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.

Universal Prekindergarten: Evidence from the Field

Welcome Carnival of Evidence-Based Parenting readers!  Today’s Carnival focuses on preschool education. I will keep an ongoing list of links from other participating blogs at the end of this post.

This is Part Three of my preschool series.

In Part One, I asked: Is Preschool Necessary? The answer? No, if there is enough enrichment, play-based activities, and speaking to your child at home. Which means the majority of middle-to-upper class families likely don’t need preschool. So what about more disadvantaged kids?

Enter Part Two, in which I asked: Does Head Start Work? The answer? To a point, yes. Like any preschool, it provides modest gains in kindergarten-1st grade. The problem is the 3rd/4th grade fade-out, which affects almost any preschool-type learning for almost any socio-economic group. So, short-term – yes, it often is helpful. Long-term – the jury is out.

So here we have Part Three. We are spending exorbitant amounts of money to educate disadvantaged kids through Head Start and other programs, with spotty results. We are also now advocating universal prekindergarten, even though the evidence shows preschool in general provides spotty results. There are confounding factors throughout, including the way one measures achievement, the varying degrees of quality in Head Start programs across the nation, and the quality of the schools the children enter for elementary.

Here we ask: So what is the measure of quality? What makes one program better than the other? And do we trust these measures of quality?

The Oklahoma Experiment vs Georgia vs Florida

First, let’s clear up a misstatement in President Obama’s State of the Union speech:

Tonight, I propose working with states to make high-quality preschool available to every child in America.  Every dollar we invest in high-quality early education can save more than seven dollars later on – by boosting graduation rates, reducing teen pregnancy, even reducing violent crime.  In states that make it a priority to educate our youngest children, like Georgia or Oklahoma, studies show students grow up more likely to read and do math at grade level, graduate high school, hold a job, and form more stable families of their own. (my bolding)

Somewhat disingenuous.  The bolded parts are in reference to very specific preschool programs  such as the Perry Preschool Project and the Abcerdarian Experiment. Hardly a large scale universal prekindergarten program such as Oklahoma’s. No universal prekindergarten program has been able to prove that students are more likely to graduate high school, hold a job, or form more stable families – as a matter of fact, they are too new anyway.

Despite that misstatement, Oklahoma (Tulsa, specifically) does boast a “quality” Head Start program as well as a “quality” prekindergarten program. Due to the presence of these programs and a 74% enrollment rate for Tulsa prekindergarteners, Tulsa-area prekindergarten and its Head Start program is a subject of a multi-year Georgetown University research project.

However, first, we must define quality, as it is a contentious measure.  What most researchers call the ‘accepted’ measures of a program’s quality are measuring input factors – the amount of money spent per student, the student-teacher ratio, teacher pay and certification, and the facilities in which the children learn. Input then, rather than output.

Let’s look at input first.

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