Dr. Harvey Karp is meeting with leaders from the Minnesota Department of Human Services next week to promote swaddling in licensed child care facilities as a way to help infants get safely to sleep. The pediatrician/author's advice runs counter to the current thinking by state and county regulators, who want child care providers to place infants to sleep on their backs in cribs without toys, pillows or loose bedding that could present choking or suffocation hazards.
In an interview, Karp agreed with the recommendations by the American Academy of Pediatrics that infants should be placed to sleep on their backs, and without any toys or loose bedding, to reduce their risks of sleep-related deaths. (These recommendations are the basis for Minnesota's child care safety rules.) But he said there is no conclusive evidence that swaddled infants are at increased risk, at least if they are swaddled properly with light blankets. And if swaddling helps infants get to sleep, he argued that it will reduce the risk of death in child care facilities, because providers won't be so exasperated that they take risky shortcuts such as putting infants on their tummies.
"If child care workers are not allowed to swaddle babies and put them to sleep, some of these babies are going to cry and cry. And that crying creates problems," Karp said.
"I look at swaddling use like car seat safety," he added. "If you use car seats incorrectly, that can kill a child. But if you use them correctly, they save lives. Today it’s the law in most states to use car seats, even though parents still don’t use them correctly 100 percent of the time."
Swaddling is the practice of wrapping infants snuggly in blankets, creating a womb-like environment. Support for swaddling has been inconsistent. Recent studies found babies could develop abnormalities in their hips if swaddled too tightly. And swaddling does increase an infant's risk of a sleep-related death if the baby is placed on his or her stomach or rolls over. On the other hand, a study this March from Dr. Rachel Moon -- one of the nation's top experts on infant sleep deaths -- found that swaddling generally increased the likelihood that parents put their children in the safest sleep position -- on their backs.
Karp has written books, including The Happiest Baby on the Block, that recommend that parents use swaddling in conjunction with other techniques to ease their babies to sleep. This does present a conflict of interest, in that his advice to state regulators on swaddling favors his book. Karp argued he isn't acting out of self-interest, but rather so that states conform their infant safety policies to the best medical evidence.
His visit comes as Minnesota child care regulators are grappling with an increase in deaths in licensed in-home day cares over the past decade. The Star Tribune has found that 82 of 85 deaths in licensed child care since 2002 have occurred in homes, and that the number of deaths has nearly doubled in the last five years. The state announced it would be toughening penalties for child care facilities that violate safe sleep standards, particularly if they put infants to sleep on their stomachs. But there is some confusion among regulators about whether the use of a light receiving blanket for swaddling or other purposes is a violation of those standards.
The American Academy of Pediatrics discouraged heavy blankets, bumper pads and toys in cribs in its latest safe sleep policy guidance last fall, but was noncommittal about receiving blankets or swaddling. Still, some county agencies -- which handle the inspections of licensed home day cares -- have taken an across-the-board stance that all blankets are risky. Hennepin County recently adopted a no blanket policy for licensed home day cares.
State licensing records show cases in which day care providers were penalized for putting infants in sleep positions that Karp believes are favorable. Cindy Reding of Zumbrota received a correction order from her county inspector in 2010 because she swaddled infants and placed them to sleep in swings. (Of course, she lost her license altogether this year for falling asleep repeatedly while children were in her care. But that's another story for another day.)
Karp believes it is OK to swaddle a sleeping infant in a swing, as long as the swing reclines back enough that an infant's head and neck are supported. A major risk of infants sleeping in car seats is that their heads can fall forward and that they can struggle to breathe, Karp said. This also contradicts current state policy, though, against child care providers placing infants to sleep in anything other than cribs.
The Star Tribune found many child death cases in which providers didn't follow widely accepted guidelines -- and put babies to sleep on floors or on their stomachs. Karp acknowledged that it would take more training to ensure that providers could swaddle infants properly and increase their sleep safety rather than put them at greater risk.
The California doctor is visiting Minnesota en route to a pediatric conference in Chicago. He said he plans to visit with policy leaders in other states as well where he believe the efforts to improve infant safety have gone beyond what current medical research would recommend.