Snug as a bug in a rug ain’t all it’s wrapped up to be

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Image courtesy of Laurie Shirazi

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.”

froggy legs copyFor 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.

tight swaddles copyHip 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.

safe swaddles copyWrapping 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.

More information about hip healthy swaddling along with information about other baby products such as carriers, swings and walkers can be found on the International Hip Dysplasia Institute website.

Pictures of infants with no swaddles (natural “froggy” position), tight swaddles and safe swaddles

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About greenleftyidealist

Green, left and idealistic. A mum, a runner, a rogainer, a public servant and wanna be writer. My dog is golden.
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16 Responses to Snug as a bug in a rug ain’t all it’s wrapped up to be

  1. Laurie says:

    Well written and very informative! Thank you for the “head’s up” when it came to keeping my little one safe!

  2. Corri says:

    This article is well meaning but is actually really misleading and could be causing parents a lot of unnecessary worry. (as if they don’t already have so much to worry about) some of the swaddles you have in your pictures are perfectly safe and don’t pose any risk for hip dysplasia. I have checked these with my peadiatrician. (Love the dream swaddle for example) As long as the swaddle is not holding the legs in a tight straight out position and they have reasonable hip flexion (which you can’t tell from looking at a photo!!) there are no problems. Even if you were to tightly swaddle a very small baby, as long as the legs are positioned upwards in the froggy position it is perfectly fine (the australian child youth health nurses and midwives are well aware of the hip dysplasia risk and this is how they show you to swaddle your baby). It is fine to make others aware of the risk of hip dysplasia but not by fear mongering and misinformation going along with it.

    • Thanks for reading the post and taking the time to respond with your thoughts. I am glad you understood that it is indeed well meaning – some forms of hip dysplasia are developmental (not congenital or inherited) and can be prevented. I wrote the post to inform parents about the risks of swaddling causing hip dysplasia to help prevent further cases.

      I must take issue though with your claim that the post is misleading.

      The first question my daughter’s orthopaedic surgeon asked me when she was diagnosed with hip dysplasia at three months (after passing her newborn and 6 week check) was whether we used a swaddle suit. It is orthopaedic surgeons who are the experts in this field. Midwives and child health nurses (and even paediatricians) cannot compare to orthopaedic surgeons in their knowledge of DDH – especially orthopaedic surgeons who specialise in DDH. Orthopaedic surgeons from around the world are warning about the rise of hip dysplasia which can be directly attributed to increased use of swaddle suits etc. It is orthopaedic surgeons who are at the front line of treating the repercussions of the latest trends in baby products.

      It is wonderful that you have experienced child health nurses and midwives who are informed about DDH and swaddling. Sadly, the experience you have had is not the case for all. There are still many health professionals who are ignorant of the risks. As a result of a lack of prenatal education about DDH most parents are not aware of the potential risks of tight wrapping or swaddling. When parents go to the shops to buy a baby product or are given a gift of a swaddle they assume that the product is safe. We have an inbuilt assumption that if it’s being sold it meets certain standards. Parents need to be aware there are no such standards in place to protect their children from swaddle suits. The post is not an attempt to fear monger but to provide information to parents (that often they’re not getting elsewhere) so that they can make informed choices for their children. It is not fear mongering to let parents know that they have a 1/20 chance that their child has hip instability and that if they choose to use a tight swaddle their child may get hip dysplasia. Swaddles have a place in helping calm fussy babies, and most parents will use them with no ill effects. But for some the use of swaddles will result in a lengthy medical journey.

      With regards to your assertion that some of the photos that show tight swaddles actually don’t pose a risk to hip dysplasia the International Hip Dysplasia Institute only endorses one commercial swaddle suit – the Halo sleep sack. You can get a sense from photographs of the way a baby’s legs are lying. In every one of these photos the babies’ knees are all forced downwards by the swaddles. Their legs aren’t always completely straight (the worst case scenario) but the downwards pressure is enough (especially when used for the extended periods that babies do sleep) to push immature and unstable hips out of their correct alignment.

      When new medical findings come to light people are often accused of fear mongering. People think if it really was true we would have heard about it before. In reality new information about the causes of different conditions comes to light all the time. Without valuable research and education campaigns conducted in the late 1980s and early 1990s about the risk of stomach sleeping and SIDS many more babies would have succumbed to cot death. Hopefully in 20 years we’ll look back and see a decline (rather than the current rise) in the rates of hip dysplasia in babies because of research and education campaigns conducted into tight swaddling and other causes of developmental hip dysplasia.

      With regards to the Love to Dream Swaddle I personally believe it is bad news for babies with hip instability. Love to Dream say on their web site that they are not giving “medical or allied health professional advice” about their swaddles and that they “recommend you seek professional advice for your and your child’s individual needs”. Personally I’m going to be wary of any baby product that tells me to seek the advice of a medical professional to be sure it’s right for my child.

  3. M says:

    What about native Americans who kept their babies swaddled in cradle boards for most of their infanthood? Is there documented evidence of hip dysplasia there? I haven’t seen any and they were very conscientious about their habits and this was practiced widely throughout the different tribes and regions.

    • Thanks for critically thinking about this issue and wondering about the validity of it and seeking further evidence.

      Yes there is documented evidence of high rates of hip dysplasia in First Nations in North America. Here is an online source from the American Academy of Pediatrics (see http://aapnews.aappublications.org/content/32/9/11.1.full):

      “Studies of Native American Indians prior to the 1950s demonstrated a very high prevalence of hip dislocation in tribes that carried babies on a “cradle board” with the hips and knees strapped in an extended and adducted position. The frequency of childhood hip dislocation decreased dramatically among Navajos after cloth diapers were introduced. This decrease was attributed to the slightly flexed and abducted position from the bulky cloth diapers even when the infants were strapped on the cradle board. As the frequency of cradle board use in Navajo society has diminished recently, the prevalence of hip dysplasia has further decreased from a rate of six times the U.S. average to a similar prevalence.”

  4. A says:

    Thanks for the article! After reading this, indeed changed my perception about the swaddle products available in the market. I understand that it might probably happen to 1 of 1000 babies who are using the popular swaddle but i am not taking any chances which will lead to potential medical problem for my bub.

  5. Christine says:

    Just came across this post and I want to say, THANK YOU! My daughter is 5 months old and in her 11th week of the Pavlik harness due to DDH. She will likely need a harder brace soon and possibly will need a pelvic osteotomy and spica cast. She was a breech baby. My mother had given me 3 Halo Sleepsacks at my baby shower so thankfully those were the only swaddlers my daughter used until she was diagnosed with DDH at 6 weeks. After she was diagnosed I researched everything about hip dysplasia and breathed a sigh of relief that were were using the only “hip friendly” swaddlers (albeit unknowingly). While my daughter’s hip dysplasia is almost certainly congenital, I’ve been spreading the word to all my friends with babies about the correct way to swaddle. I wouldn’t want ANYONE to deal with what we’ve been dealing with if they can avoid it!

    • You’re welcome Christine! I’m really glad your mum inadvertently gave you hip-healthy swaddles. Unfortunately many people just aren’t aware of the potential problems and do use themselves (I did until I became informed) or give swaddles as gifts that can impact upon a baby’s hips. Unfortunately there are no standards that are protecting babies against this danger so until there is it’s great that people like you are spreading the word.

  6. For those wanting to read up further on the scientific research into swaddling and DDH a great place to start is this paper by Professor NMP Clarke from University Hospital Southampton http://adc.bmj.com/content/99/1/5.full

  7. Tina says:

    Thanks for the article. Now I’m really worried. I’ve got my 6 months bub in the love to dream swaddle. We were swaddling her in muslin wraps until about 5 months as she started to roll. However the love to dream swaddle is just snug enough to keep her arms from hitting her face but there is plenty of room for her legs to move. I have just double checked her now and her legs are in the frog position as suggested with plenty of room for her to adjust herself.
    In your opinion, is that okay? Or is there still too much pressure on her little hip?

    • It is difficult to say and you are probably in the best position to judge. As she is 6 months old she would have more strength than a newborn and may be able to fight against the tightness of the swaddle suit to bring her legs up more effectively. If you’re using a largish sized one this may also help. I’d observe if she gets in the froggy position most times or not or if she has legs straightened when tired etc and without the energy to fight the swaddle’s tendancy to straighten out the legs. If in doubt consider hip friendly alternatives like sleepy wings and sleeves which just swaddle the arms or perhaps it’s a good time to wean off a swaddle.

  8. austinsmom says:

    Thanks so much for putting this information out! I think I’m going to skip the swaddle with my next baby. I loved the zipadee-zip transition blanket, since it worked so great with my first boy, so I’ll be going straight to that. I don’t want the risk of hurting my baby!

  9. See the below link for more compelling clinical research linking swaddle suits to the increase in hip dysplasia http://www.uhs.nhs.uk/ClinicalResearchinSouthampton/About/Research-stories/Tackling-infant-hip-problems-through-research.aspx

  10. Very happy to say that the International Hip Dysplasia Institute is now assessing baby products and acknowledging products that are hip friendly see http://hipdysplasia.org/news/hip-healthy-products/ for interest also see their statement on swaddling at http://hipdysplasia.org/swaddling-statement/

  11. Julie Fedele says:

    Maybe you could consider updating the blog post in light of your above comment? As if I hadn’t read through the comments I would have thought the Halo Sleep Sack was still the only one the Institute assessed as hip friendly.

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