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Manger? Yes – Swaddling Clothes? No

July 1, 2016

Short Attention Span Summary

You may lay your child in a manger (but only on his or her back), but do not wrap them in swaddling clothes.  Swaddling babies is associated with increased risk of SIDS, according to this meta-analysis.  This is especially true as they become better able to roll into a prone position.  Why does this matter?  Even though most infant sleep issues fall within the purview of the primary care provider, it is important for us to reinforce safe infant sleep practices in the ED.  We are the ones who encounter ALTEs, or should I say BRUE, and teaching safe sleeping habits is key for patients we are able to discharge home.

FOAM Report


Pediatrics. 2016 Jun;137(6). pii: e20153275. doi: 10.1542/peds.2015-3275. Epub 2016 May 9.

Swaddling and the Risk of Sudden Infant Death Syndrome: A Meta-analysis.

Pease AS1, Fleming PJ2, Hauck FR3, Moon RY4, Horne RS5, L’Hoir MP6,Ponsonby AL7, Blair PS2.

Author information:

1School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom; a.pease@bristol.ac.uk.

2School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom;

3Departments of Family Medicine and.

4Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia;

5The Ritchie Centre, Hudson Institute of Medical Research and Department of Pediatrics, Monash University, Victoria, Australia;

6TNO Innovation for Life, Child Health, Leiden, Netherlands; and.

7Murdoch Childrens Research Institute, Royal Children’s Hospital, University of Melbourne, and Menzies Institute for Medical Research, University of Tasmania, Tasmania, Australia.




Swaddling is a traditional practice of wrapping infants to promote calming and sleep. Although the benefits and risks of swaddling in general have been studied, the practice in relation to sudden infant death syndrome remains unclear.


The goal of this study was to conduct an individual-level meta-analysis of sudden infant death syndrome risk for infants swaddled for sleep.


Additional data on sleeping position and age were provided by authors of included studies.


Observational studies that measured swaddling for the last or reference sleep were included.


Of 283 articles screened, 4 studies met the inclusion criteria.


There was significant heterogeneity among studies (I(2) = 65.5%; P = .03), and a random effects model was therefore used for analysis. The overall age-adjusted pooled odds ratio (OR) for swaddling in all 4 studies was 1.58 (95% confidence interval [CI], 0.97-2.58). Removing the most recent study conducted in the United Kingdom reduced the heterogeneity (I(2) = 28.2%; P = .25) and provided a pooled OR (using a fixed effects model) of 1.38 (95% CI, 1.05-1.80). Swaddling risk varied according to position placed for sleep; the risk was highest for prone sleeping (OR, 12.99 [95% CI, 4.14-40.77]), followed by side sleeping (OR, 3.16 [95% CI, 2.08-4.81]) and supine sleeping (OR, 1.93 [95% CI, 1.27-2.93]). Limited evidence suggested swaddling risk increased with infant age and was associated with a twofold risk for infants aged >6 months.


Heterogeneity among the few studies available, imprecise definitions of swaddling, and difficulties controlling for further known risks make interpretation difficult.


Current advice to avoid front or side positions for sleep especially applies to infants who are swaddled. Consideration should be given to an age after which swaddling should be discouraged.

Copyright © 2016 by the American Academy of Pediatrics.

PMID: 27244847 [PubMed – in process]

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