell you to use one method or the other.  All I can tell you is that there isn’t much to scientifically give you an answer one way or the other.

Here are some more breakdowns on the research (or, that is to say, a lack thereof) on crying it out:

http://answers.google.com/answers/threadview/id/774928.html

http://www.infantsleep.org/cryingitoutresearch.html

The studies cited in the thread and in the article are below:

http://www.ncbi.nlm.nih.gov/pubmed/14989452?dopt=Abstract

http://www.ncbi.nlm.nih.gov/pubmed/1527680?dopt=Abstract