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Wrapping and swaddling infants: Child health nurses' knowledge, attitudes

and practice

Article  in  Neonatal, Paediatric and Child Health Nursing · November 2013

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N E ON ATA L , PA ED IAT R IC A ND CH ILD H EALTH NU RSING

Wrapping and swaddling infants: child health nurses’

knowledge, attitudes and practice

Jeanine Young *
Professor of Nursing, School of Nursing and Midwifery, University of the Sunshine Coast; Adjunct Professor, Centre for Health Practice
Innovation, Griffith University; Honorary Adjunct Professor, Centre for Online Health, University of Queensland, QLD, Australia
Email [email protected]

Rosemary Gore
Clinical Nurse, Ellen Barron Family Centre, Children’s Health Queensland Hospital and Health Service, Brisbane, QLD, Australia

Barbara Gorman
Clinical Nurse, Child Youth and Family Health Services, QLD, Australia

Karen Watson
Research Assistant, School of Nursing & Midwifery, University of the Sunshine Coast, QLD, Australia

*Corresponding author

Abstract
Infant wrapping and/or swaddling is an evidence-based care practice that when applied appropriately can be a strategy for
settling an infant and promoting supine sleep positioning as recommended for the reduction of sudden unexpected deaths in
infancy (SUDI). This study aimed to describe the knowledge, attitudes and practices of child health nurses (CHN) relating to the
advantages and disadvantages of wrapping; principles of safe infant wrapping; and parent education about infant wrapping as
a settling strategy.
Design
Using a descriptive, cross-sectional survey design the knowledge, attitudes and self-reported practices of CHNs working within
nine health service districts throughout south-east Queensland, Australia, were explored.
Results
Conducted at a time when no statewide guidelines for infant wrapping existed and achieving an excellent response rate
from participants (161, 89%), this study demonstrated a wide variation in knowledge, attitudes and practices in relation to
wrapping as a strategy to promote infant sleep and to encourage babies to sleep on their backs, consistent with public health
recommendations.
Conclusions
Study results identified a need for the development of evidence-based practice guidelines for CHNs to promote consistency in
practice, parent advice and education that would help to further reduce the risk of SUDI. There is a need for further investigation
into the impact that a targeted educational intervention based on evidence-based guidelines for safe infant wrapping would
have on CHN knowledge and practice.

Implications for clinical practice

• CHNs are an important information source for parents.
• Prone position is a risk factor for SUDI.
• Wrapping strategies based on principles of safe infant wrapping can assist parents to settle their babies in the
recommended supine infant sleep position.
• Evidence-based information and guidelines will promote consistent practice by CHNs.
• Consistent, evidence-based information use by parents in caring for their baby will reduce the risk of SUDI.
Keywords: Wrapping, swaddling, sleep positioning, safe sleep, SUDI, SIDS.

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What is known about this topic What this paper adds

• Infant wrapping or swaddling is a common infant care • This study identified a wide variation in CHNs’ knowledge,
practice used by many cultures since medieval and attitudes and practices relating to wrapping as a strategy
ancient times. to promote infant settling and safe infant sleeping to
· 
Wrapping has many benefits, but is associated with reduce the risk of SUDI.
some adverse outcomes depending on techniques used. · 
Consistent evidence-based guidelines are needed at
· Infant wrapping based on safe wrapping principles can a local, state and national level to support CHNs in
assist parents to settle babies in the recommended educating parents about how to use this common infant
supine sleeping position to reduce the risk of SUDI. care strategy safely and effectively.

Declarations Literature review

Manuscript category: Empirical research — quantitative. Wrapping and/or swaddling in the supine position is an
ancient practice of encircling an infant in a cloth or blanket
Conflict of interest statement: No conflict of interest has (with head exposed) to restrict movement11. A recent
been declared by the authors. systematic review highlighted both the potential advantages
Funding source: The Royal Children’s Hospital Foundation and disadvantages of this practice2. There is evidence that
(RCHF Grant No: 914-046). wrapping increases sleep, reduces motor activity, reduces
startles, and lowers heart rate variability, without reducing
Introduction responsiveness to stimulation12-15. Wrapping also improves
neuromuscular development, facilitates better motor
Managing unsettled infant behaviour and promoting
organisation, and increases self-regulatory ability in preterm
infant sleep are issues that health professionals who work
infants16,17. Following painful stimuli, infants can be soothed
with parents of young infants around the world routinely
using wrapping18 and have improved temperature control1.
address. Health professionals who provide guidance to
When compared with massage as a treatment for excessively
parents relating to these issues also need to support public
crying infants who have cerebral damage, swaddling achieved
health recommendations that promote evidence-based safe
better outcomes19.
infant sleep practices. Prone sleep positioning for infants
is a known risk factor for sudden infant death1. The use of Most importantly, wrapping and/or swaddling infants in the
infant wrapping, also commonly termed swaddling, has been supine position has been associated with a reduced risk of
identified as a strategy that can be used to calm infants, SUDI, including SIDS1,20-22. The mechanism by which this is
improve settling and promote supine sleep2. achieved is believed to be a reduced risk of the infant rolling
to the prone position, and reduced likelihood of the infant’s
Background head being covered by bedding; both established risk factors
In Australia, the state of Queensland has reported a rate of for sudden unexpected infant death13,14. The success in the
prone sleeping of approximately 12% for infants aged three reduction of sudden infant death internationally (estimated
months, a figure substantially higher than rates reported most recently to be 83% in Australia) has been attributed
by other states and territories3-5. Queensland has also to public health campaigns which advise parents to place
experienced a higher than national rate of infant mortality their babies on their back to sleep23-25. A meta-analysis of 19
attributed to sudden unexpected deaths in infancy (SUDI) retrospective case-controlled studies demonstrated an almost
including sudden infant death syndrome (SIDS) and fatal threefold increased risk of sudden infant death associated
sleeping accidents6,7 since the first Australian Reducing the with infants sleeping in the prone position26, findings which
Risk of SIDS campaign in 1991 (Table 1). Given the key role have been supported in subsequent investigations of the role
health professionals play in health promotion8, the extent to of sleep positioning in SUDI26-28.
which child health nurses (CHNs) were aware of, and utilise,
infant wrapping and/or swaddling as a sleep strategy in their There are, however, potentially negative aspects of wrapping
parenting support and education was explored. and/or swaddling that need to be considered. Ponsonby

Table 1: Definition of terms

Sudden and unexpected death in SUDI is the sudden, unexpected death of an infant usually occurring during sleep, in which the cause is not
infancy (SUDI) immediately obvious. SUDI includes sudden infant death syndrome (SIDS) and fatal sleeping accidents10.

Sudden infant death syndrome Sudden infant death syndrome (SIDS) is defined as the sudden and unexpected death of an infant under one
(SIDS) year of age, with onset of the lethal episode apparently occurring during sleep, that remains unexplained after a
thorough investigation including performance of a complete autopsy and review of the circumstances of death
and the clinical history6,9,10.

Fatal sleeping accident A death occurring during infant sleep, resulting from an accident, fall, suffocation, or mechanical asphyxiation.
Fatal sleeping accidents are explained deaths that meet SUDI Criteria10.

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and colleagues reported that an infant who was swaddled Table 2: Summary of safe infant wrapping principles available to
and positioned prone had a twelvefold increased risk of clinicians at time of study*
SIDS compared with non-swaddled prone infants for whom
the risk of SIDS was increased by three times22. Adverse SIDS and KIDS Australia endorses the practice of wrapping infants to
promote sleeping in the supine position40.
outcomes associated with wrapping include increased
respiratory infections with tight swaddling13,14,29; increased If parents choose to wrap their baby for sleep*:
developmental dysplasia of the hip when lower limb flexion is
overly restricted30-32; hyperthermia when baby is overdressed • wrap material should be muslin or light cotton
and wrapped, or inappropriate wrapping material is used,
• wrap does not cover baby’s head to prevent overheating
especially if the infant’s head is also covered2; and delayed
postnatal weight gain if the infant is separated from the • avoid overheating — do not overdress baby under the wrap
mother immediately after birth33. Thus, it is critical that the
correct technique for swaddling is used. Wrapping and/or • ensure SIDS and KIDS Safe Sleeping guidelines are followed.
swaddling does not negatively influence the incidence of
Put baby on the back to sleep, from birth.
rickets34 or breastfeeding outcomes33.
Sleep baby with face uncovered.
More recently the need for differentiation between the types
of wrapping and/or swaddling practices used within a study Cigarette smoke is bad for babies.
has been highlighted. British research reported an increased
risk of sudden infant death with swaddled infants; however, Start loosening the wrap with view to not using it at all when baby
starts rolling over.
did not account for known risk factors (for example, sleep
position, bed-sharing while swaddled) or consistency with If parent or baby not comfortable with wrapping, do not use this
safe infant wrapping principles in the analyses35. The current method for settling.
statement on swaddling compiled by the International
*Safe infant wrapping principles at time of study based on recommendations stated
Society for the Prevention of Infant Death (ISPID)36 includes in Wrapping Your Baby 0–4 months40. This pamphlet was available in some states of
the evidence thus far surrounding ‘changes’ in sleep habits. Australia, and used in some of the health districts participating in this study.

One physiological study with a small sample has identified

that arousability is reduced by swaddling when the practice Statement of the problem
is newly introduced in older infants in a way that is not seen
The CHN is an important source of information regarding
when infants are swaddled from birth37. Further research
safe sleeping and settling strategies for parents. The need
needs to be conducted to replicate these findings; however,
for this study originated in the development of a clinical
it does have clinical implications for practitioners in relation
pathway for settling infants under three months of age
to the timing of changes to sleep practices36.
that had been introduced into early parenting and child
Overall, there are several important advantages of wrapping health centres within the study region. Anecdotally, nurses
and/or swaddling in the supine position, the most important displayed varying levels of knowledge and differing attitudes
being a reduction in sudden infant death. The disadvantages to wrapping and/or swaddling babies. The aims of this study
of infant wrapping and/or swaddling have been identified as were, therefore, to describe the knowledge, attitudes and
being predominantly related to the use of incorrect swaddling practices of CHNs relating to:
practices2,38, highlighting the importance of evidence-based
1 advantages and disadvantages of wrapping
safe sleep and settling information being provided to parents
and carers. Wrapping and/or swaddling is a widely used 2 knowledge of the principles of safe wrapping
practice that is promoted by CHNs; however, up until the
time that this study was conducted, there were no specific 3 techniques used in wrapping
guidelines for clinical practice. At the time of this study,
resources available to CHNs included the Karitane pamphlet 4 parent education about wrapping as an infant settling
on wrapping39 and, immediately prior to this study, a position strategy and SUDI risk reduction strategy.
statement released by SIDS and Kids that supported infant
The study
wrapping as a strategy to support safe sleep positioning40
(Table 2). Methodology
Design
Karitane nurses are nurses trained in the care of young
babies and their mothers according to the principles of the This study used a descriptive, cross-sectional survey design to
Plunket Society, New Zealand39. There was no specific state describe the knowledge, attitudes and self-reported practices
(Queensland Health) or local policy to guide clinical practice. of CHNs in south-east Queensland in relation to wrapping
Interestingly, the Karitane pamphlet also highlighted that and/or swaddling.
there was (at the time), little scientific information which
explained why people wrap babies and nor was there any Questionnaire development and pilot
one correct way39. No existing survey tools were identified that specifically

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 N EON ATAL, PAED I ATRI C AN D C H I LD H EALT H NU R S I NG

addressed the topic under investigation. Questions were Data analysis

developed following an examination of the literature, and
Medians, interquartile ranges (IQR), frequencies and
themes identified through focus group sessions conducted
percentages were used to report the central tendency, spread
with a sample of CHNs working in two child health centres.
and empirical distributions of the categorical variables.
The questionnaire was based on a previously successful
Statistical computations and comparisons (chi-squared) were
format which examined safe infant sleeping priorities41,42. To
conducted using the SPSS statistical software package45. An
establish content validity, the instrument was first examined
alpha level of p<0.05 was considered statistically significant.
by an expert panel (n=6) comprising nurse researchers,
educators, managers and clinicians43,44. The instrument was Findings
tested according to the Lynn method for clarity, apparent
Response rate
internal consistency and content validity44. Language,
wording, appropriateness, relevance and comprehensiveness The response rate was 89%, with 161 of the 181 surveys being
of the questionnaire items were examined. Whilst there completed and returned.
were some individual comments about completion of the
Demographics
demographic questions and interpretation of the knowledge
items; consensus by the panel was achieved for 83% of the Respondents were all female, aged predominantly 35–54
items included; therefore no changes were made to the years, and most identified as being Australian born (138,
questionnaire. In addition to demographic questions (n=13), 86%). There was an equal distribution of full-time and part-
the questionnaire comprised multiple choice (n=24) and short time workers. Most participants held specialist level positions
answer questions (n=1) relating to knowledge and attitudes (clinical nurse or above; 129, 80%) and had been working
(n=15) and practice (n=11). Content included advantages with parents of young children for 10 or more years (145,
and disadvantages of wrapping/swaddling, infant settling 90%). The majority held a child health nurse qualification
strategies, wrapping materials and styles, principles of safe (151, 94%) and all but two participants were involved in
infant sleeping, sources of knowledge, and parent advice. parent education (Table 3).
The survey was piloted amongst a sample of CHNs from three Preference in terminology and sources of knowledge
facilities within the study region (n=30). Pilot results (n=24,
Participants identified a clear preference for the term
80% response rate) supported both the appropriateness of
"wrapping" over "swaddling" (116, 72% vs 25, 16%) with
the tool and highlighted the need for further investigation
90 (56%) participants indicating they believed there was a
of this subject.
difference between the terms. The term wrapping will be
Sample/participants used herein for ease of reporting results.

A purposive sample was drawn from the target population Over half of respondents (91, 57%) identified that they
of registered nurses working in child health nursing roles were from a culture that did not traditionally wrap babies.
within one of nine health service districts throughout south- Although a third of the sample identified that they were
east Queensland, Australia. Participants were identified by from a culture that traditionally practised wrapping in the
their area managers in collaboration with the research team. home, only 19% (30) had learned about wrapping from
Eligible participants (n=181) worked within the selected their immediate family. Other sources of knowledge about
study areas in a permanent or temporary, full-time, part time wrapping were identified as originating from midwifery (93,
or casual capacity, and were rostered to work at the time of 58%), child health (22, 14%), or paediatric nursing (9, 6%)
recruitment (that is, not on maternity, annual, long service or practice.
extended sick leave).
Knowledge
  and attitudes
Data collection Participants responded
Figure  1:  Situations   to questions
where  participants   about
identified  wrapping   the
was  useful   usefulness,
in  practice.  

 
Each participant was provided with a participant information 60

sheet and questionnaire distributed via institutional mail or  

by postal services. Completed questionnaires were returned
either via reply-paid envelopes or to sealed collection points. 4 0  

Participants were recruited from the nine participating

 
districts during an eight-week period, July–August 2005. The
survey took approximately 10 minutes to complete. 2 0  

 
Ethical considerations
 
Ethical approval from each of the nine participating Health 0
  s u p in e  is s id e  is  n o t p ro n e  is  n o t wra p p in g u n s u re  o f
Services Districts and organisational Human Research Ethics re c o m m e n d e d re c o m m e n d e d re c o m m e n d e d s u p p o rte d  b y S ID S &K id s
  S ID S  &  K id s g u id e lin e s
Committees was obtained prior to study commencement.
Participant consent was implied by the return of a completed Figure   1: Situations where participants identified wrapping was
survey. useful in practice

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N E ON ATA L , PA ED IAT R IC A ND CH ILD H EALTH NU RSING

Table 3: Sample demographics

Demographic variable Number %

Sex
Female 161 100
Age
25–34 years 9 5.6
35–44 years 47 29.2
45–54 years 69 42.9
≥ 55 years 36 22.4
Cultural background
Australian 138 85.7
British 11 76.8
European 4 2.5
African 4 2.5
Other 4 2.5
Employment status
Full-time 73 45.3
Part-time 74 46
Casual 14 8.7
Post-registration experience
0–4 years 3 1.9
5–9 years 13 8.1
10 or more 145 90
Involvement in parent education
Yes 159 98.8
No 2 1.2
Length of time working with parents of young infants
0–4 years 5 3.1
5–9 years 28 17.4
10 or more years 128 79.5
Practice areas*
Child health clinic 86 53.4
Home visiting 44 27.3
Residential care 35 21.7
Parent education groups 20 12.4
Child health line 11 6.8
Parent management or education/early feeding clinic/management 19 All < 5%
Highest level of education*
Post-registration certificate 57 35.4
Diploma/degree 53 32.9
Postgraduate certificate 52 32.3
Postgraduate diploma 30 18.6
Masters 7 4.3
Enrolled nurse 3 1.9
Speciality qualifications*
Child health 151 93.8
Midwifery 132 82
Lactation consultant 37 23
Paediatric 20 12.4
Mental health/neonatal/immunisation/health promotion/community health/continence/ 32 All ≤ 5%
management/family planning

* Multiple responses possible

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 N EON ATAL, PAED I ATRI C AN D C H I LD H EALT H NU R S I NG

advantages and disadvantages associated with wrapping indicated that they knew the difference between safe versus
babies. unsafe wrapping techniques; however, 32 (20%) respondents
were unsure. Participants were asked to express their
Most participants identified that the practice of wrapping understanding of the SIDS and Kids guidelines regarding
was most helpful for babies aged between birth and three wrapping in the context of parent education if parents chose
months (144, 89%). More than 70% of participants identified to wrap their baby. Less than half (46% or less) of the sample
positive effects of infant wrapping including increased correctly identified SIDS and Kids recommendations relating
feelings of security (138, 86%), calming (133, 83%), reduced to safe wrapping in terms of advised infant sleep position.
startle reflex (118, 73%) and improved settling to sleep Less than a third (47, 29%) of participants were aware that
(110, 68%). Less well identified were advantages relating SIDS and Kids supported the practice of wrapping as an infant
to increased duration of sleep (80, 50%), reduced crying settling strategy (Figure 2) while a quarter (40, 25%) were
(53, 33%), reduced colic symptoms (16, 10%) and improved unsure of existing guidelines. Participant education levels
neuromuscular and behavioural development in premature or years of experience were not significantly associated with
babies (15, 9%). Less than a third of participants were aware awareness of SIDS and Kids recommendations.
that wrapping was an evidence-based strategy to support
supine positioning (49, 30%) (Figure 1). Prior to this study no official policy guidelines existed in
relation to wrapping practices in Queensland; an issue
Participants identified their main concern with wrapping identified by 121 (75%) respondents. Most respondents
as being the risk of overheating (115, 71%). The risk of (147, 91%) agreed that development of evidence-based
developing an infant sleep association (68, 42%); impaired policy guidelines would be useful in supporting their clinical
normal development (53, 33%); increased risk of SIDS (42, practice.
26%); compromised respiratory function (33, 21%); increased
risk of suffocation (32, 20%), and hip dysplasia (9, 6%) were Practice
each identified as potential risks associated with infant
Most CHNs (126, 78%) reported that they would initiate
wrapping. Less than half (66, 41%) of the participants correctly
wrapping as an infant settling strategy if appropriate to the
identified that there were no negative effects as long as the
family’s circumstances. CHNs were significantly more likely
infant was "safely" wrapped.
to discuss the practice and aspects of wrapping with parents
When asked to identify what type of material was suitable for of an infant less than three months old on a "sometimes" to
wrapping a baby, more than 90% of participants (144, 93%) "frequently" basis (139, 86%) compared to parents of an older
identified that the appropriate material for a wrap would infant (3–6 months) (69, 43%) (chi-squared test statistic =
be a light cotton or muslin, with 28 (17%) considering that 51.08, df 9, p<0.0001).
flannelette or cotton air cell blankets were also appropriate.
The most frequently identified wrapping style was for
Over half the respondents (92, 57%) correctly identified that
the wrap to be firmly or tightly folded around the infant
the subtropical Queensland climate did not pose a problem
and loosened with development to allow arm movement
as long as the infant was lightly clothed in summer, while 45
(45, 28%), with the arms flexed and loosely contained (59,
(28%) participants indicated the heat in summer, the heat
37%). Approximately one half of the respondents (84, 52%)
experienced in Queensland’s north, or the heat in general,
responded with a wrapping style consistent with evidence.
may impact decision-making related to the appropriateness
The remaining 48% (77) were unsure, did not having a style
of wrapping a baby.
of wrapping, or selected a loosely folded wrap; responses
Participants were asked if they were familiar with "safe" and that were not consistent with evidence-based principles of
"unsafe" wrapping practices. Most participants (114, 71%) safe wrapping.
Figure  2:  Knowledge:    Number  of  participants  who  identified  correctly  the  SIDS  &  
Kids  guideline  statements.   For parents who chose to wrap their baby, few CHNs reported
  that they would discourage the practice (9, 6%) although
60
some would also suggest alternative settling strategies (65,
 
40%). Almost a third identified that they would support the
  parent’s decision (46, 29%) and most would discuss safe wrap
40
techniques with the parents (129, 80%). Over half (92, 57%)
 
the group identified they would specifically discuss SIDS and
  Kids Australia recommendations; but interestingly there were
20
just 72 (45%) respondents who had demonstrated awareness
 
of a SIDS and Kids position statement about infant wrapping.
 
0
s u p in e   is s id e   is   n o t p ro n e   is   n o t wra p p in g   s u p p o rte d
To further determine CHN wrapping practice with
  re c o m m e n d e d re c o m m e n d e d re c o m m e n d e d b y   S ID S   &   K id s
regard to infant age, participants were asked what their
recommendations would be for management of a situation
  Figure 2: Knowledge: Number of participants who identified
correctly the SIDS and Kids guideline statements where a two-month-old was being settled in the prone
position by his/her parents. Most (101, 63%) identified that

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N E ON ATA L , PA ED IAT R IC A ND CH ILD H EALTH NU RSING
 

 
Figure 3: Wrapping advice for parents of infants at 2 months & 4 months

cotton and muslin wraps for wrapping babies in most climates

100 2 month infant was well known; however, a third of nurses reported that the
90 4 month infant
Queensland climate inhibited the utilisation of wrapping as
80
70
an infant care strategy. Dressing an infant appropriate to the
% of participants

60 environment is an important consideration for caregivers as

50 overheating is a risk for sudden infant death if an infant is too
40 heavily dressed under a wrap, particularly if the head is also
30
covered51. For warmer climates, minimal dressing of an infant
20
prior to wrapping (singlet and nappy) is advised, and does
10
0
not preclude wrapping52.
Yes No Unsure
Most nurses indicated that the first three months of life
Would you recommend wrapping in supine as an
alternative to prone? was the developmental period in which wrapping a baby
was the most helpful. The term "wrapping" was preferred
Figure 3: Wrapping advice for parents of infants at 2 and 4 months
in practice with the terms themselves invoking responses
they would recommend to the parents the use of the supine whereby "swaddling" was generally interpreted as being a
sleep position, with the infant wrapped, as an alternative to more restrictively applied cloth, or alternatively, a very loose
prone positioning. However, 60 (37%) of the sample either bundling of material, with or without head covering. Only
would not, or were unsure about, recommending wrapping half of the respondents identified the preferred response
in this situation. When asked what their parent advice would of "wrapping" being "cloth firmly folded around the infant".
be for a similar situation but with an older baby (four These findings did indicate that education regarding the
months) who was rolling to prone during sleep, only 11 (7%) practice was necessary to avoid the unsafe extremes (wrap
participants reported that they would recommend a trial of being applied too loosely or too tightly)53. A variety of
wrapping to keep the infant on the back during sleep (Figure applications of the practice of wrapping were identified with
3). Almost a third (50, 31%) would not recommend wrapping over half of respondents using a technique that allowed
to support back positioning for this older infant. CHNs were for infant development in which there was increasing arm
significantly more likely to advise parents to try wrapping to freedom or arm placement near the mouth before ceasing
support supine positioning for a younger infant aged two wrapping altogether. Wrapping techniques need to be
months than compared to advice for parents with an26older tailored to the infant and individual practitioners may have
infant aged four months or more (63% vs 7%) (chi-squared their own preferences in the style used; however, practice
test statistic = 15.45, df 4, p=0.004). should be consistent with basic principles of safe wrapping.

Discussion Most nurses correctly identified the absence of state

organisational or district policy guidelines regarding
The findings from this study identified a wide variation
in CHNs’ knowledge, attitudes and practices relating to the practice of infant wrapping while the vast majority
wrapping as a strategy to: a) promote infant settling and (>90%) reported that evidence-based guidelines should be
sleep; and b) encourage babies to sleep on their backs, developed. These results suggest that nurses may be more
consistent with public health recommendations. inclined to advocate and implement an evidence-based
practice such as safe infant wrapping if policy guidelines
Knowledge and attitudes have been developed, endorsed and disseminated by their
organisation.
Most participants reported having developed their knowledge
base about wrapping from their practice. At the time of this Practice
study there were no statewide policies or guidelines for
The majority of study participants were very experienced in
infant wrapping in place. In the absence of guidelines it
child health and nearly all worked within roles that involved
is possible that this informal passage of knowledge was
education. The potential for this practice group to impart
neither comprehensive nor evidence-based. SIDS and Kids
information and support recommendations within the
Australia had developed a position statement supporting
community is great. The importance for the information to be
infant wrapping according to safe principles as a strategy to
evidence-based and current is, therefore, vital. Most nurses
support supine positioning for sleep in 200540, available on
advocated wrapping as a settling and sleep strategy from
their website, but participants demonstrated poor awareness
"sometimes" to "frequently" in their practice, and were more
of this.
likely to discuss these strategies with parents of younger
Most respondents indicated that they were aware of safe infants, aged less than three months. Most CHNs indicated
and unsafe wrapping practices; however, less than half of the that if a parent chose to wrap their infant that they would
group were aware of the SIDS and Kids position statement discuss safe wrapping techniques, while interestingly only
and a quarter reported use of a wrapping style that was not a third of respondents identified that they would actively
recommended by evidence at the time. The suitability of light support the parent’s decision to wrap.

8 Volume 16 Number 3 – November 2013

 N EON ATAL, PAED I ATRI C AN D C H I LD H EALT H NU R S I NG

Most CHNs indicated they would recommend infant Conclusions

wrapping as a strategy to support supine sleep as an
This study aimed to investigate the extent to which health
alternative to prone positioning for a two-month-old infant; professionals were aware of, and utilise, infant wrapping
however, a considerable proportion (about a third) would as a safe settling and sleep strategy. With the incidence of
not suggest use of this strategy to parents as an alternative prone sleep positioning in the region where this study was
to prone, despite the evidence to support it2,54. Sudden conducted being one of the highest in Australia48, and with
infant deaths occur most frequently in the first six months Indigenous infants significantly less likely to be placed in the
of life, with a peak between two and four months of age55. recommended supine sleep position than non-Indigenous
With indisputable evidence that supine sleep positioning infants49, this issue has important practice implications. Many
has been a key contributor in the reduction in sudden infant parents choose to place infants prone to sleep because they
deaths globally, all caregivers should be made aware of the perceive it as being more comfortable and conducive to
importance of settling babies to sleep on their back, from improved sleep for the infant50. Some parents may choose
birth25,56. Wrapping is a safe and effective strategy to promote prone positioning because they are unaware of an alternative
supine sleep positioning that CHNs should be aware of to settling strategy. However, wrapping in the supine position
share with parents, particularly if they are having difficulty calms infants and improves settling to sleep, facilitating
with infant settling and sleep. maintenance of the supine sleep position, a recognised risk
reduction factor for sudden infant death20-22. Of particular
CHNs were also significantly less likely to suggest to parents concern was that, despite the evidence, almost a third
a trial of wrapping for an older infant of four months of nurses would not recommend wrapping to encourage
who was rolling prone during sleep, compared to younger supine sleep with two-month-old infants whose parents are
infants, aged two months. However, evidence suggests that choosing to settle them prone when those infants are within
wrapping is a strategy that potentially has a role in situations the developmental age associated with the greatest risk of
where supine sleep positioning could be prolonged if the SUDI; between two and four months. This finding supports
infant was wrapped appropriately for their developmental previous studies which have suggested that contributing
level2,54. For example, once the startle reflex disappears the factors to Queensland’s high prone sleeping rate for young
baby’s legs and torso can be wrapped firmly (not tightly) in babies may be due to poor awareness of, or a failure to
a flexed position with hands free to facilitate self-soothing promote, safe infant settling and sleep strategies3,6,41, which
behaviours to promote supine settling and sleep57. include safe infant wrapping.

Strengths and limitations Study results highlighted areas for knowledge and practice
improvements in child health nursing related to the practice
This study achieved an excellent response of 89%, and was of wrapping infants, especially as a strategy to support
representative of the knowledge, attitudes and practices of the use of the supine sleep position for young infants less
CHNs from nine health services in south-east Queensland. It than six months of age. Knowledge content areas which
provided important benchmarking data for infant wrapping required improvement include: principles of safe wrapping;
prior to the development of practice guidelines. As the study advantages of safe infant wrapping; potential disadvantages
was conducted amongst a child health nursing sample, if safe wrapping principles are not followed; and appropriate
further research amongst other nursing, allied and medical infant age, developmental stage, wrapping materials and
health professionals who provide education and advice to styles. Practice areas which reported a wide variation in
parents of infants would also be valuable. The timing of responses included parental advice, support and frequency of
this study was opportune, as findings were used to inform education provision, particularly where it may be appropriate
the development and implementation of statewide policy to suggest to a trial of infant wrapping to assist settling and
relating to safe infant care practices to reduce the risk of support the supine sleep position as an alternative to prone;
SUDI9 and directly contributed to the development of a consistent with safe sleeping recommendations.
SIDS and Kids Information statement57 Wrapping babies.
CHNs are a primary resource for support and advice for
Health professional practice tools and educational materials
parents. This study provides the first Australian benchmarking
that incorporate safe infant wrapping practices have been data of nursing practice related to infant wrapping. Study
developed in collaboration with research team members, results have identified knowledge and practice deficits
health department policy advisors and SIDS and Kids, related to the use of infant wrapping as a safe settling and
and have been reported elsewhere58. While surveys have sleep strategy to support safe sleeping messages in a sample
been demonstrated to be a valid and reliable method of of CHNs from nine health service districts. These deficits have
obtaining information about the knowledge and attitudes been demonstrated to impact on the quality of information
of respondents relating to a particular practice issue46,47, provided to parents. Study results have also identified a need
there are inherent difficulties recognised with the collection for the development of evidence-based practice guidelines
of information in this manner due to the need to self-report for CHNs to promote consistency in practice, parent advice
practice data48. Audits of practice are also required but were and education that would help to further reduce the risk
beyond the scope of this cross-sectional survey study. of SUDI. As a result of this study, the authors have since

Volume 16 Number 3 – November 2013 9

N E ON ATA L , PA ED IAT R IC A ND CH ILD H EALTH NU RSING

collaborated with SIDS and Kids National Scientific Advisory 9. Commission for Children and Young People and Child Guardian
Group to develop national evidence-based guidelines for safe Queensland. Annual Report: Deaths of children and young people,
Queensland 2006–07. Commission for Children and Young People
infant wrapping57. There is a need for further investigation
and Child Guardian Queensland, Brisbane; 2007. [cited 2013
into the impact that an educational intervention based on Feb 12]. Available from: http://www.ccypcg.qld.gov.au/pdf/
evidence-based guidelines for safe infant wrapping would publications/reports/annual_report_dcyp_2006-2007/DCYP-
have on CHN knowledge and practice. Annual-Report07.pdf
10. Krous H, Beckwith J, Byard R, Bajanowski T, Corey T, Cutz E et al.
Implications for practice Sudden infant death syndrome and unclassified infant deaths: a
definitional and diagnostic approach. Pediatr. 2004;114(1):234–
• CHNs are an important information source for parents. 238.
11. van Gestel JP, L’Hoir MP, ten Berge M, Jansen NJ, Plotz FB. Risks of
• Prone position is a risk factor for SUDI.
ancient practices in modern times. Pediatr. [Internet] 2002 [cited
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• Wrapping strategies based on principles of safe infant
aappublications.org/content/110/6/e78.full.pdf
wrapping can assist parents to settle their babies in the
12. Lipton EL, Steinschneider A, Richmond J. Swaddling, a child
recommended supine infant sleep position. care practice: Historical, cultural, and experimental observations.
Pediatr. 1965;11(3):521–567.
• 
This study provides benchmarking data of CHNs’
13. Gerard CM, Harris KA, Thach BT. Physiologic studies on swaddling:
knowledge, attitudes and practices relating to infant an ancient child care practice, which may promote the supine
wrapping as an infant settling strategy and risk reduction position for infant sleep. J Pediatr. 2002;141(3):398–403.
strategy for SUDI. 14. Gerard CM, Harris KA, Thach BT. Spontaneous arousals in supine
infants while swaddled and unswaddled during rapid eye
• Evidence-based information and guidelines will promote movement and quiet sleep. Pediatr. 2002;110(6):e70.
consistent practice by CHNs. 15. Franco P, Scaillet S, Grosswasser J, Kahn A. Increased cardiac
autonomic responses to auditory challenges in swaddled infants.
• Consistent, evidence-based information use by parents in Sleep. 2005;27(8):1527–1532.
caring for their baby will reduce the risk of SUDI. 16. Short MA, Brooks-Brunn JA, Reeves DS, Yeager J, Thorpe JA. The
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