Should you swaddle your baby? A 2016 study in Pediatrics, which linked swaddling– tightly wrapping an infant in a light cloth–with an increased risk of SIDS, especially, put the question on the table and caused an uproar.

“There has been a lot of press about the study and it’s gotten blown out of proportion,” says Rachel Y. Moon, MD, a professor of pediatrics at the University of Virginia School of Medicine who is co-author of the study and the book, 14 Ways to Protect Your Baby from SIDS.

Babyproductsmom spoke with Dr. Moon to set the record straight on swaddling safety and common mistakes many parents are still making when it comes to SIDS risk.

 BPM: Did your Pediatrics study find that swaddling increases the risk of SIDS, especially in babies 6 months and older?

Dr. Moon: Yes, there is an increase in SIDS if you swaddle versus if you don’t swaddle. But the increase depends on what position the baby is in. If babies are placed on their back when they’re sleeping, there’s a small but statist
ically significant increase if they’re swaddled versus not being swaddled. But it’s not that big. The risk increases if you put swaddled babies on their side in the crib, and or, particularly, on their stomach. If you put swaddled babies down on their stomach, the risk of SIDS increases 13 to 14 times.

BPM: Does that mean swaddling is a no no?

Dr. Moon: I think swaddling is fine for the first couple of months of life. There are definitely benefits to swaddling. For some babies, swaddling can help them sleep. And we know for some babies, that if you swaddle, you could actually get them to sleep on their back. And some babies just like it.

BPM: If you’re going to swaddle your baby for the first two months or so, what’s the safest way to do it?

Dr. Moon: You definitely want swaddled babies on their back. That’s key. When they’re swaddled, it’s almost like they’re in a straight jacket. If you put them on their stomach and they’re swaddled and they roll over and end up on their stomach, that’s a huge issue. [The prone (stomach position) for sleeping is strongly associated with SIDS.] The bottom line is, if you’re going to swaddle your baby, make sure your baby is on her back.

BPM: When should you stop swaddling?

Dr. Moon: Once your baby starts looking like she’s trying to roll over, you need to stop swaddling. As babies get older, most babies don’t want to be swaddled anymore anyway. They don’t need it.

BPM: If you’re going to swaddle, what’s the safest way to do it?

Dr. Moon: There are all kinds of different ways to swaddle: Arms by the head, arms down. I don’t think there’s any data on which arm position is more or less dangerous. But if your baby’s arms are down, there’s a little bit less protective effect if your baby ends up rolling.

We do know that it’s important for babies to have wiggle room around their hips. If babies are too tightly swaddled around their hips, it could cause hip problems. If you swaddle them too tightly around their chest, it can constrict their breathing.

 BPM: Putting a baby to sleep on her back greatly reduces the risk of SIDS. Do you find that some parents still put their baby to sleep on their stomach anyway?

Dr. Moon: I do. There are the two main reasons why. Babies sleep longer when they’re on their stomach and they don’t wake up as easily, which is why parents like that position. They perceive it as being a more comfortable for the baby. But one of the issues with SIDS that it seems to be a problem of arousal, that babies don’t wake up to save themselves. They don’t wake up as easily if they get into a situation in which they’re not getting enough oxygen, or whatever. We actually want them to wake up occasionally during the night.

The second reason parents still put their babies to sleep on their back is think that if the baby is on her stomach, she’ll be less likely to choke if she spits up. But that’s not true. We know that anatomically, it’s easier for a baby to choke when she’s on her stomach because the trachea, the windpipe, is underneath the esophagus (the tube food goes down). So if she spits up, the food can more easily go down into the trachea/windpipe if she’s on her stomach. If she’s on her back, the trachea is on top of the esophagus. If a baby is going to choke or aspirate, which means the food is going down into her lungs, the food has to go up against gravity to get from the esophagus into the trachea. And, there’s no more risk of choking and aspiration when your baby is on his back compared to when he’s on his stomach.

For both of these reasons, people putting their babies to sleep on their tummies. It’s still a big problem.

BPM: Besides putting babies to sleep on their backs and stopping swaddling when they’re around 2 months old or so, what else can parents do to reduce their baby’s risk of SIDS?

Dr. Moon: Keep the crib bare. Nothing should be in the crib except for the baby. People are still using blankets, pillows and bumper pads in the crib. There’s potential risk so why do it? Decorate the room without decorating the crib. The room can look nice even if the crib is bare.

Another mistake is buying a soft crib mattress. Crib mattresses with memory foam–that’s a big no no. Babies just sink into it. People think that soft is more comfortable but for a baby, but soft actually is more dangerous. If babies sink into their crib mattress, it’s tougher for them to get out of that situation. Firm is going to be more comfortable and much safer.

BPM: When it comes to crib mattresses, I always tell parents to “think brick.” A crib mattress that seems too hard for you is not too hard for your baby.

Dr. Moon: Yes, that’s definitely the case.

BPM: Let’s talk crib styles. When you’re selecting a crib, is it better to…

buy one with spindles on all four sides like this versus a crib that has a solid panel on one side, like this? Doesn’t a spindly crib offer better air flow? 

Dr. Moon: I don’t have a preference. If your baby is on his back, it shouldn’t matter if the crib has spindles on all four sides or not. But we do like the baby to start in the parents’ room, if possible. It’s a protective mechanism.

BPM: Is a standard, stationary crib safer than a bassinet or a portable travel crib?

Dr. Moon: It doesn’t matter. Some parents don’t like the crib because they think the baby looks too small in it initially, or a crib is too big to put in the parents’ room. Of those three things, all three of them are fine; it’s whatever works best for the family.

 BPM: Does running a fan in your baby’s room help reduce the risk of SIDs?

Dr. Moon: Only one study has found a fan to be helpful. Nobody else has found that to be true.

I don’t think a fan is going to hurt. But we do know that overheating is an issue. Don’t have your baby in a room that’s too hot. Another thing I worry about is that parents trade off on risk factors. They’ll say, “If I have a fan in the baby’s room, I can put my baby in her to sleep on her stomach.” You can’t do that.

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BPM: What about using a pacifier?

Dr. Moon: Using a pacifier is great in terms of SIDS risk reduction. If you’re not breastfeeding, you can start the pacifier immediately. If you are breastfeeding, you’ll want to wait until breastfeeding has been well established, until you and your baby are both comfortable with it and your baby is gaining weight well. That generally takes a couple of weeks. Once that happens, it’s fine to introduce the pacifier.

The Take-Away on Swaddling and Baby Sleep Safety 

• Swaddling is fine for the first two months or so, as long as your baby is put to sleep on his/her back. If you swaddle your baby, leave some wiggle room in the hips.
• Running a fan in your baby’s room may or may not reduce the risk of SIDS, but keeping the room your baby sleeps in at the right temp and using a pacifier can. You don’t have to go nuts with a nursery thermometer and try to hit the target of 68 to 72 degrees F. First Candle says: “Keep the temperature in the baby’s room at a level that feels comfortable to a lightly clothed adult.”
• Your baby can safely sleep in a stationary crib, bassinet or portable travel crib.
• Bare is always best in the crib.
  Crib DON’Ts:
• Use bumpers (of any kind, even breathable ones), blankets, pillows, stuffed animals or a sleep positioner. The same goes for a bassinet or travel crib. They should be bare too; don’t add an extra mattress or padding. A travel crib mattress pad is thin for a reason.
• Buy a firm crib mattress. BPM recommends any mattress by Colgate Kids because they’ve been in the crib mattress business for over 50 years. Crib mattresses are what they do.
• Be roommates with your baby for the first six months (but not bedmates).
• Put your baby to sleep on her back. Can’t stress that enough. Back, back, back! Once your baby starts to roll over, though, don’t worry about turning her back on her back. It’s an expected milestone and besides, you need your sleep too.