Swaddling

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Ambrogio Lorenzetti's Madonna and Child (1319) depicts swaddling bands.

Swaddling is an age-old practice of wrapping infants in blankets or similar cloth so that movement of the limbs is tightly restricted. Swaddling bands were often used to further restrict the infant. Swaddling fell out of favor in the seventeenth century.

Some authors are of the opinion that swaddling is becoming popular again, although the medical and psychological effects of swaddling are in dispute. Some modern medical studies indicate that swaddling assists babies to sleep, and to remain asleep; and that supine sleep lowers the risk of Sudden Infant Death Syndrome (SIDS).[1] However, one recent study indicated that swaddling increased the risk of SIDS.[2] Additionally emerging evidence is showing certain swaddling techniques may increase the risk of developmental dysplasia of the hip.[3]

Origin and history[edit]

Several authors presume that swaddling was invented in the paleolithic.[4][5][6] In Europe the earliest depictions of swaddled babies are votive offerings and grave goods from Crete and Cyprus, 4000 to 4500 years old.

Swaddled babies. Votive offerings from Agia Triada (Crete), Bronze age, 2600-2000 BC., Heraklion (Iraklion), Crete. Archeological museum Iraklion

Votive statuettes have been found in the tombs of Ancient Greek and Roman women who died in childbirth, displaying babies in swaddling clothes. In shrines dedicated to Amphiaraus, models representing babies wrapped in swaddling clothes have been excavated. Apparently, these were frequently given as thank-offerings by anxious mothers when their infants had recovered from sickness.[7]

Probably the most famous record of swaddling is found in the New Testament concerning the birth of Jesus in Luke 2:6–2:7:

And so it was, that, while they were there, the days were accomplished that she should be delivered. And she brought forth her firstborn son, and wrapped him in swaddling clothes and laid him in a manger; because there was no room for them in the inn.

Swaddling clothes described in the Bible consisted of a cloth tied together by bandage-like strips. After an infant was born, the umbilical cord was cut and tied, and then the baby was washed, rubbed with salt and oil, and wrapped with strips of cloth. These strips kept the newborn child warm and also ensured that the child's limbs would grow straight. Ezekiel 16:4 describes Israel as unswaddled, a metaphor for abandonment. [8]

Swaddled baby and bad mother, 1505–1510, detail from The Temptation of St. Anthony by Hieronymus Bosch (ca. 1450–1516). Museu Nacional de Arte Antiga, Lisbon
The Cholmondeley Ladies and their swaddled babies. c.1600–1610

During Tudor times, swaddling involved wrapping the new baby in linen bands from head to foot to ensure the baby would grow up without physical deformity. A stay band would be attached to the forehead and the shoulders to secure the head. Babies would be swaddled like this until about 8 or 9 months.[9]

The Swiss surgeon Felix Würtz (approx. 1500 to approx. 1598) was the first who criticized aspects of swaddling openly.[10]

I also saw right and straight children created by God and born into this world by humans, who became nevertheless bent and lame men, who never got straight and healthy thighs. (…) In addition, I have for instance let a child lay again down and tied up, so that I see, in which way he was swaddled. There I then really saw, where it was gone wrong (…). By misunderstanding however the wanted to bind him straight, but in fact they bind him bent and tighten the bandages hard, so that the child cannot have peace (….).[11]

In the seventeenth century the scientific opinion towards swaddling began to change. There was an association of neglect with swaddling, especially in regard to wetnurses who would leave babies in their care swaddled for long periods without washing or comforting them.[12] More than a hundred years after Würtz, physicians and philosophers from England began to openly criticize swaddling and finally demanded its complete abolishment. The British philosopher John Locke (1632–1704) rejected swaddling in his 1693 publication Some Thoughts Concerning Education, becoming a lobbyist for not binding babies at all.[13] This thought was very controversial during the time, but slowly gained ground, first in England and later elsewhere in Western Europe.

William Cadogan (1711–1797) seems to have been the first physician, who pleaded for complete abolition of swaddling. In his "Essay upon Nursing" of 1748 he expressed his view of contemporary child care, swaddling, the topic of too much clothing for infants and over feeding. He wrote:

But besides the Mischief arising from the Weight and Heat of these Swaddling-cloaths, they are put on so tight, and the Child is so cramp'd by them, that its Bowels have not room, nor the Limbs any Liberty, to act and exert themselves in the free easy Manner they ought. This is a very hurtful Circumstance, for Limbs that are not used, will never be strong, and such tender Bodies cannot bear much Pressure.[14]

Native American baby of the Nez Perce tribe, 1911

Philosophers and physicians more and more began to reject swaddling in the 18th century. Jean Jacques Rousseau wrote in his book Emile: Or, On Education in 1762:

The child has hardly left the mother's womb, it has hardly begun to move and stretch its limbs, when it is given new bonds. It is wrapped in swaddling bands, laid down with its head fixed, its legs stretched out, and its arms by its sides; it is wound round with linen and bandages of all sorts so that it cannot move […]. Whence comes this unreasonable custom? From an unnatural practice. Since mothers despise their primary duty and do not wish to nurse their own children, they have had to entrust them to mercenary women. These women thus become mothers to a stranger's children, who by nature mean so little to them that they seek only to spare themselves trouble. A child unswaddled would need constant watching; well swaddled it is cast into a corner and its cries are ignored […]. It is claimed that infants left free would assume faulty positions and make movements which might injure the proper development of their limbs. This is one of the vain rationalizations of our false wisdom which experience has never confirmed. Out of the multitude of children who grow up with the full use of their limbs among nations wiser than ourselves, you never find one who hurts himself or maims himself; their movements are too feeble to be dangerous, and when they assume an injurious position, pain warns them to change it.

Although this form of swaddling has fallen out of favour in the Western world, many Eastern cultures and tribal people still use it.[15]

Modern swaddling[edit]

The swaddling cloths of mediaeval Madonna and Child paintings are now replaced with cotton receiving blankets, cotton muslin wraps, or specialised "winged" baby swaddles. Modern swaddling is becoming increasingly popular today as a means of settling and soothing irritable infants and helping babies sleep longer with fewer awakenings. Since the early 1990s the medical community has recommended placing babies on their back to sleep to reduce the risk of SIDS. As studies proved swaddled babies sleep better in the back sleeping position, swaddling has become increasingly popular and recommended so parents avoid the dangerous stomach sleeping position. Swaddling also prevents newborns waking themselves with their moro reflex.[1]

A modern application of swaddling

Loose and ineffective swaddling techniques made while using an undersized blanket can generally be kicked off by a wakeful baby. It is important for caregivers to accomplish a secure swaddle to ensure the blanket does not become loose and the baby remains wrapped during the sleep period. The act of swaddling does carry a risk of the baby overheating if the caregiver uses multiple blankets that are too thick or uses thick fluffy fabric that creates excessive thermal insulation.[16]

Modern specialized baby swaddles are designed to make it easier to swaddle a baby than with traditional square blanket. They are typically fabric blankets in a triangle, 'T' or 'Y' shape, with 'wings' that fold around the baby's torso or down over the baby's shoulders and around underneath the infant. Some of these products employ Velcro patches or other fasteners. Some parents prefer a specialized device because of the relative ease of use, and many parents prefer a large square receiving blanket or wrap because they can get a tighter and custom fit and the baby will not outgrow the blanket.

To avoid hip dysplasia risk, the swaddle should be done in such a way that the baby is able to move his or her legs freely at the hip.[17] This is more easily done with a large blanket that can keep the arms in place while allowing the legs flexibility, all while allowing for proper hip development.

By the time the baby is learning to roll over, often around 4–5 months, parents and caregivers should transition the baby from swaddling to a less restrictive covering for sleep. If the baby is able to roll over, then it is important for the baby to have use of its hands and arms to adjust his or her head position after rolling over. The traditional swaddling uses flat strings for babies to be tied, care is needed not to tie them too hard or bloodflow would be restricted.

Regional variations[edit]

Swaddling still is distributed worldwide.[18] In some countries swaddling is the standard treatment of babies. In Turkey for instance 93.1% of all babies become swaddled in the traditional way.[19] According to the Human Relations Area Files (HRAF) 39% of all documented contemporary non-industrialized cultures show swaddling practices; further 19% use other methods of movement restriction for infants.[20] Some authors assume that the popularity of swaddling is growing in the U.S., Great Britain and the Netherlands.[21] A British sample showed up 19.4% of the babies are swaddled at night.[22] In Germany swaddling is not used as routine care measure and experiences relatively little acceptance, as the missing mentioning of this practice in the standard work on regulatory disturbances of Papusek shows.[23]

Medical uses[edit]

Swaddling as a medical intervention with a clearly limited indication range is used in the care practices of premature babies or cry babies with brain-organically provable damage.[24] Also for reducing pain in such care actions as for instance the blood collecting at the heel, swaddling is used.[25] The swaddling of these premature babies (very low birth weight infants, VLBW infants) takes place only very loosely. It is meant to hold the weak arms at the body and make certain movements possible.[26] This "swaddling" is something completely different from traditional swaddling in stretched position.

Psychological and physiological effects[edit]

Modern medical studies of swaddling use a form that is considerably shorter and less severe than the historical forms. The results of such studies are therefore to be understood only as assessments of historical practices. The classical study by Lipton et al. of 1965 dealt with a modern swaddling form. The researchers described the two main effects of tightly wrapping babies: they are motorically calm and sleep much.[27] These effects are detected by means of various psycho-physiological parameters, such as heart rate, sleep duration and duration of crying. The research group around the Dutch biologist van Sleuwen in 2007 confirms this picture in their latest meta-analysis of medical studies on swaddling and its effects.[28]

However, severe restrictions on the scope of these studies should be kept in mind, because most of the positive effects mentioned by van Sleuwen et al. are not related to normally developed newborns, but to impaired babies, namely premature babies and cry babies with detectable organic brain damage.[29] Swaddling enhances the REM sleep (quiet sleep) and also the whole sleep duration.[30] The effect of swaddling on the regulatory disturbance excessive crying is not very convincing: By adding the swaddling there is an immediate "calming" effect on children, but after a few days the effect of the introduction of regularity with swaddling is exactly the same as the regularity on its own.[31] In other words: after a few days swaddling is completely unnecessary. It is therefore contraindicated to address the potential risk of swaddling, because the effect is only for a short term available, but after a little while is negligible.[32]

Motor development[edit]

Two studies based on indigenous peoples of the Americas did not show a delay in the onset of walking caused by the restraint of the use of the cradleboard.[33] In other areas of the motor development clear delays of the development show up even when mild restrictions take place.[34] Skepticism concerning the allegedly missing effect of swaddling on the onset of walking delivers a Japanese study: the application of the basket cradle (ejiko) leads to a retarded onset of walking.[35] An older Austrian study showed that swaddled Albanian babies were retarded concerning crawling and their ability to reach things with their hands.[36] This shows the need for further substantial scientific clarifying regarding the impairment of motor skills by swaddling.

Sudden Infant Death Syndrome[edit]

The effects of swaddling on the Sudden Infant Death Syndrome (SIDS) are discussed controversially. SIDS is the most common cause of death in babies after the newborn period.[37] It is a disorder with unknown causes. As it turned out statistically, that prone sleeping of babies is one risk factor for SIDS, it seemed appropriate to pediatricians to start campaigns for supine sleeping.[38] Subsequently the number of SIDS declined.[39] Swaddling was supposed to keep the babies on their back, in order to prevent SIDS. Swaddling itself is not seen as a protective factor for SIDS. Swaddling even increases the risk when babies sleep in the prone position, it reduces the risk if they sleep in the supine position.[40] A recent study demonstrated now, that swaddling is apparently a risk factor for SIDS, although the opposite was often previously assumed: Of the babies who died of SIDS 24% were swaddled, in the control-groups only 6% were swaddled.[41] Other studies showed that "heavy wrapping" – a form of swaddling – in connection with infectious diseases also enhances the risk of SIDS.[42] Overall, therefore, several new studies show a significant risk potential of swaddling associated with SIDS.[citation needed]

Proven negative effects[edit]

There are several empirical studies that clearly demonstrate the negative effects of swaddling.

  • Swaddling, especially traditional forms, increases the risk for hip dysplasia.[43]
  • Tight swaddling, particularly where the head is covered, reduces the baby's ability to cool its body temperature which can lead to hyperthermia .[44] In the scientific literature, a tragic case is described in which a heavily wrapped child died of hyperthermia.[45]
  • In one study, the risk of developing respiratory infections increased fourfold by swaddling.[46]
  • A pediatrician found in his sample the flattening of the occipital aspect of the head of babies, who were wrapped tightly and lay in their traditional cradles.[47]
  • In the most important contemporary study on swaddling practices in maternity wards by Bystrova et al., it is shown that swaddling in the hours after birth is linked with a delayed recovery from post-natal weight loss.[48] A positive effect on the recovery is given by direct skin-to-skin contact between mother and baby in the hours after birth.[49] Skin-to-skin contact was shown to reduce the impact of the stress of being born, with babies maintaining their body temperature to a greater degree than those swaddled in a nursery.[50]
  • The recent results of an investigation of Bystrova et al. demonstrates that maternal behavior develops weaker under swaddling conditions, reciprocity within the mother-child dyad is reduced.[51]

See also[edit]

Notes[edit]

  1. ^ a b Gerard, Claudia M.; Kathleen A. Harris and Bradley T. Thach (6 December 2002). "Spontaneous Arousals in Supine Infants While Swaddled and Unswaddled During Rapid Eye Movement and Quiet Sleep". Pediatrics 110 (6): e70. doi:10.1542/peds.110.6.e70. PMID 12456937. Retrieved 2009-12-15. 
  2. ^ See Blair et al. (2009).
  3. ^ hipdysplasia.org
  4. ^ Phillips, Eustace Dockray (1965). The royal hordes: Nomad peoples of the steppes. Library of the early civilizations. McGraw-Hill Book Company. p. 15. 
  5. ^ DeMause, Lloyd (2002). The Emotional Life of Nations. New York: Karnac. p. 328. ISBN 1-892746-98-0. 
  6. ^ DeMeo, James (2006). Saharasia: The 4000 BCE Origins of Child Abuse, Sex-Repression, Warfare and Social Violence, In the Deserts of the Old World (Revised Second ed.). Natural Energy Works. ISBN 978-0-9621855-5-7. 
  7. ^ Thompson, Charles John S. (March 1922). "Greco-Roman votive offerings for health in the Wellcome Historical Medical Museum". Health (Wellcome Library, London: Hazell, Watson and Viney). 
  8. ^ Bromiley, Geoffrey W. (1995). "Swaddling". The International Standard Bible Encyclopedia (reprint, revised ed.). Wm. B. Eerdmans Publishing Co. p. 670. ISBN 978-0-8028-3784-4. Retrieved 2009-12-15. 
  9. ^ Sim, Alison (1998). The Tudor Housewife. McGill-Queen's Press. p. 26. ISBN 978-0-7509-3774-0. 
  10. ^ Würtz (1612), p. 726 f.
  11. ^ Würtz (1612), p. 714 ff.
  12. ^ DeMause, Lloyd (2002). The Emotional Life of Nations. Other Press. p. 322. ISBN 978-1-892746-98-6. 
  13. ^ Locke (1779), p. 12.
  14. ^ Cadogan (1748), p. 10.
  15. ^ Odent, Michel (2007-12-23). "The Future of Suicide". Birth Works, Inc. Retrieved 2009-12-15. 
  16. ^ van Gestel, Josephus Petrus Johannes; Monique Pauline L’Hoir, Maartje ten Berge, Nicolaas Johannes Georgius Jansen, and Frans Berend Plötz (6 December 2002). "Risks of Ancient Practices in Modern Times". Pediatrics 110 (6): e78. doi:10.1542/peds.110.6.e78. PMID 12456945. Retrieved 2009-12-15. 
  17. ^ [1]
  18. ^ See Frenken (2011 a), p. 321-351, Frenken (2011 b), p. 233 ff..
  19. ^ See Caglayan et al (1991), p. 117, the statistics are from the Turkish population and health survey (1978), Ankara, p. 78, 82, 114.
  20. ^ See Nelson et al. (2000), p. e 77.
  21. ^ See van Sleuwen (2007), p. e1097.
  22. ^ See Bacon et al. (1991), p. 630.
  23. ^ See Meyer & Erler (2009), p. 24, also Papusek et al., p. 20, 408.
  24. ^ Van Sleuwen et al. (2007), p. e1097, e1101, e1102 and e1103.
  25. ^ See Fearon et al. (1997), p. 222 ff. Swaddling here had a painreducing effect.
  26. ^ See Short et al. (1996), p. 25; illustration on p. 27.
  27. ^ See Lipton, et al. (1965), S. 560 ff.
  28. ^ See van Sleuwen, et al. (2007), p. e1097.
  29. ^ See van Sleuwen, et al. (2007), p. e1097, e1101, e1102 and especially p. e1103, where 3 of 5 central and empirically convincing effects are concerned with immature babies!
  30. ^ Vgl. Franco, et al. (2005), S. 1307 ff.; Chisholm (1983), S. 83
  31. ^ See van Sleuwen, et al. (2003), (2006) und (2007)
  32. ^ See Long (2007)
  33. ^ See Dennis (1940 a), p. 107; Chisholm (1983), p. 83.
  34. ^ Aldolph et al. (2010), p. 72 ff.
  35. ^ See Lipton et al (1965), S. 564 mentioning Sofue, T.; Suye, H.; Murakami, T (1957). Anthropological study of Ejiko, Japanese cradle for child. Journal of the anthropological society of Nippon, 66, S. 77-91.
  36. ^ See Danzinger & Frankl (1934), S. 235; see also Frenken (2011), S. 44 ff.
  37. ^ See Task Force on Infant Sleep Position and Sudden Infant Death Syndrome (2000), p. 650 f. (by the American Academy of Pediatrics).
  38. ^ See Gilbert (1994), p. 445, Gerard et al. (2002 b).
  39. ^ See Gilbert (1994), p. 445.
  40. ^ See Thach (2009), p. 461, Richardson et al. (2009), p. 475 ff.
  41. ^ See Blair et al. (2009). In the sample one quarter of the babies who died of SIDS was swaddled. See also Richardson et al. (2009).
  42. ^ See Gilbert et al. (1992).
  43. ^ See Kutlu et al. (1992), p. 598 f., Akman et al. (2007), p. 290, Chaarani et al. (2002), Kremli et al. (2003), Torjesen (2013) http://www.bmj.com/content/347/bmj.f6499, bibliography in Mahan & Kasser (2008). For a historical population (5th-17th centuries) see Mafart et al. (2007).
  44. ^ See Bacon et al (1991), p. 627 ff., Cheng & Partridge (1993), p. 238 ff., also van Sleuwen et al. (2007), p. e1101.
  45. ^ See van Gestel et al. (2002). See also Task Force on Infant Sleep Position and Sudden Infant Death Syndrome (2000), p. 654.
  46. ^ See Yurdakok et al. (1990), p. 878
  47. ^ See Bloch (1966). p. 645 (Kurdish sample), also Young (2005) for a prehistoric indigenous population.
  48. ^ See Bystrova et al. (2007 a), p. 29 ff.
  49. ^ See Bystrova et al. (2007 a), p. 37 f.; also Bystrova et al. (2003), p. 324.
  50. ^ See also Kennell & MacGrath (2003), p. 273.
  51. ^ See Bystrova (2008), p. 46.

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