Swaddling and SIDS

As if parents don’t have enough to worry about these days: Now they are worried about swaddling and SIDS. I am sure that parents all across the world saw the news come across their Facebook feed and were sent into a panic.

Does swaddling your baby increase the rate of Sudden Infant Death Syndrome? You would think so, to read media accounts of a paper published recently in the journal Pediatrics. Here’s a link, and the reference for those who want to read it.

Pease AS, Fleming PJ, Hauck FR, et al. Swaddling and the Risk of Sudden Infant Death Syndrome: A Meta-analysis. Pediatrics. 2016;137(6):e20153275

Here are some headlines from some of our most respected media outlets. Almost all of them misunderstood the paper’s findings:

New York Times: “Swaddling May Increase the Risk of SIDS”

Washington Post: “Swaddling babies is tied to heightened risk of sudden infant death syndrome”

Yahoo! News: “New Research Suggests Swaddling Could Increase Risk Of SIDS”

Thank God for the Atlantic Monthly and to science writer Adrienne LaFrance.  LaFrance is the only medical and science writer I’ve read so far who detected the flaws in the paper. Here’s the headline:

“About That Scary Swaddling Study: A new meta-analysis seems to link infant swaddling with a higher risk of SIDS. But there’s more to the data than that”

Indeed there is more to the story. Let’s get to the bottom of that study on swaddling and SIDS.

Why Even Study Swaddling and SIDS?

In the early 2000s, there was just as much uncertainty as there is today about the causes of SIDS.  The famous Back-to-Sleep campaign in the US was already succeeding in dropping SIDS rates. Our success was similar to results seen in other countries.  Researchers were stumped. Was it really as simple as all that? How could a silly little change like having the baby sleep on her back reduce the risk of SIDS? Many studies were performed looking at body functions like heart rate and breathing in babies. It was known that swaddled babies were generally calmer and less sensitive to waking up suddenly. The question was asked whether being quiet and less sensitive put a baby at risk for SIDS.

A Look at the Studies

Many studies were done, but most of them were lousy. Pease, et al., who wrote the paper that got all the headlines, decided to perform a “meta-analysis” of all the studies they could find on the subject of swaddling and SIDS. A meta-analysis is considered to be the highest form of scientific study. It looks at all scientific studies of a particular question and sort of pools the results. The idea is that many different groups looking at the same problem collectively get to the truth better than any one study does. It’s never a good idea to rely on only one study to answer a question. The more investigators who come up with the same result, the closer to the truth you are probably getting.swaddling and sids 3

They looked at a lot of studies. Since the 1950’s there have been almost 400 studies asking the question: Is there a link between swaddling and SIDS? Of these studies, Dr. Pease and her colleagues could find only 4 that met a standard rigorous to be considered worthy. And one of these had never been published the data on swaddling. When they were done with their analysis the investigators discovered that they could not easily compare the results of all four studies. So to present their final results they needed to eliminate one study, leaving them with three. Out of 400.

What Did They Find?

After pooling all these data, the investigators found that swaddling increased the risk of SIDS very slightly if the baby was put down on her stomach or side. In other words, it was riskier to violate the “back-to-sleep” rule. It was also riskier to swaddle a baby older than 6 months of age. The most confusing part of the study showed that there was a slightly increased risk to swaddling if you lay the baby on her back. It’s confusing because even so, many more SIDS deaths occurred in un-swaddled babies than in swaddled babies. The so-called “increased risk” was only compared to the comparison (“control”) group.

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More Problems

There were other problems with the meta-analysis. The investigators could not be sure that all the studies used the same definition of “swaddling”. Swaddling means different things in different places. Some of the studies lumped together swaddled and “wrapped” babies. It isn’t entirely clear what was being compared. Perhaps more damaging, the pooled studies were so different from one another that it was impossible to eliminate all the features that could confound the results. In other words, they couldn’t really be sure that swaddling was the thing that increased the risk of SIDS!swaddling and sids 2

The Bottom Line on Swaddling and SIDS

  • It’s okay to swaddle, but if you do, lay the baby on her back. Swaddling is only risky if the baby is face down or on her side.
  • Older babies probably shouldn’t be swaddled, but that’s okay, since it’s really difficult to swaddle a six-month old baby anyway. They fight out of the swaddle too easily.
  • Learn to swaddle a baby correctly. There are lots of terrific videos on YouTube that show you how. Here’s one:

Best Preemie Products

Premature babies need pretty much the same things that full-term babies need. They just tend to be smaller, and require a little more padding sometimes. And they need to be warmer. Preemies are born with very little subcutaneous fat. Add to this the fact that they often have difficulty keeping their temperature up! I don’t list any hats here among these “Best Preemie Products”, but don’t forget them! Babies in general lose a lot of heat from their heads, and this goes double for premature babies!

Best Preemie Products

Swaddling Blankets

Such a simple product, so much good! I’m still astonished by how quickly even the fussiest, most sensitive baby calms almost instantly when she’s swaddled. Swaddling (at least partially) reproduces conditions inside the uterus, where the baby feels most secure and warm. It’s not a difficult skill to learn. Done right, you can help your baby settle down to sleep in practically no time.

The key is to achieve a balance between snugness and constriction. Most new parents, fearing that the baby is too fragile, err on the side of keeping the swaddling too loose. This seldom works. With a little practice and good feedback from baby, you’ll gain confidence and swaddle like a pro in a few days.

There are dozens of videos on YouTube that teach good swaddling methods I like this one from Raeanne Brazee. Practice makes perfect.

Best Preemie Products: Sleep Sacks!

For sleep wear, there are two important things to keep in mind. The first is that preemie sizes are always too big… at first.

It’s just a fact of life and product sales that parents of preemies must deal with. Happily, the very little one grows into her clothes remarkably quickly. The second point is probably more important: Your baby doesn’t need to walk around in pajamas so why struggle to get her legs into pajama bottoms? One of the things I like most about the Carters One Pieces is the zipper. I’ll be forever astonished at the number of baby clothes with as many as 15 snaps. Speaking as a Dad, I protest: there is no way to do up all those snaps correctly! Same goes for buttons, only more so.

Best Preemie Products: Hug Me Joey Car Seat Insert

The hug me Joey is just the insert that goes in your existing car seat. It is a wedge and a bumper.Why is this important? Existing car seats must sit the baby more or less upright. But the best, safest position for a premature baby is laying on her back on a flat surface! The wedge and padding provides a compromise. It is to be used only when the baby is in the car. It’s not a good idea to leave a preemie in the seat and bring her inside, as tempting as that might be, especially if she falls asleep. For her safety, and to help prevent “flat head“, the car seat and Joey wedge should only be used when you take baby for a ride.
Another oddity about the Joey wedge I’ve observed is that parents of preemies get so used to using them that they continue to place the wedge in the car seat long after the baby is too big for it! Here’s a good index: when the baby gets to full-term, corrected gestational age, you can put the wedge away (or lend it to a friend!)

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Best Preemie Gear: Dr. Brown’s Bottles and Nipples

Premature babies have particular feeding issues that full-term babies do not. If your preemie is not able to latch onto your own nipples at first, Dr. Brown is here to the rescue!
They often have difficulty coordinating sucking and swallowing. They also have smaller mouths and stomachs (obviously!) so they often cannot handle the rate of flow that comes out of “regular” nipples.

Eating consumes a lot of energy for a little baby, as paradoxical as that sounds. The smaller the preemie, the more energy relatively they spend trying to eat! Feeding and growing is her #1 job of the preemie. Anything we can do to help her grow without taxing her system too much in the process, is a good thing. The “ultra preemie” nipple is smaller yet. The rate of flow is only 35% that of the original Dr. Brown’s preemie nipples. The “younger” preemies need to rest a lot and breathe more often. This nipple helps the baby avoid becoming exhausted during feeding.

Twins Should Sleep in the Same Crib

Is it okay for twins to sleep in the same crib? People worry about bed-sharing: is it safe to have a baby sleep in the same bed as an adult? What about siblings? Well, what about siblings of the same age? I would say that, for at least the first four months, twins should sleep in the same crib. Here’s why:

Why twins should sleep in the same crib

In the first few weeks to months of their lives, the twins will probably sleep in the same room as mom, at least in the US. It’s likely that they will sleep in a “Moses Basket” type of bassinet, or a co-sleeper for twins. You should observe the same safety rules you would use if you had a singleton (these are from the American Academy of Pediatrics):

  • Always use a firm sleep surface. Car seats and other sitting devices are not recommended for routine sleep.
  • The baby should sleep in the same room as the parents, but not in the same bed (room-sharing without bed-sharing).
  • Babies should sleep on their backs!
  • Keep soft objects or loose bedding out of the crib. This includes pillows, blankets, and bumper pads.
  • Wedges and positioners should not be used.
  • Don’t smoke! Get help quitting if you can’t do it on your own!
  • Breastfeeding is recommended.
  • Offer a pacifier at nap time and bedtime (until 6 months, max!)
  • Avoid covering the infant’s head or overheating with too many blankets.
  • Do not use home monitors or commercial devices marketed to reduce the risk of SIDS. They don’t work!
twins should sleep in the same crib 5
Start close, stay close

Now that you follow all the safety guidelines, you should know that your twins have some advantages that singletons don’t! It all starts in the womb. These guys have been up close and personal for a long time! For reasons we do not understand well, twins appear to be calmer and they feed better when they stay close.

And there’s another factor that will matter very much to you over time: Laundry. One set of baby sheets instead of two. I’m terrible at math but I can appreciate how much time, energy, and money this will save you in the long term!

Any arguments against why twins should sleep in the same crib?

“But won’t they get so used to being together that we won’t be able to separate them later?”

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No. That’s a myth. Just as an example, I know a pair of identical twins who shared a room throughout primary and secondary school. Then they were roommates in college. Then they were roommates again in medical school! That’s approximately 26 years of sleeping in the same room! They both married (women who are not twins themselves) and live happy, well-adjusted lives in different cities. And no, they don’t feel each other’s pain. This too is a myth.

Won’t I get confused as to which twin is which?

This is a concern, but there are lots of clever ways around it. I once consulted with a family with identical twin 4-month old girls. When I met the father, he was holding one of them on his shoulder. I made eye contact with her and smiled.

 

twins should sleep in the same crib 2
Yup. Still wearing nail polish

“And, who is this?”, I asked him, as I was rewarded with a big open mouth “social smile” from his daughter. Dad shrugged. He honestly didn’t know. When they are identical, sometimes they are identical. Mom could tell them apart, fortunately for Dad.

In another family met when the twin girls were much younger, even the mother had a tough time telling them apart. She was worried that at night in the dark she’d get confused and forget who got fed on which breast and when. This mom came up with a neat solution. She painted the toenails of one of the daughters. Then they made up a rhyme to help themselves remember which twin had the painted nails! (I kept in touch with this family for quite some time. When both girls were older, they both insisted on nail polish. By this time the parents could easily tell them apart).

The safety pin has also been a big help to the mother of twins. You can use safety pins with little colored ribbons on them to mark the swaddling blanket of each twin. A lot of mothers I know also use the same color-coded safety pins on their nursing bras to keep track of which twin ate on which side.

At what age is it not a good idea any more that twins should sleep in the same crib?

twins should sleep in the same crib 4
They still dig one another

The answer, like so many answers in parenting, is “it depends”. If they’ve got enough room, and there’s an absolute minimum of loose blankets and clothing for them to get tangled in, you can keep it going for a very long time indeed.

According to pediatric nurse Jennifer Walker, “[i]f they sleep better when they know the other is close by, crib-sharing can last up until they move into their childhood beds.”

The bottom line is, as long as they are safe, the twins can sleep together. I believe they should.