The five S's

Five steps for parents to turn on the calming reflex

S ucking

Sucking triggers the calming reflex and deepens a baby's level of relaxation.

S waddling

Tight swaddling is the cornerstone of calming. Swaddling also helps keep babies from accidentally flipping onto their stomach. Avoid overheating and loose blankets. I recommend wrapping babies with their arms straight at their sides. Wrapping with flexed arms usually fails because the arms soon wiggle free. Swaddling is the cornerstone of calming. Swaddling is the only "S" that does not directly turn on the calming reflex. In fact, many babies struggle even more for a minute or two when first swaddled with straight arms; that's probably because their biceps are hypertonic from their position in utero—we don't know with certainty.

S hushing

Loud, harsh, white noise mimics the noise of blood flowing through placental arteries when a fetus is in the womb. The louder a baby cries, the louder the shushing has to be to calm him. The "shhh" sound imitates the sound of blood flow that fetuses hear. It has been measured at 75 to 88 dB.37 This white noise is approximated by harsh, loud sounds from hair driers (85 dB) and vacuum cleaners (75 dB).

The noise needs to be as loud as a baby is crying for it to trigger the calming reflex. Continued white noise (at levels up to 80 dB) can keep the reflex turned on and help babies stay soothed and asleep.

S winging

Lying motionless deprives newborns of sensory stimulation. Swinging (rhythmic, jiggly movement) in rapid, tiny movements, like a shiver (two to three times a second), soothes agitated babies. Use slow, broad swinging to keep your baby soothed. Never shake a baby in anger. Slow motion, however, is usually ineffective at soothing babies who are upset. Turning on the calming reflex in a crying baby requires fast, low-amplitude movements of the head (to stimulate the vestibular apparatus). This motion is like a fine shimmy or shiver (my patients call this the "Jell-o head" jiggle). The head is supported so it moves with the body, and it goes back and forth only about an inch but very quickly—120 to 180 times a minute! This imitates the fetus's in utero experience and is completely different from the large amplitude, whiplash-like swings that cause shaken baby syndrome. Nonetheless, parents should be warned never to jiggle their baby when they're angry or frustrated.

S ide or stomach position

All babies should be put to sleep on their back.* However, being on the side or stomach is best for calming the baby; it turns on the calming reflex and shuts off the Moro reflex. (The Moro reflex makes a baby's arms shoot out when he is startled by his own crying.) Being supine triggers the very upsetting Moro reflex. This "S" can be activated by putting a baby on her side, on her stomach (again, not for sleeping), or over an adult's shoulder. Some babies are so sensitive to position that, even on their side, they won't calm down if they are rolled the least bit toward their back.

. . . and one V

To stop a baby's cycle of crying, you must meet his level of intensity. Once the screaming diminishes for a few moments, you can gradually lessen the vigor of the calming maneuvers.

*This recommendation is consistent with the American Academy of Pediatrics' statement on the prevention of sudden infant death syndrome (SIDS).

GUIDE FOR PARENTS

Swaddling 101

Remember—always put your baby to sleep on her back!

When can I start swaddling?

Babies can be swaddled as soon as they're born. It makes them feel cozy and warm, like they're "back home."

Do all babies need to be swaddled?

Many calm babies do well with no swaddling at all. But the fussier your baby is, the more she'll need to be swaddled. Tight bundling is so successful at soothing infants that some babies even have to be unswaddled to wake them up for feedings.

Should the swaddling always be snug or are loose blankets okay?

Never put your baby into bed with loose blankets. Make sure her swaddling is snugly wrapped around her so it doesn't loosen during the night. Loose blankets can get around a baby's face and contribute to sudden infant death syndrome (SIDS).

How can I tell if my baby is overheated or overwrapped?

Premature babies often need incubators to keep them toasty, but full-term babies just need a little clothing, a blanket, and a room that is between 65° and 70° F. If the temperature in your home is warmer than that, you can skip some clothing. In hot weather, you can wrap your baby naked in a light cotton blanket. (Parents living in warm climates often put cornstarch powder on their baby's skin to absorb sweat and prevent rashes.) Always check to see if your baby is overheated by feeling her ears and fingers. If she's hot, red, and sweaty, she's overwrapped. If she's only slightly warm and not sweaty, her temperature is probably perfect.

How can I tell if I'm swaddling my baby too tightly?

In traditional cultures, parents swaddle their babies tightly because loose wraps invariably pop open. Although some Americans worry about tight swaddling, most of the time bundling fails because it is done too loosely. For your peace of mind, here's an easy way for you to make sure your wrapping is not too tight. Slide your hand between the blanket and your baby's chest. It should feel as snug as your hand slid between your pregnant belly and the elastic waistband of your pants at the end of your ninth month.

Can swaddling help a baby sleep?

Yes! In fact, even babies who don't need wrapping to keep calm often sleep more when they're swaddled. Bundling keeps them from startling themselves awake. In my experience, swaddling plus white noise can add one to two hours to a baby's nighttime sleep.

If a baby has never been swaddled, at what age is it too late to start?

Even if you have never swaddled your baby before, swaddling may still help soothe her "fussies" during her first three months of life. But, be patient. You may have to wrap her a few times before she gets used to it. Try doing it when she's already sleepy and in her most receptive frame of mind.

When is a baby too old to continue to be swaddled?

The age for weaning off the wrapping varies from baby to baby. Many people think they should stop swaddling after a few weeks, when their baby starts resisting it. But, actually, this is when swaddling becomes the most valuable. To decide if your infant no longer needs to be wrapped, try this: After she reaches 2 to 3 months of age, swaddle her with one arm out. If she gets fussier, continue wrapping (with both arms in) for a few more weeks. However, if she still sleeps well with one arm out, she probably doesn't need swaddling any more. Most babies are ready to be weaned off wrapping by 3 to 4 months of age, although some continue to need the wrapping to help them sleep up to 9 months of age.

How many hours a day should a baby be wrapped?

All babies need some time to stretch, bathe, and get a massage. But, you'll probably notice your baby is calmer if she's swaddled 12 to 20 hours a day, to start with. (Remember, as a fetus, she was snuggled 24 hours a day.) After one or two months, you can reduce wrap time according to how calm she is without it.

This guide can be photocopied and distributed without permission to give to your patients' parents. Reproduction for any other purpose requires express permission of the publisher, Advanstar Medical Economics Healthcare Communications.

Reference

Karp H: The Happiest Baby on the Block: The New Way to Calm Crying and Help Your Newborn Baby Sleep Longer. N.Y., Bantam Books, 2002