Wrapping or swaddling babies has traditionally been used as a means to help settle them to sleep. Wrapping is thought to mimic the atmosphere of the womb and confines the limbs of young babies to avoid the ‘moro’ or startle reflex from waking them up. Understandably parents keen for a good night’s sleep will readily embrace this proven measure for a restful night.
For many years the weapon of choice against a baby who fought sleep was a simple muslin square. However; in recent years the humble baby wrap has had a radical makeover. A proliferation of swaddling products has hit the shelves and infiltrated online stores. Cocoon shaped zip-up wraps made of stretchy fabric are on every new mum’s “must have” list. The websites spruiking these products cite medical and scientific research into the benefits of swaddling giving an air of credibility to their products. Yet parents using these products may unwittingly be harming their children.
Orthopaedic surgeons from around the globe are raising concerns that these new swaddle suits are behind increasing rates of hip dysplasia in children. If untreated hip dysplasia can cause a child to have a limp, lead to the early onset of arthritis and even the need for a hip replacement as young as in their 20s. If caught early (before 6 months of age) the condition can usually be treated through non invasive bracing. After 6 months of age surgery is likely to be required.
The head of orthopaedics at Sydney Children’s Hospital Randwick, Dr Angus Gray, noted in a media release in 2010 a steady increase in cases of hip dysplasia and warned parents against the dangers of tight wrapping. In 2012 Associate Professor Peter Cundy (head of paediatric orthopaedics at the Women’s and Children’s Hospital Adelaide) outlined his research which linked swaddling to hip dysplasia to an international orthopaedic conference in Colorado. In the past few years Dr Cundy has noted up to a fivefold increase in cases of hip dysplasia at the Women and Children’s Hospital in Adelaide. In 2012 Professor Nicholas Clarke of Southampton General Hospital in the UK called for renewed awareness campaigns to highlight the risk of tight wrapping to parents. Similar awareness campaigns conducted in Japan have reduced the incidents of hip dysplasia there fivefold.
Awareness of the risks of tight wrapping is crucial. Online communities of parents whose children are being treated for hip dysplasia are ripe with regretful stories of swaddling and wrapping. In almost all cases it was only after their child was diagnosed with the condition that they became aware of the risks. Even doctors, midwives and early childhood nurses seem unaware of the issue themselves and as a result are not helping to educate parents about safe wrapping techniques. Yet awareness is not everything. Even parents who are aware of the link between tight wrapping and hip dysplasia may unfortunately fall prey to products that are questionably marketed. There are cocoon style wraps which openly refer to hip dysplasia on their websites – explaining that tight wrapping can contribute to the condition. They infer that their swaddle suits are not tight and safe for hips but many of these swaddes remain a concern to orthopaedic surgeons. Parents who are concerned can visit the International Hip Dysplasia Institute website to investigate safe wrapping and see a list of products that have been endorsed as “hip healthy“. The majority of swaddle suits on the market are far from hip healthy and are arguably dangerous for some babies. Dr Gray warned recently “”They often don’t look very tight, they can be very elastic, but a little weak baby is not going to fight against it. They will lie in the resting position with their knees together.”
For babies’ hips to develop properly the ball of the hip must be in place in the socket. The natural position of newborn babies is to have their legs curled up and flopping out “froggy style”. This position is also the most optimal position for healthy hip development. When babies’ legs are straightened out in a cocoon style wrap there is the potential for the hips to partially slip out of the socket or, in the worst case, to become fully dislocated.
In the United States, Texas has recently enforced a swaddling ban in child care centres to help stop unsafe wrapping practices (both to prevent hip dysplasia from overly tight wrapping and for SIDS concerns where loose wrapping can result in wraps that pose a safety threat to babies). In response to the ban many child care workers are complaining it is impossible to get babies to sleep for any length of time. This highlights the nub of another problem related to tight wrapping and hip dysplasia. How do you convince parents whose baby is sleeping soundly when snugly wrapped to change their wrapping practices? Many parents have had success with these new cocoon type swaddles and rave about them to other parents. Their baby never developed hip dysplasia so “it’s all an urban myth”. In reality it’s all a bit of a lottery.
Hip dysplasia used to be called Congenital Dislocation of the Hip (CDH) but the medical profession changed the name to Developmental Dysplasia of the Hip (DDH) in recognition of the fact that it is not just a hereditary condition, but can be acquired (through tight swaddling and the like). DDH affects approximately 2-3 out of 1000 babies and occurs significantly more in girls than boys. However, approximately 1 in 20 babies have hip instability at birth. It is these babies who are arguably at risk of becoming one of the statistics of an increasing rate of hip dysplasia if their already unstable joints are straightened out through tight swaddling and the use of swaddle suits. Unfortunately there are no Australian Standards to ensure products like swaddle suits (and other products like baby carriers) are not risking the health of babies’ hips. Infant sleep bags must comply with the standard for reduced fire hazard but there is no requirement for swaddle suits to be hip friendly.
Wrapping and swaddling are not bad per se. Wrapping can help settle fussy babies but babies should never be wrapped up like a burrito or a caterpillar in a cocoon. There are products on the market that are genuinely hip friendly and a baby can be wrapped in a simple muslin square in a hip friendly way as well. We don’t have to throw the baby out with the bath water and abandon wrapping altogether but if we are to stop the increase in hip dysplasia we do need to learn hip friendly ways to settle fussy babies.