Caring for Our Childen, 3rd Edition (CFOC3)

Chapter 3: Health Promotion and Protection

3.1 Health Promotion in Child Care

3.1.4 Safe Sleep

3.1.4.2: Swaddling

Frequently Asked Questions/CFOC3 Clarifications

Reference: 3.1.4.2

Date: 4/5/2013

Topic & Location:
Chapter 3
Health Promotion
3.1.4.2: Swaddling

Question:
Does CFOC3 ban swaddling?

Answer:

CFOC3 Standard 3.1.4.2: Swaddling states: “In child care settings, swaddling is not recommended or necessary.”

This specific language was carefully chosen and reviewed by national contributors and stakeholders, and then approved by the CFOC3 Steering Committee and each author organization (AAP, APHA, NRC). A child care setting is a group care setting, and therefore presents different health and safety concerns when compared to a private home. One of these concerns is inconsistency with caregivers/teachers. As noted in CFOC3 Standard 3.1.4.1: Safe Sleep Practices and SIDS/Suffocation Risk Reduction, “Infants who are cared for by adults other than their parent/guardian or primary caregiver/teacher are at increased risk for dying from SIDS” (Moon, 2005). To that end, implementing swaddling guidelines, training, and compliance across child care programs would be a significant challenge.

We recognize the many benefits of swaddling (when done correctly) by parents/guardians for newborns and young infants in hospital nurseries and in private homes. However, the primary target audience for the CFOC3 standardsis caregivers/teachers in early education and child care settings.

The majority of standards in CFOC3 use the phrase “should” or “should not.” The national contributors that developed Standard 3.1.4.2 made the conscious decision not to use this terminology in the standard language.Thus, CFOC3 does not ban or prohibit swaddling. Instead, it states that swaddling is not recommended or necessary.

CFOC3 does, however, account for programs that may choose to swaddle in this same standard (Standard 3.1.4.2). The last sentence of the Comments section states: “If swaddling is used, it should be used less and less over the course of the first few weeks and months of an infant’s life.”

Moreover, it is important to note that CFOC3 also includes Standard 1.1.2.1: Minimum Age to Enter Child Care, which states that Healthy full-term infants can be enrolled in child care settings as early as three months of age.” The national contributors recognized that swaddling becomes less necessary for older infants, a time at which CFOC3 recommends entering a child care setting. 

Frequently Asked Questions/CFOC3 Clarifications

Reference: 3.1.4.2

Date: 4/5/2013

Topic & Location:
Chapter 3
Health Promotion
3.1.4.2: Swaddling

Question:
Does the AAP have a Policy Statement prohibiting Swaddling?

Answer:
The American Academy of Pediatrics (AAP) does not have a Policy Statement prohibiting swaddling. The AAP does have a Policy Statement on the Safe Sleep Environment, which does recommend against loose blankets in a safe sleeping environment. “Loose bedding, such as blankets and sheets, might be hazardous and should not be used in the infant’s sleeping environment” (Task Force on Sudden Infant Death Syndrome, 2011).

The AAP Technical Report specifically addresses swaddling (page e1356) in expanded recommendations for a safe infant sleep environment. The Technical Report states that “there is insufficient evidence to recommend routine swaddling as a strategy for reducing the incident of SIDS” (Task Force on Sudden Infant Death Syndrome, 2011).
CFOC3 is co-authored by AAP, APHA, and NRC, and published by the AAP. It is consistent with AAP Policy, but is not “AAP Policy”, nor “APHA Policy”.

Citations:
Moon, R. e. (2005). Stable prevalence but changing risk factors for sudden infant death syndrome in child care settings in 2001. Pediatrics, 116(4):972-7.

Task Force on Sudden Infant Death Syndrome. (2011). Policy Statement: SIDS and Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe infant Sleeping Environment. Pediatrics, 128:5 1030-1039.

Task Force on Sudden Infant Death Syndrome. (2011). Technical Report: SIDS and Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe infant Sleeping Environment. Pediatrics, 128:5 e1341-e1367.


In child care settings, swaddling is not necessary or recommended.
RATIONALE
There is evidence that swaddling can increase the risk of serious health outcomes, especially in certain situations. The risk of sudden infant death is increased if an infant is swaddled and placed on his/her stomach to sleep (1,2) or if the infant can roll over from back to stomach. Loose blankets around the head can be a risk factor for sudden infant death syndrome (SIDS) (3). With swaddling, there is an increased risk of developmental dysplasia of the hip, a hip condition that can result in long-term disability (4,5). Hip dysplasia is felt to be more common with swaddling because infants’ legs can be forcibly extended. With excessive swaddling, infants may overheat (i.e., hyperthermia) (6).
COMMENTS
Most infants in child care centers are at least six-weeks-old. Even with newborns, research does not provide conclusive data about whether swaddling should or should not be used. Benefits of swaddling may include decreased crying, increased sleep periods, and improved temperature control. However, temperature can be maintained with appropriate infant clothing and/or an infant sleeping bag. Although swaddling may decrease crying, there are other, more serious health concerns to consider, including SIDS and hip disease. If swaddling is used, it should be used less and less over the course of the first few weeks and months of an infant’s life.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction
REFERENCES
  1. Pease AS, Fleming PJ, Hauck FR, et al. 2016. Swaddling and the risk of sudden infant death syndrome: A Meta-analysis. Pediatrics;137(6):e20153275.
  2. Richardson, H. L., A. M. Walker, R. S. Horne. 2010. Influence of swaddling experience on spontaneous arousal patterns and autonomic control in sleeping infants. J Pediatrics 157:85-91.
  3. Contemporary Pediatrics. 2004. Guide for parents: Swaddling 101. http://www.aap.org/sections/scan/practicingsafety/Toolkit_Resources/Module1/swadling.pdf.
  4. Van Sleuwen, B. E., A. C. Engelberts, M. M. Boere-Boonekamp, W. Kuis, T. W. J. Schulpen, M. P. L’Hoir. 2007. Swaddling: A systematic review. Pediatrics 120:e1097-e1106.
  5. Mahan, S. T., Kasser J. R. 2008. Does swaddling influence developmental dysplasia of the Hip? Pediatrics 121:177-78.
  6. Franco, P., N. Seret, J. N. Van Hees, S. Scaillet, J. Groswasser, A. Kahn. 2005. Influence of swaddling on sleep and arousal characteristics of healthy infants. Pediatrics 115:1307-11.