What are the recommendations for infant nighttime sleep once swaddling is no longer an option?

Safe Sleep Practices After Swaddling is No Longer an Option

When infants show signs of attempting to roll, swaddling should be discontinued and replaced with alternative safe sleep practices that maintain the supine position while providing comfort and safety. 1

When to Stop Swaddling

Swaddling must be discontinued when:

• Infant shows signs of attempting to roll over 1
• Typically around 2-4 months of age (varies by individual development)
• Rolling from back to front poses significant safety risks if swaddled 1

Safe Sleep Alternatives After Swaddling

1. Sleep Sacks/Wearable Blankets

• Use wearable blankets or sleep sacks that allow free movement of arms while keeping the lower body warm
• These provide warmth without the risk of loose bedding that could cover the face

2. Maintain Supine Sleep Position

• Continue placing infant exclusively on their back for sleep until 1 year of age 2
• Even after infants can roll over on their own, initially place them on their back 2
• The risk of SIDS is significantly higher when infants sleep in prone or side positions (odds ratios ranging from 2.0-13.1) 2

3. Safe Sleep Environment

• Use a firm, flat sleep surface with a fitted sheet 1
• Keep the sleep area free from pillows, blankets, stuffed animals, and other soft objects 1
• Room-share without bed-sharing for at least the first 6 months, ideally the first year 2

4. Supervised Tummy Time

• Increase supervised, awake tummy time during the day 1
• This helps develop upper body strength and prevents positional plagiocephaly (flat spots on the head) 1
• Tummy time should only occur when infant is awake and being observed 1

Strategies to Help Transition from Swaddling

1. Gradual Transition:

   • Start by swaddling with one arm out for a few nights
   • Then swaddle with both arms out before completely stopping

2. Consistent Bedtime Routine:

   • Establish a calming pre-sleep routine (bath, gentle massage, quiet reading)
   • Consistent routines help signal sleep time even without swaddling

3. White Noise:

   • Consider using white noise machines to mimic womb sounds
   • Helps create a soothing sleep environment

4. Room Temperature:

   • Maintain comfortable room temperature (68-72°F/20-22°C)
   • Avoid overheating which is a risk factor for SIDS 1

Common Pitfalls to Avoid

• Continuing to swaddle after rolling begins: This creates a significant suffocation risk if infant rolls to prone position while swaddled 1
• Using loose blankets as alternatives: Loose bedding increases SIDS risk 2
• Placing rolled towels/positioning devices: These can pose suffocation hazards and are not recommended 1
• Relying on commercial monitoring devices: Home cardiorespiratory monitors have not been documented to decrease SIDS incidence 1

Evidence on Swaddling and Sleep

Research shows that swaddling can be effective for promoting sleep in young infants. One study found that parents who routinely used swaddling were more likely to place their infants in the recommended supine position 3. Another study demonstrated that swaddling decreases spontaneous arousals in quiet sleep and increases REM sleep duration 4.

However, a meta-analysis found that swaddling was associated with increased SIDS risk, particularly when infants were placed in prone position (OR: 12.99) or side position (OR: 3.16), with some increased risk even in supine position (OR: 1.93) 5. This reinforces the importance of discontinuing swaddling when infants begin to roll.

By following these recommendations, parents can maintain safe sleep practices after swaddling is no longer an option, promoting both infant safety and comfort during nighttime sleep.