CALIFORNIA STATE UNIVERSITY SAN MARCOS

PROJECT SIGNATURE PAGE

PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE

MASTER OF SOCIAL WORK

PROJECT TITLE: The Benefits of Swaddling Preterm Infants

AUTHOR: Nycole De La Torre

DATE OF SUCCESSFUL DEFENSE: 412812016

THE PROJECT HAS BEEN ACCEPTED BY THE PROJECT COMMITTEE IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SOCIAL WORK.

Jacky Thomas, PhD PROJECT COMMITTEE CHAIR NATU

Luis Terrazas, Ph.D. PROJECT COMMITTEE MEMBER t6 Running head: THE BENEFITS OF SWADDLING PRETERM INFANTS 1

The Benefits of Swaddling Preterm Infants

Nycole De La Torre

California State University San Marcos

Committee:

Jacky Thomas, Ph.D., Chair

Luis Terrazas, Ph.D. THE BENEFITS OF SWADDLING PRETERM INFANTS 2

Abstract

Premature infants are born three or more weeks before their due date and are at risk for many health challenges. Swaddling is a nonpharmacological technique that has been identified in research as having several health benefits for these infants. This project reviews the literature regarding swaddling premature infants, including a discussion of the history of swaddling, information about health issues premature infants’ face, and the health benefits and risks of swaddling. Because the research indicates that swaddling has significant health benefits for preterm infants, this project also focuses on writing and submitting a grant proposal for an in- kind contribution of swaddles. The primary goal of the project is for future premature babies who are discharged from the Neonatal Intensive Care Unit (NICU) at Sharp Mary Birch Hospital for

Women and Newborns (SMBHWN), to leave with one free Halo SleepSack Swaddle. It is hoped that after parents or caregivers have been properly educated on safe swaddle and sleep practices by the NICU nurses, they will be encouraged to continue those healthy habits such as safe sleep environments and swaddling practices for their infants in their homes.

Keywords: Swaddling, Swaddle, Halo SleepSack Swaddle, Premature infant/baby,

Preterm infant/baby, Full term/term infant/baby, Sudden Infant Death Syndrome (SIDS),

Neonatal Intensive Care Unit (NICU) THE BENEFITS OF SWADDLING PRETERM INFANTS 3

Acknowledgments

First of all, I am grateful to God for giving me the strength to complete the MSW program. I would like to thank my family and friends for their continuous encouragement, love and support during the last two years. My daughter Christina, thank you for being a constant source of motivation for completing my MSW program. My prayer for you is that you will never allow challenges or barriers keep you from achieving your goals and dreams.

I express my appreciation to all my professors for providing me a tremendous learning experience, academically and professionally. I would like to express the deepest appreciation to my committee chair, Professor Jacky Thomas, whose wisdom, understanding, generous guidance and support made it possible for me to work on a topic that was of great interest to me. I have enjoyed being taught by you immensely; you are an excellent professor and I have learned so much from you. Also, I am extremely thankful and pay my gratitude to my committee member,

Professor Luis Terrazas, for providing me valuable guidance, advice and support to complete my capstone project.

To my cohort, thank you all so much for the journey we shared during these past two years, and the difference you each have made in my life. Your knowledge, life experience and stimulating discussions made my learning experience memorable, rich and rewarding. My dear friend and classmate Gladys, thank you for always listening to me, supporting me, and encouraging me. You truly are a great friend and I appreciate you so much.

Last but not least, I would like to express my deepest thanks and sincere appreciation to the social work department at Sharp Mary Birch Hospital for Women and Newborns. My special thanks to Karen Anderson and Cara Fairfax for their support and assistance in the development of my capstone project. THE BENEFITS OF SWADDLING PRETERM INFANTS 4

Table of Contents

Abstract ...... 2

Acknowledgments...... 3

Chapter

1. Introduction ...... 7

Definition of Terms ...... 10

2. Literature Review...... 12

Historical Review of Swaddling ...... 12

Premature Infants and Their Challenges ...... 14

Medical Risk of Premature Infants...... 15

Sudden Infant Death Syndrome...... 16

Benefits of Swaddling Premature Infants ...... 17

Potential Risks of Swaddling ...... 21

Summary of the Literature Review ...... 23

3. Methods...... 24

Search Strategy and Selection of the Literature ...... 25

Project Design ...... 26

Budget ...... 27

The Funder ...... 27 THE BENEFITS OF SWADDLING PRETERM INFANTS 5

The Stakeholders ...... 28

Evaluation of the Project ...... 29

4. Grant Proposal ...... 30

Executive Summary ...... 30

Problem Statement ...... 32

The Benefits of Swaddling Preterm Infants...... 33

The Problem in SMBHWN NICU...... 34

Community Served ...... 34

Organizational Background ...... 35

Project Description...... 36

Project Goal ...... 36

Evaluation of the Grant Proposal ...... 37

Budget Request ...... 37

Sustainability...... 37

5. Discussion ...... 39

Identification of a Need ...... 39

Social Justice ...... 40

Implications for Social Work Practice ...... 41

Implications for Research ...... 41 THE BENEFITS OF SWADDLING PRETERM INFANTS 6

References ...... 43

Appendix A ...... 48

Appendix B ...... 49

Appendix C ...... 51

Appendix D ...... 53

THE BENEFITS OF SWADDLING PRETERM INFANTS 7

The Benefits of Swaddling Preterm Infants

Introduction

Swaddling, an almost universal child-care practice before the 18th century (Lipton,

Steinschneider, & Richmond, 1965), is wrapping an infant tightly with a blanket, pieces of cloth, or bands, to prevent free movement of their limbs (Merriam-Webster, 2015). Swaddling has traditionally been thought to offer many benefits to newborn infants (Van Sleuwen et al., 2007).

This technique varies considerably, from the European way of wrapping the infant in bands to the swaddling practices of South America and countries of the former Soviet Union of tightly folding blankets or sheets around the baby (Van Sleuwen et al., 2007). Swaddling is used for both full term and preterm infants, although the technique may need to be different depending on the infant’s age and needs (Van Sleuwen et al., 2007).

Preterm infants are born before 37 weeks and are at an increased risk for numerous health issues (U.S. National Library of Medicine, 2014). Because these infants' organs are not fully developed, they need specialized care until the organs have developed enough to keep them alive without medical support, which may take weeks to several months (U.S. National Library of

Medicine, 2014). Only hospitals that are medically equipped can provide specialized care to this unique population (U.S. National Library of Medicine, 2014), and that care is usually provided is in a Neonatal Intensive Care Unit (NICU).

The environment in the uterus provides physical containment and weightlessness for the baby (Short et al., 1996). When infants are in the uterus, the containment process plays a role in helping them fully develop (Short et al., 1996). When an infant is born prematurely, the conditions outside the uterus can cause them to have an increased incidence of complications and mortality (Short et al., 1996). THE BENEFITS OF SWADDLING PRETERM INFANTS 8

Several studies on swaddling have examined the advantages and disadvantages of swaddling term infants. For example, term infants who were swaddled were aroused less while sleeping, slept longer, cried less, and were soothed when in pain (Van Sleuwen et al., 2007).

Swaddling can also recreate the fetal in-utero posture (Huang, Tung, Kuo, & Chang, 2004).

There are also many studies that show the advantages of swaddling preterm infants. Van

Sleuwen et al. (2007), did a systematic review on the benefits of swaddling preterm infants and found that several studies support the findings that infants who are swaddled have shown improved neuromuscular development, less physiologic distress, better motor organization, and more self-regulatory ability compared with those who were not swaddled.

If swaddling is done improperly, however, it can pose some risk for babies. Therefore, it is important for parents or caregivers to be educated on proper swaddling practices such as swaddling infants with their head free, without extra bedding, and preventing unnecessary tightness that can lead to injury around the chest, hips, and knees (Van Sleuwen et al., 2007).

In many countries such as Russia, Turkey, China, Central Asia, and South America swaddling is still commonly practiced, and it is becoming increasingly popular in the

Netherlands as an intervention for excessive crying in infants (Van Gestel, L’Hoir, Ten Berge,

Jansen, & Plötz, 2002; Yilmaz et al., 2012). In recent years, there has been a resurgence of the use of swaddling in the United Kingdom, United States, and Netherlands because of the favorable effects the practice is having on infant behavior (Van Sleuwen et al., 2007). For example, 19.4% of a British sample showed that babies are swaddled at night (Frenken, 2012).

Presently, it is estimated that more than 20% of all babies in the world are swaddled (Yilmaz et al., 2012). Currently at Sharp Mary Birch Hospital for Women and Newborns (SMBHWN), swaddling is almost always used for safe sleeping practices for the infants who are cared for at THE BENEFITS OF SWADDLING PRETERM INFANTS 9 the hospital (Personal Communication, Rachelle Sey, SMBHWN Clinical Nurse Specialist for the NICU, March, 4, 2016). Additionally, in the NICU, one of the nonpharmacological measures when mild pain is present or pain is anticipated in neonates is swaddling (Sharpnet, 2016).

Sharp Mary Birch Hospital for Women and Newborns cares for up to 84 infants at a time, born at the hospital, in the Neonatal Intensive Care Unit (NICU) (Sharp Healthcare, 2016-c). In addition to the NICU babies born at SMBHWN, there are more than 130 babies who are transferred from other area hospitals each year (Sharp Healthcare, 2016-c). Sharp Mary Birch

Hospital for Women & Newborns is San Diego's only hospital that exclusively serves women and newborns, and more babies are born at SMBHWN than at any other hospital in San Diego

County (Sharp Healthcare, 2016-d) and even in the state of California (Personal Communication,

Elizabeth Chan, Grants & Resource Officer, February 12, 2016). As a specialty hospital for women and newborns, SMBHWM serves all of San Diego County; however, the primary cities served by the hospital include the City of San Diego, Chula Vista, the east region and the north inland communities surrounding Rancho Bernardo (Personal Communication, Elizabeth Chan,

Grants & Resource Officer, February 12, 2016). SMBHWN also serves the underserved diverse population in these communities and provides care for all women and newborns regardless of their ability to pay (Personal Communication, Elizabeth Chan, Grants & Resource Officer,

February 12, 2016). On average, there are about 130 infants who are discharged from the NICU each month and during the most recent quarter (October 2015 to January 2016) there were 520 infants discharged from the NICU (Personal Communication, Susan Davis, SMBHWN Director of Obstetrical and Neonatal Services, March 2, 2016).

In this paper I will analyze the literature regrading swaddling premature infants, including a discussion of the history of swaddling, information about health issues premature THE BENEFITS OF SWADDLING PRETERM INFANTS 10 infants face, and the health benefits and risk of swaddling. I will also propose that preterm infants can greatly benefit from swaddling. Because of these health benefits of swaddling preterm infants, I am also seeking a grant which will provide a Halo SleepSack swaddle (the type of swaddle brand currently used at SMBHWN NICU) for every preterm infant who is discharged from SMBHWN for the calendar year beginning January 2017. Even though Halo SleepSack swaddles are one of many brands of swaddles, since 2014 this swaddle has been approved by

SMBHWN and is commonly used by the NICU nurses (Personal Communication, Rachelle Sey,

SMBHWN Clinical Nurse Specialist for the NICU, March, 4, 2016). Currently, these nurses routinely educate parents on safe swaddle practices using the Halo SleepSack (Personal

Communication, Rachelle Sey, SMBHWN Clinical Nurse Specialist for the NICU, March, 4,

2016). These swaddles have been known for their safe design and quality and recognized by leading safe sleep and safety organizations in the United States and Canada including First

Candle/SIDS Alliance, the Home Safety Council, and the International Hip Dysplasia Institute

(Halo Innovations , 2015-a).

Definition of Terms

Swaddling: Wrapping an infant tightly with a blanket, pieces of cloth, or bands, to prevent free movement of their limbs (Merriam-Webster, 2015).

Swaddle: A blanket, pieces of cloth, or bands used to swaddle a baby (Merriam-Webster,

2015).

Halo SleepSack Swaddle: A wearable blanket with an adjustable swaddle wrap (Halo

Innovations, 2015-b).

Premature infant/baby: A baby born before 37 completed weeks of gestation, at least three weeks before the baby’s due date (U.S. National Library of Medicine, 2014). THE BENEFITS OF SWADDLING PRETERM INFANTS 11

Preterm infant/baby: A baby born before 37 completed weeks of gestation, at least three weeks before the baby’s due date (U.S. National Library of Medicine, 2014).

Full term/term infant/baby: A baby born after 37 completed weeks of gestation (U.S.

National Library of Medicine, 2014).

Sudden Infant Death Syndrome (SIDS): A sudden unexplained death of an infant under one year (U.S. National Library of Medicine, 2015)

Neonatal Intensive Care Unit (NICU): A high-risk nursery for premature infants. In this nursery infants are placed under a warmer or in a clear, heated box called an incubator, which controls the air temperature and monitoring machines track the baby's breathing, heart rate, and level of oxygen in the blood (U.S. National Library of Medicine, 2014).

THE BENEFITS OF SWADDLING PRETERM INFANTS 12

Chapter 2

Literature Review

Research shows that there are many different insights into the technique of swaddling

(Van Sleuwen et al., 2007). Although the literature on swaddling covers a wide variety of such insights, this review will focus on four major topics which appear repeatedly throughout the literature reviewed. These topics are: historical review of swaddling, premature infants and their challenges, benefits of swaddling preterm infants, and potential risks of swaddling.

Historical Review of Swaddling

Swaddling, an ancient custom that was practiced by early Greeks, Romans, and Jews, is wrapping infants in blankets, cloths, or bands so that they are prevented from freely moving their limbs (Lipton, Steinschneider, & Richmond, 1965). In Roman Italy, the earliest signs that swaddling existed were terracotta (clay-based unglazed or glazed ceramic) models of swaddled infants used as ex-votos, a religious offering given in order to fulfill a vow (Graham, 2013).

These artifacts, primarily of the third to early fifth century, celebrated the infant’s survival of a vulnerable period of development (Graham, 2013). In this ancient socio-religious community, the infant was swaddled for forty to sixty days, and then the bands were removed from the infant and it was believed that he or she was equipped physically, morally, and spiritually to be accepted as a member of the community (Graham, 2013).

The Bible defines swaddling as cloth tied together by bandage like strips (Bromiley,

1995). When an infant was born, their umbilical cord was cut and tied and they were washed, rubbed with salt and oil, and wrapped with strips of cloth (Bromiley, 1995). The purpose of these strips was to keep the infant warm and to insure that their limbs would grow straight (Bromiley,

1995). One of the most well-known accounts of swaddling is found in the New Testament Bible THE BENEFITS OF SWADDLING PRETERM INFANTS 13 concerning the birth of Jesus in Luke 2:6–2:7 (New International Version): “And so it was, that, while they were there, the days were accomplished that she should be delivered. And she brought forth her firstborn son, and wrapped him in swaddling clothes and laid him in a manger; because there was no room for them in the inn.”

Swaddling was used in the 16th century Tudor period (Sims, 2001). After birth, an infant’s umbilical cord was cut and tied, he/she was washed, and then swaddled (Sims, 2001). Swaddling in that era consisted of wrapping the newborn infant in linen bands from head to foot and was considered necessary for the infant to grow up without physical deformity (Sims, 2001). Tudor babies were completely swaddled for their first month of life, and lived mostly indoors (Sims,

2001). After that time these babies were swaddled with their arms and legs free, and the nurse would begin to carry them more often, but it was not until these babies were about eight or nine months old that swaddling would stop completely (Sims, 2001).

In the seventeen and eighteen century, influenced by the views of philosophers and physicians, attitudes toward swaddling became more negative. Swaddling was associated with neglect, mainly because there were reports of wet-nurses caring for swaddled babies without washing or comforting them for long periods of time (DeMause, 2002). William Cadogan, a physician during the eighteenth century, argued for swaddling to be completely eliminated

(Cadogan, 1748). In his controversial essay, “An Essay Upon Nursing and The Management of

Children, From Their Birth to Three Years of Age,” he wrote, “But besides the mischief arising from the weight and heat of these swaddling-cloths, they are put on so tight, and the child is so cramped by them that its bowels have not room, nor the limbs any liberty to act and exert themselves in the free easy manner they ought. This is a very hurtful circumstance, for limbs that are not used will never be strong, and such tender bodies cannot bear much pressure” (Cadogan, THE BENEFITS OF SWADDLING PRETERM INFANTS 14

1748 p. 10). Jean Jacques Rousseau, a philosopher during that era, made some assertions that swaddling was an unreasonable and unnatural practice, that babies needed the freedom to move their arms and legs, and that swaddling can cause deformities (Rousseau, 1889). These views, as well as other similar views of swaddling during the seventeen and eighteen century, may have been the reason why swaddling began to disappear in Europe before industrialization (Van

Sleuwen et al., 2007) and was confined to a few rural societies in Eastern Europe (Lipton,

Steinschneider, & Richmond, 1965).

Nevertheless, the practice of swaddling still continued to persist into the twentieth century, particularly in parts of Eastern Europe and the Middle East (Lipton, Steinschneider, &

Richmond, 1965). In Russia, for example, mothers often expressed fear that the infant would harm himself/herself unless his/her movements were restricted, and the Jewish infant in Poland and the Ukraine was loosely swaddled on a soft pillow (Lipton, Steinschneider, & Richmond,

1965). Also, among the Navajo Native Americans and other cultures in the Americas the cradleboard (a method of swaddling) was still commonly used (Lipton, Steinschneider, &

Richmond, 1965). Today, swaddling is still a tradition in parts of the Middle East, Russia,

Turkey, China, Central Asia, and South America and is becoming more popular in the United

Kingdom, United States, and Netherland to sooth and reduce excessive crying in infants (Van

Sleuwen et al., 2007; Yilmaz et al., 2012).

Premature Infants and Their Challenges

A premature infant is a baby born before 37 completed weeks of gestation, at least three weeks before the baby’s due date (U.S. National Library of Medicine, 2014). In 2013, 8.3% of births in San Diego County were premature (Health & Human Services Agency, 2015). Among those preterm infants, 2.3% were early preterm births (babies born before 35 weeks) and 6% THE BENEFITS OF SWADDLING PRETERM INFANTS 15 were late preterm births (babies born between 35 to 37 weeks) (Health & Human Services

Agency, 2015; U.S. National Library of Medicine, 2014).

Medical risk of premature infants. Premature infants may have: trouble breathing, difficulty keeping a constant body temperature, problems with anemia (the blood does not carry enough oxygen to the rest of the body), bleeding into the brain, damage to the brain's white matter, neonatal sepsis (a blood infection that occurs in an infant younger than 90 days old), hypoglycemia (low blood sugar), neonatal respiratory distress syndrome, pulmonary interstitial emphysema (extra air in the tissue of the lungs), pulmonary hemorrhage (bleeding in the lungs), and newborn jaundice. Additional difficulties include problems breathing due to immature lungs, pneumonia, patent ductus arteriosus (when the blood vessel that allows blood to go around the baby's lungs before birth does not close), necrotizing enterocolitis (severe intestinal inflammation), lower birth weight than a full-term infant, apnea (shallow, irregular pauses in breathing), less body fat, lower muscle tone, problems feeding due to trouble sucking or coordinating swallowing and breathing, etc. (U.S. National Library of Medicine, 2014).

After the birth of a premature infant, the baby is admitted to a high-risk nursery, also called a Neonatal Intensive Care Unit (NICU) (U.S. National Library of Medicine, 2014). The infant is placed under a warmer or in a clear, heated box called an incubator, which controls the air temperature (U.S. National Library of Medicine, 2014). Monitoring machines track the baby's breathing, heart rate, and level of oxygen in the blood (U.S. National Library of Medicine, 2014).

Because these babies’ organs are not mature, they can develop a range health concerns

(Symington & Pinelli, 2006). The unfavorable environment in the Neonatal Intensive Care Unit can add to these problems and negatively affect these infants’ growth, with the brain being particularly vulnerable (Symington & Pinelli, 2006). THE BENEFITS OF SWADDLING PRETERM INFANTS 16

The intrauterine environment provides physical containment and weightlessness (Short et al., 1996). When preterm infants are born, they do not develop fully the muscle tone and flection that is in part provided by the containment process by the uterus (Short et al., 1996).The conditions outside the uterus can causes the preterm infant to be exposed to disorders such as constant patterns of shoulder retraction, adduction of the hips, legs, and knees, increased activities of the lower extremities, and dominance of the exterior posturing (Short et al., 1996).

Premature infants also undergo invasive treatments and examinations such as injections, repeated heel sticks (a medical procedure that pricks the heel of an infants to obtain a small amount of capillary blood samples for various laboratory tests), insertion of central venous catheters, etc. (Hung et al., 2004). These treatments can cause severe pain and as a result lead to physiological and behavioral changes in premature infants such as an increase in heart and respiration rate, intracranial pressure, elevated cortisol levels, facial and body reactions, decline of oxygen saturation, and intense crying (Stevens, Johnston, & Grunau, 1995).

Sudden infant death syndrome. Each year in the United States, there are about 3,500

Sudden Unexpected Infant Deaths (SUID) also called Sudden Infant Death Syndrome (SIDS).

SIDS are defined as a sudden unexplained death of an infant under one year (U.S. National

Library of Medicine, 2015), and from 2010 to 2012 there were 58 SUIDs in San Diego County alone (California Department of Public Health, 2015). Among this population, one of the factors that puts an infant at risk for SIDS is being born premature (U.S. National Library of Medicine,

2015). This is particularly a risk factor if the premature infant slept in the prone position (on their stomach) compared with premature infants who slept on their backs in the supine position (Bhat, et al., 2006). THE BENEFITS OF SWADDLING PRETERM INFANTS 17

Benefits of Swaddling Premature Infants

Several studies on swaddling show this technique has many health benefits for preterm babies. Hung et al. (2004) conducted a study that compared the effects of containment

(restricting premature infants’ reflex motions by holding or using an arm to place the neonate’s arms and legs near its trunk to maintain a flexed in-utero posture) and swaddling on premature infants’ heart rates, oxygen saturation, and scores on the Premature Infant Pain Profile (PIPP), a behavioral measure of pain for premature infants, after heel stick. This study selected 32 premature infants with gestational age less than 37 weeks, bodyweight less than 2,500 grams, and no diagnosis of congenital heart disease, deformity, sepsis or greater than grade three intraventricular hemorrhage as subjects (Hung et al., 2004). The results of the study showed that premature infants who were swaddled returned to their baseline heart rates and oxygen saturation values in shorter periods of time and their pain responses to heel stick yielded lower scores compared to those in containment (Hung et al., 2004). The findings in this study supported the use of swaddling for an alternative non-pharmacological intervention for premature infants to help with decreasing their physiological and behavioral stress caused by the pain after heel stick

(Hung et al., 2004).

Shu, Lee, Hayter, & Wang (2014) did a randomized controlled trial to determine the effectiveness of swaddling and heel warming on pain response in neonates following heel stick.

Twenty-five neonates were randomly assigned to a swaddling, heel-warming, or a control group.

The infants’ heart rate, oxygen saturation, Neonatal Infant Pain Scale (behavioral assessment tool for measurement of pain in preterm and full-term neonates), and duration of crying were used to assess pain reactivity and pain recovery (Shu et al., 2014). The study showed that both swaddling and heel warming reduced the pain response of neonates during the heel stick procedure, and THE BENEFITS OF SWADDLING PRETERM INFANTS 18 provided evidence that both swaddling and heel warming are effective in reducing the pain of neonates after heel stick (Shu et al., 2014).

Short et al. (1996) carried out a randomized control design study used to compare the effects of swaddling to standard positioning (a routine nursery position that used blankets rolls to position infants prone, lateral, and supine) on neuromuscular development in 50 very low birth weight infants who weighed less than 1,250 gm. The infants’ neuromuscular development was measured at 34 weeks postconceptional age using the Morgan Neonatal Neurobehavioral Exam

(MNNE) (Short, et al., 1996). The MNNE evaluates behavioral response, tone and motor patterns, and primitive reflexes in infants 32-42 weeks post conceptional age to quantitatively describe various aspects of neurobehavioral fitness at different conceptional ages. The study indicated that the swaddled infants had significantly higher total scores on the Morgan Neonatal

Neurobehavioral Exam compared to infants who were standard positioned and showed that swaddling as an intervention can enhance neuromuscular development of very low birth weight infants who are neurologically intact (Short et al., 1996).

Neu and Brown (1997) conducted a study with a repeated-measures crossover design to evaluate the use of blanket swaddling during weighing on the physiologic and behavioral responses of preterm infants. The study randomly assigned fourteen preterm infants with a mean gestational age of 32 weeks and weight of 1427 grams in a children's hospital intensive care nursery setting to either be weighed while swaddled or unswaddled (Neu & Brown, 1997). The study used the Assessment of Behavioral Systems Organization (a scale that measures physiological arousal, motor organization, and self-regulatory ability in infants) to measure the effects of swaddled and unswaddled weighing on the infants (Neu & Brown, 1997). The results showed that when the infants were swaddled they showed less physiologic distress, better motor THE BENEFITS OF SWADDLING PRETERM INFANTS 19 organization, and more effective self-regulatory ability than the unswaddled infants during weighing, which suggests that swaddling before weighing may decrease physiological and behavioral distress in preterm infants.

Another study was done to determine differences in the temperature for very low birth weight infants when swaddled and unswaddled in heated, double-walled incubators (Short,

1998). The study used 15 very low birth weight infants that weighed less than 1,500 grams and were between postconceptional ages 27 weeks and 6 days to 30 weeks and 6 days, assigned to either a swaddled or unswaddled condition (Short, 1998). The results of the study showed that the swaddled infants’ abdominal temperatures were 0.2 degree C higher than the infants who were unswaddled and the infants in the swaddled condition required a lower incubator temperature (Short, 1998). The results in this study indicated that swaddling may be beneficial for helping premature infants control and regulate their body temperature (Short, 1998).

Ohgi, Akiyama, Arisawa, & Shigemori (2004) conducted a randomized three-week parallel comparison study of the effectiveness of swaddling versus massage therapy in the management of excessive crying of infants with cerebral injuries, such as periventricular leukomalacia, a lack of oxygen or blood flow to the periventricular area of the brain. This condition can result in the death or loss of brain tissue, intraventricular hemorrhage (bleeding into the fluid-filled ventricles areas inside the brain), or hypoxic-ischaemic encephalopathy

(brain damage caused by impaired cerebral blood flow and oxygen loss). These infants are susceptible to excessive crying as a result of difficulties with self-regulation (Allen & Brandon,

2011; Ohgi, Akiyama, Arisawa, & Shigemori, 2004; U.S. National Library of Medicine, 2016-a;

U.S. National Library of Medicine, 2016-b). Participants were infants who: were less than three months old, whose parents perceived their cry as bothersome, cried a least three hours per day, THE BENEFITS OF SWADDLING PRETERM INFANTS 20 were of a singleton birth, and didn’t have the following medical conditions: the presence of epilepsy, feeding disability, respiratory disease, and/or atopic disease. Infants and their parents were randomly assigned to a swaddling intervention or a massage intervention group (Ohgi et al.,

2004).The findings in this study reveal that the amount of total daily crying decreased significantly in the swaddling group, but not in the massage group, and indicates that swaddling may be more effective than the massage intervention in reducing crying in infants with cerebral injuries (Ohgi et al., 2004). Also, the infants’ behavioral profiles, measured by the Neonatal

Behavioral Assessment Scale ( a scale that measures the infants’ habituation, orientation, motor performance, range of state, state regulation, and autonomic stability) and maternal anxiety levels (as indicated by a scale used to assess the anxiety of parents during pediatric procedures) improved significantly in the swaddling group post-intervention (Ohgi et al., 2004). As a result, parents in the swaddling group were more satisfied with the effectiveness of the intervention in reducing crying than parents in the massage group (Ohgi et al., 2004).

Oden, et el., (2012), found in their study that parents often use swaddling to comfort their infants, and those parents who routinely used swaddling were more likely to find it effective and to place their infant supine (flat on the back) when swaddled, which is a position during sleep that can reduce the possible risk of SIDS. As a result, the study suggests that swaddling can help with decreasing the risk of SIDS in infants (Oden, et el., 2012). Bhat, et al., (2006) conducted a prospective observational study on 24 preterm infants with bronchopulmonary dysplasia (a chronic lung condition that affects newborn babies who were either put on a breathing machine after birth or were born prematurely), in a tertiary or level three NICU to assess if preterm infants with or without bronchopulmonary dysplasia being prepared for neonatal unit discharge would sleep longer, and have less arousals and more central apneas (a disorder in which your breathing THE BENEFITS OF SWADDLING PRETERM INFANTS 21 repeatedly stops and starts during sleep) in the prone compared to the supine position. The results of this study showed that infants sleep more efficiently with fewer arousals and more central apneas in the prone position compared to the supine position, and therefore highlights the importance of specifically recommending supine sleeping after neonatal unit discharge for prematurely born infants (Bhat, et al., 2006). Though parents are routinely encouraged to place their infants in supine positions for sleep, the results of the Oden et al.’s (2015) study suggest that parents of swaddled infants are more likely to follow through with this suggestion.

Potential Risks of Swaddling

Swaddling can be a useful intervention, but when parents or caregivers are not properly educated on safe swaddle practices, swaddling can be used incorrectly and may carry some potential risk. Yurdakok, Yavuz, and Taylor (1990) conducted a cross-sectional study on 189 infants between the ages of three to 12 months, who were either from Turkey or China (countries where the practice of swaddling is still commonly used and countries that have extremely high rates of pneumonia during the neonatal period). These infants had either been completely swaddled (swaddling tightly bound in layers of cloth, with the baby’s legs pressed firmly together with the knees straight, and the arms bound to the sides or slightly to the front of the body), partially swaddled (the cloth is wrapped around the legs and torso up to the armpits but the arms are free), or unswaddled (baby is not swaddled at all) (Yurdakok et al., 1990). The results of this study showed that babies who had been swaddled (completely or partially) for at least three months were four times more likely to have developed pneumonia (confirmed radiologically) and upper respiratory infections than babies who were unswaddled (Yurdakok et al., 1990). Also, it has been found that compromised cardiorespiratory functioning may be THE BENEFITS OF SWADDLING PRETERM INFANTS 22 associated with swaddling, especially if infants are swaddled too tightly (Kahn, Rebuffat, &

Sottiaux, 1992).

There is also evidence that shows developmental dysplasia of the hip may be associated with swaddling (Van Sleuwen et al., 2007). Wang et al., (2012) did an experiment that looked at the influence of straight-leg swaddling in an animal model observed radiographically and histologically. In this study, one hundred and twelve neonatal rats were divided into a control group and three experimental groups (Wang et al., 2012). The rats in the experimental group were swaddled with the use of surgical tape in a manner similar to the way humans swaddle their infants for either the first five days of life (early swaddling), the first ten days of life (prolonged swaddling), or for any five days after the first five days of life (late swaddling) (Wang et al.,

2012). Also, hip dislocation and subluxation (partial dislocation) were evaluated in these rats on anteroposterior pelvic radiographs and histological studies were performed to further observe the morphology of the hips (Wang et al., 2012). This study showed that the rats in the prolonged swaddling group had the highest prevalence of hip dysplasia (thirty-six of forty-four), followed by the early swaddling group (twenty-one of forty-four) (Wang et al., 2012). The findings in this study showed that straight-leg swaddling was demonstrated to increase the risk of developmental dysplasia of the hip in this animal model, and therefore suggested that traditional tight swaddling in infants should be avoided to allow normal hip development, and more modern swaddling alternatives that do less harm to hip development should be used (Wang et al., 2012).

In addition, (Van Sleuwen et al., 2007), looked at several studies that showed the possible risk of swaddling, as a result of parents not being properly educated about and practicing safe swaddle techniques. The findings in those studies showed that when misused, swaddling can be associated with an increased risk of overheating, SIDS (when the infant is place prone or is able THE BENEFITS OF SWADDLING PRETERM INFANTS 23 to turn prone), vitamin D deficiency (due to lack of exposure of the infants skin to sunlight), and delayed weight-loss recovery (when infants are swaddled and briefly separated from their mothers or placed in a nursery and receive supplements after birth) (Van Sleuwen et al., 2007).

With education, parents can learn and practice safe swaddling techniques, such as swaddling with the baby’s head free and without extra bedding, and not swaddling too tightly around the chest, hips, and knees (Van Sleuwen et al., 2007).

Summary of the Literature Review

Swaddling is age-old child-rearing technique that is increasingly practiced in the twenty- first century. Even though it may be considered antiquated, the practice has prevailed in many different cultures over many centuries (Lipton, Steinschneider, & Richmond, 1965). Clear evidence exist about the psychological and physiological benefits of swaddling preterm infants who are at risk for various medical problems and undergo invasive treatments and examinations

(Hung et al., 2004). Swaddling is also shown to have beneficial effects on term infants such as helping them sleep longer and curbing excessive crying (Van Sleuwen et al., 2007). When considering the practice of swaddling, there is not one method of swaddling but many variations involving when to start swaddling, the duration of swaddling, the type, and tightness of wrappings used, etc. (Van Sleuwen et al., 2007). Extreme or improper use of swaddling can cause health problems for infants (Van Sleuwen et al., 2007). Because of this, proper education for parents is important.

THE BENEFITS OF SWADDLING PRETERM INFANTS 24

Chapter 3

Methods

This grant proposal began with identifying a need among the population I serve at Sharp

Mary Birch Hospital for Women and Newborns (SMBHWN). As a medical social worker intern,

I witnessed many of the complicated medical problems and invasive treatments and examinations that premature infants in the NICU undergo. While exploring with Cara Fairfax, a

License Clinical Social Worker at SMBHWN, about nonpharmacological measure to soothe these babies, I was informed that there was literature that indicated swaddling had health benefits for preterm infants. Cara Fairfax shared with me that Lorie Schooler, a Nurse Leader for the

University of Rochester Medical Center Golisano Children’s Hospital (URMC Golisano

Children’s Hospital), is part of a current project that provided funds for babies who are discharged from the URMC Hospital’s NICU to leave with a Halo SleepSack Swaddle. Also,

Rochelle Sey, a NICU Clinical Nurse Specialist at SMBHWN, was involved in a blanket exchange program that provides Halo SleepSack Swaddles to be used for infants while they are in the NICU at SMBHWN.

I contacted Lorie Schooler, and discussed how the project was implemented at the

URMC Golisano Children’s Hospital. The information she provided me was that this project was motivated by the significant number of cases of SIDS in the surrounding communities of the hospital and the literature that showed swaddling can help with decreasing the possible risk of

SIDS in infants (Personal Communication, Lorie Schooler, URMC Golisano Children’s Hospital

Nurse Leader, September 9, 2015). Also, that project started with a donation from a family, and when the hospital exhausted all those funds, the hospital continued to fund the project through THE BENEFITS OF SWADDLING PRETERM INFANTS 25 other private donations (Personal Communication, Lorie Schooler, URMC Golisano Children’s

Hospital Nurse Leader, September 9, 2015).

During my meeting with Rochelle Sey, I was informed that in 2014 all the nurses that worked in SMBHWN NICU were educated and trained on safe swaddling techniques and sleep practices for babies in the NICU, and Halo Innovations, Inc.’s corporate office reached out to

SMBHWN and informed them of their blanket exchange program that provides hospitals with a

Halo SleepSack Swaddle in exchange for a blanket. This program was developed as a result of blankets being used improperly, creating unsafe sleep environments for babies in hospital settings (Personal Communication, Rochelle Sey, SMBHWN NICU Clinical Nurse Specialist,

March 4, 2016). As a result, the nurses now educate, teach, and model to all parents who have a baby in the NICU safe swaddling techniques and sleep practices (Rochelle Sey, SMBHWN

NICU Clinical Nurse Specialist, March 4, 2016). However, when babies are discharged from the

NICU, the hospital does not provide their parents or caregivers with a Halo SleepSack Swaddle, or any other swaddle (Personal Communication, Rochelle Sey, SMBHWN NICU Clinical Nurse

Specialist, March 4, 2016).

Search Strategy and Selection of the Literature

After gathering all of this information, electronic searches were conducted on the

California State University San Marcos (CSUSM) Kellogg Library databases including CINAHL

Plus, PubMed, Google Scholar CSUSM, PsycINFO, JSTOR, Highwire Press Free, EBSCOHost,

Cochrane Database of Systematic Reviews, Lexis Nexis Academic, Sage Journals Online, ebrary

Academic Complete, California Department of Public Health Library Collection, U.S. National

Library of Medicine, and via Google for swaddling, swaddle, preterm, premature, swaddling or swaddle and preterm infants, swaddling or swaddle and premature infants, swaddling or swaddle THE BENEFITS OF SWADDLING PRETERM INFANTS 26 and preterm babies, swaddling or swaddle and premature babies, history of swaddling, Sharp

HealthCare, Sharp Mary Birch Hospital for Women and Newborns, undocumented residents in

San Diego County, United States Census in San Diego County, durable medical equipment for

Medicaid, and Halo SleepSack Swaddle. Also, I manually searched reference lists and used interlibrary loans to obtain material not available in the CSUSM library. Published randomized, control trials that assessed the intervention of swaddling were chosen, as well as other literature on swaddling associated with pain control, temperature control, motor development, SIDS, breastfeeding, respiratory infections, sleep state and arousal, the effect on crying behavior, developmental dysplasia of the hip, neonatal weight loss, and the history of swaddling. In addition, I reviewed literature on undocumented residents in San Diego County and preterm or premature infants or babies.

Project Design

After reviewing the literature on swaddling and specifically swaddling premature infants and discussion with Cara Fairfax, I developed the idea to write a grant proposal to Halo

Innovations, seeking Halo SleepSack Swaddles for every premature baby who is discharged from the NICU for the calendar year beginning January 2017. After presenting the proposal to Karen

Anderson, SMBHWN Clinical Social Worker Supervisor, and Elizabeth Chan, Sharp Healthcare

Grants & Resource Officer, I received the needed approval and support to move forward with the grant proposal. I also contacted Halo Innovations, Inc.’s corporate office and discussed with

Christine Anderson, Halo Innovations Office Administrator, about the proposal and asked permission to submit a full grant request to obtain Halo SleepSack Swaddles for the parents or caregivers of each baby who is discharged from SMBHWN’s NICU for one year. On behalf of

Halo Innovations, Inc., she accepted my request and informed me about the application process THE BENEFITS OF SWADDLING PRETERM INFANTS 27 and how to submit my grant. Therefore, there was no need to seek another outside funder for this project.

Before I submitted the grant proposal to Halo Innovations, Inc., I submitted a completed grant proposal to Elizabeth Chan, Sharp Healthcare Grants & Resource Officer, for review. She reviewed the grant proposal to verify that it was in compliance with the standards of Sharp

HealthCare and approved the grant proposal. After I went through the internal approval process with Elizabeth Chan, I submitted the actual proposal to Christine Anderson, Halo Innovations

Office Administrator via fax, which she accepted without a deadline (Personal Communication,

Christine Anderson, Halo Innovations Office Administrator, February 16, 2016).

Budget

Since, on average, 1560 infants are discharged from SMBHWN’s NICU each year, the total number of swaddles that this grant proposal would request is 1560. The average cost for one

Halo SleepSack Swaddle is $28.95 (Halo Innovations, 2015-b) with a total dollar value for this grant of $45,162. I also verified that Halo SleepSack swaddles and other brands of swaddles were not covered by Medicaid (Medi-cal) for infants who have this health insurance (Centers for

Medicare and Medicaid Services, n.d.).

The Funder

Halo SleepSack Swaddles have been approved as the provider of swaddles for the NICU by SMBHWN because the safe design and superior quality of these swaddles have been recognized and endorsed by leading safe sleep and safety organizations in the United States and

Canada including First Candle/SIDS Alliance, the Home Safety Council, and the International

Hip Dysplasia Institute (Halo Innovations, 2015-a). The SMBHWN NICU nurses have regularly been educating parents/caregivers about how to use Halo SleepSack Swaddles on their preterm THE BENEFITS OF SWADDLING PRETERM INFANTS 28 infants. It is hoped that receiving these swaddles upon discharge will encourage the parents or caregivers to continue healthy habits such as safe sleep environments and swaddling practices for their infants in their homes (Personal Communication, Rochelle Sey, SMBHWN NICU

Clinical Nurse Specialist, March 4, 2016). Halo Innovations, Inc., the inventor of these swaddles, was started after the founder, Bill Schmid, and his wife Cathy lost their firstborn daughter to SIDS. For more than 20 years the company has had the mission and dedication to putting the health, safety and well-being of babies first, by designing swaddles that help babies sleep safely and comfortably (Halo Innovations, 2015-a).

The Stakeholder

The recipients of this in-kind contribution of Halo SleepSack Swaddles will be the premature infants who receive care in the NICU at Sharp Mary Birch Hospital for Women &

Newborns (SMBHWN) and their parents/caregivers. SMBHWN is San Diego's only hospital exclusively dedicated to the care of women and newborns and is nationally recognized for its care of expectant mothers with high-risk pregnancies, as well as for its Level III Neonatal

Intensive Care Unit (Sharp Healthcare, 2016-d). More babies are born at SMBHWN than at any other hospital in San Diego County and even in the state of California (Personal Communication,

Elizabeth Chan, Sharp Healthcare Grants & Resource Officer, February 12, 2016). This hospital serves the entire county of San Diego (Sharp Healthcare, 2016-a); however, the primary communities served by the hospital include the City of San Diego, Chula Vista, the east region and north inland communities surrounding Rancho Bernardo (Personal Communication,

Elizabeth Chan, Sharp Healthcare Grants & Resource Officer, February 12, 2016). THE BENEFITS OF SWADDLING PRETERM INFANTS 29

Evaluation of the Project

A pre-stamped mail in survey will be sent to the parents or caregivers of each discharged infant from the NICU three months after discharge. The survey will consist of four questions that will inquire about parents’/caregivers’ use of and satisfaction with the swaddles. Use/satisfaction will be measured by how long they have used the swaddle during three months post-discharge, how frequently they used the swaddle, the reason for using the swaddle, and parents/caregivers’ overall satisfaction with the swaddle (see Appendix A for the questionnaire). After twelve months of distributing the swaddles, all returned surveys will be analyzed and a written report outlining the findings will be presented to Halo Innovations, Inc.’s corporate office.

THE BENEFITS OF SWADDLING PRETERM INFANTS 30

Chapter 4

Grant Proposal

Executive Summary

Swaddling is wrapping an infant in blankets, cloths, or bands so that he/she is prevented from moving their limbs freely (Lipton, Steinschneider, & Richmond, 1965). Swaddling is a technique that can recreate the position that the baby was in when in the womb (Huang, Tung,

Kuo, & Chang, 2004). Many cultures in the past practiced this technique, though the way the technique was practiced varied across different cultures. In many countries swaddling is still commonly practiced, and in recent years the use of swaddling has become increasingly popular among parents in the United States, United Kingdom, and Netherlands, because of the favorable effects the practice is having on infant behavior (Van Sleuwen et al., 2007). Currently at

SMBHWN, swaddling is used for safe sleeping practices for most of the infants who are cared for at the hospital (Personal Communication, Rachelle Sey, SMBHWN Clinical Nurse Specialist for the NICU, March, 4, 2016). In addition to safe sleeping practices, swaddling is used in the hospital’s NICU as a nonpharmacological measures when mild pain is present or pain is anticipated in neonates (Sharpnet, 2016).

Preterm infants are babies born before 37 weeks and are at risk for a number of health issues (U.S. National Library of Medicine, 2014). Because these infant's organs are not fully developed, they need specialized care for weeks to several months in the Neonatal Intensive Care

Unit (NICU), until their organs have developed enough to keep them alive without medical support (U.S. National Library of Medicine, 2014). Preterm infants also undergo invasive treatments that can cause severe pain, and are prematurely exposed to conditions outside the uterus, which can lead to a number of disorders and can cause these infants to have an increased THE BENEFITS OF SWADDLING PRETERM INFANTS 31 incidence of complications and mortality (Hung et al., 2004; Short et al., 1996; Stevens,

Johnston, & Grunau, 1995).

Research on swaddling has shown that there are many advantages to using the technique.

For example, term infants were aroused less while sleeping, slept, longer, cried less, and were soothed when in pain when swaddled (Van Sleuwen et al., 2007). In addition, several studies on swaddling show this technique has many health benefits for preterm babies. For example, premature infants were less physiologically distressed, had better motor organization and more self-regulatory ability, and improved their neuromuscular development when they were swaddled (Neu & Browne, 1997; Short et al., 1996).

Because research indicates that swaddling has significant health benefits for preterm infants, I am proposing a grant to Halo Innovations requesting an in-kind contribution of swaddles so that premature babies who are discharged from the NICU at SMBHWN during the calendar year beginning January 2017 will leave with one free Halo SleepSack Swaddle. Halo

SleepSack Swaddles were chosen for this grant proposal because these swaddles have been approved by SMBHWN and are currently used in their NICU. In addition, the safe design and superior quality of these swaddles have been recognized and endorsed by leading safe sleep and safety organizations in the United States and Canada including First Candle/SIDS Alliance, the

Home Safety Council, and the International Hip Dysplasia Institute (Halo Innovations, 2015-a).

Also, NICU nurses at SMBHWN have regularly been educating parents or caregivers about how to use these swaddles on their preterm infants. It is hoped that receiving the swaddles at discharge will encourage the parents or caregivers to continue healthy habits such as safe sleep environments and swaddling practices for their infants in their homes (Personal Communication,

Rochelle Sey, SMBHWN NICU Clinical Nurse Specialist, March 4, 2016). THE BENEFITS OF SWADDLING PRETERM INFANTS 32

Problem Statement

A premature infant is a baby born three or more weeks before their due date (U.S.

National Library of Medicine, 2014). These infants may have: trouble breathing, difficulty keeping a constant body temperature, problems with anemia (the blood does not carry enough oxygen to the rest of your body), bleeding into the brain, damage to the brain's white matter, neonatal sepsis (a blood infection that occurs in an infant younger than 90 days old), hypoglycemia (low blood sugar), neonatal respiratory distress syndrome, pulmonary interstitial emphysema (extra air in the tissue of the lungs), pulmonary hemorrhage (bleeding in the lungs), newborn jaundice, problems breathing due to immature lungs, pneumonia, patent ductus arteriosus (when the blood vessel that allows blood to go around the baby's lungs before birth does not close), necrotizing enterocolitis (severe intestinal inflammation), lower birth weight than a full-term infant, apnea (shallow, irregular pauses in breathing), less body fat, lower muscle tone, problems feeding due to trouble sucking or coordinating swallowing and breathing, etc.

(U.S. National Library of Medicine, 2014). Also, all these medical issues put these babies at an increased risk for SIDS, especially if parents are not properly educated about safe sleep practices, and place their premature infant in the prone position instead of supine position for sleep (Bhat et al., 2006; U.S. National Library of Medicine, 2015).

After these infants are born, they are admitted to the Neonatal Intensive Care Unit (U.S.

National Library of Medicine, 2014) and placed under an incubator. The incubator controls the infant’s air temperature and has machines that monitor and track the baby's breathing, heart rate, and level of oxygen in the blood (U.S. National Library of Medicine, 2014). Research indicates that these infants are at an increased risk for a range health concerns, because their organs are not mature and the unfavorable conditions in the NICU (Symington & Pinelli, 2006). These THE BENEFITS OF SWADDLING PRETERM INFANTS 33 conditions outside the uterus can causes these infants additional problems such as constant patterns of shoulder retraction, adduction of the hips, legs, and knees, increase activities of the lower extremities, and dominance of the exterior posturing (Short et al., 1996).

In addition, premature infants go through invasive treatments and examinations such as injections, heel stick (a medical procedure that pricks the heel of an infants to obtain a small amount of capillary blood samples for various laboratory tests), insertion of central venous catheter, etc. These treatments and examinations can cause severe pain that leads to physiological and behavioral changes in premature infants such as an increase in heart and respiration rate, intracranial pressure, higher cortisol levels, decline of oxygen saturation, and intense crying (Hung et al., 2004; Stevens, Johnston, & Grunau, 1995).

The benefits of swaddling preterm infants. Swaddling is a nonpharmacological option for parents and caregivers that has been shown to have a variety of health benefits to preterm babies. Current research has shown that swaddling helps premature infants with decreasing their physiological and behavioral stress and reducing pain after heel stick, enhancing their neuromuscular development, decreasing their physiological and behavioral distress, controlling and regulating their body temperature, and reducing their crying (Hung et al., 2004; Neu &

Brown, 1997; Ohgi et al., 2004; Short et al., 1996; Short, 1998; Shu et al., 2014). In addition, premature infants have less physiologic distress, better motor organization, and more effective self-regulatory ability when they are weighed when swaddled (Neu & Brown, 1997). Swaddling has also been shown to be effective with reducing crying in infants with cerebral injuries such as premature infants with intraventricular hemorrhage (Ohgi et al., 2004; U.S. National Library of

Medicine, 2016-a) and as a result significantly improving parent’s anxiety levels (Ohgi et al.,

2004). Studies also show that parents were more satisfied with the effectiveness of swaddling in THE BENEFITS OF SWADDLING PRETERM INFANTS 34 reducing crying in their infant compared to other interventions (Ohgi et al., 2004) and often used swaddling to comfort their infants (Oden et al., 2012). Also, those parents who routinely used swaddling were more likely to place their infant supine when swaddled (Oden et al., 2012), which is a position during sleep that can reduce the possible risk of SIDS in prematurely born infants (Bhat, et al., 2006).

The problem in SMBHWN NICU. The literature supports the idea that providing parents or caregivers with a safe swaddle for their preterm infants upon discharge from

SMBHWN NICU, after they have been properly educated on safe swaddle and sleep practices, will encourage them to continue healthy habits such as safe sleep environments and swaddling practices for their infants in their homes. At SMBHWN, parents or caregivers who have a premature baby in the NICU are properly educated by the nurses on safe swaddling and sleep practices with Halo SleepSack Swaddles (Personal Communication, Rochelle Sey, SMBHWN

NICU Clinical Nurse Specialist, March 4, 2016). However, when these babies are discharged from the NICU, their parents or caregivers are not offered a Halo SleepSack Swaddle, and they are sent home without this, or any, swaddle. Parents or caregivers may not be able to afford the cost of this swaddle or may opt out for a cheaper swaddle, not only in price but quality. As a result, the parents or caregivers and their infants may not be able to experience all the benefits that swaddles such as a Halo SleepSack Swaddle have to offer.

Community Served

Sharp Mary Birch Hospital for Women and Newborns serves the entire county of San

Diego (Sharp Healthcare, 2016-a). The racial makeup of patients served at the hospital in 2014 was 35.3% Hispanic, 35.2% White, 16.1% Asian/Pacific Islander, 8.5% other/unknown, 4.7%

Black, and 0.2% Native American (Personal Communication, Christopher Jordan, Sharp THE BENEFITS OF SWADDLING PRETERM INFANTS 35

Healthcare Director of Strategic Planning, March 16, 2016). In the NICU at SMBHWN, up to 84 babies are cared for at one time and there is an average of 130 babies discharged from NICU a month (Personal Communication, Susan Davis, SMBHWN Director of Obstetrical and Neonatal

Services, March 2, 2016). Among the infants that were admitted into the NICU in September

2014 to September 2015, 64% of the inpatient hospital cost was covered by either private insurance, Covered California Insurance, private pay, or “other”. The remaining 36% were insured by Medi-cal (Personal Communication, Mishal Al Rawaf, Lead Financial Analyst for

SMBHWN, March 17, 2016).

Organizational Background

Sharp HealthCare is a not-for-profit integrated regional health care delivery system and

SMBHWN is one of the acute care hospitals for this organization (Sharp Healthcare, 2016-a).

The mission of Sharp HealthCare is, “To improve the health of those we serve, with a commitment to excellence in all that we do, with the goal of offering quality care and programs that set community standards, exceed patients' expectations and are provided in a caring, convenient, cost-effective and accessible manner” (Sharp Healthcare, 2016-b).

For over 60 years, Sharp HealthCare has provided care for all people, with special concern for the underserved and San Diego’s diverse population, and serving everyone regardless of their ability to pay (Personal Communication, Elizabeth Chan, Sharp Healthcare

Grants & Resource Officer, February 12, 2016). In 2014, SMBHWN provided more than $17 million in unreimbursed community benefits, programs and services, including charity, uncompensated and under-compensated care (Personal Communication, Elizabeth Chan, Sharp

Healthcare Grants & Resource Officer, February 12, 2016). The NICU department at SMBHWN ranks among the top four centers in the nation for NICU infection prevention and provides THE BENEFITS OF SWADDLING PRETERM INFANTS 36 highly-skilled medical care for newborns who are born prematurely, underweight, or with other serious health problems (Sharp Healthcare, 2016-c; Personal Communication, Elizabeth Chan,

Sharp Healthcare Grants & Resource Officer, February 12, 2016 ). Sharp Mary Birch Hospital for Women and Newborns cares for up to 84 infants at a time, born at the hospital in the

Neonatal Intensive Care Unit (NICU) (Sharp Healthcare, 2016-c). The medical team in the NICU consists of neonatologists, specialized nurses, lactation specialists, neonatal nurse practitioners, nutritionists, occupational and physical therapists, research specialists, respiratory care practitioners and medical social workers who work together to help the babies heal (Sharp

Healthcare, 2016-c) and support their families during this difficult time.

Project Description

This grant proposal is seeking an in-kind contribution of Halo SleepSack Swaddles from

Halo Innovations, Inc. for all infants discharged from SMBHWN NICU for the calendar year beginning January 1, 2017. SMBHWN NICU nurses teach parents or caregivers safe swaddling and sleep techniques, but are not able to offer parents or caregivers swaddles upon discharged. If funded, this grant will provide one free Halo SleepSack Swaddle to every premature infant discharged from the NICU in 2017.

Project Goal

The primary goal of the project is for future premature babies who are discharged from the NICU at SMBHWN, to leave with one free Halo SleepSack Swaddle. After parents or caregivers have been properly educated on safe swaddle and sleep practices by the NICU nurses, they will be encouraged to continue those healthy habits such as safe sleep environments and swaddling practices for their infants in their homes. THE BENEFITS OF SWADDLING PRETERM INFANTS 37

Evaluation of the Grant Proposal

A pre-stamped mail in survey will be sent to the parents or caregivers of each discharged infant from the NICU three months after discharge. The survey will consist of four questions that will inquire about parents’/caregivers’ use of and satisfaction with the swaddles. Use/satisfaction will be measured by how long they have used the swaddle during three months post-discharge, how frequently they used the swaddle, the reason for using the swaddle, and parents/caregivers’ overall satisfaction with the swaddle (see Appendix A for the questionnaire). After twelve months of distributing the swaddles, all returned surveys will be analyzed and a written report outlining the findings will be presented to Halo Innovations, Inc.’s corporate office.

Budget Request

In the SMBHWN NICU, there are an average number of 130 infants discharged every month. The total projected number of Halo SleepSack Swaddles needed for the entire calendar year beginning January 1, 2017 and ending December 31, 2017 is 1,560. The average cost for one Halo SleepSack Swaddle is $28.95 (Halo Innovations, 2015-b). The total dollar value for this in-kind donation request for one month is $3,763.50, and $45,162 for the entire year.

Halo Innovations, Inc. SleepSack Swaddle Grant Request Qty Unit Cost Halo SleepSack Swaddle 1 28.95 Total Request For Halo SleepSack Swaddles For One Mo 130 $3,763.50 Total Request For Halo SleepSack Swaddles For One Yr 1,560 $45,162

Sustainability

The social work department at SMBHWN will accept responsibility for sustaining the

Halo SleepSack Project after the 2017 calendar year. The information from the patient use and satisfaction surveys will be used to assess benefit, and if the project goes as expected, to convince other outside funders of the benefits of the swaddle project to infants, parents and THE BENEFITS OF SWADDLING PRETERM INFANTS 38 caregivers. The social work department will first look for outside funders that support baby friendly incentives (as SMBHWN will not approve a grant proposal unless the funder supports baby friendly incentives) to fund the entire cost of the Halo SleepSack project for the following year. In particular, attempts will be made to use sources who have funded previous grant proposal submitted by the department. As an alternative, the social work department will also seek funders who will do a matching grant (a grant that will match the offer amount of a previous grant proposal).

THE BENEFITS OF SWADDLING PRETERM INFANTS 39

Chapter 5

Discussion

Identification of a Need

Throughout my experience as medical social worker intern, I have had the opportunity to serve vulnerable populations with many challenges. While working in the NICU at SMBHWN, I was assigned to work with the parents/caregivers and the medical team of premature infants that were hospitalized. On several occasions, I witnessed many of the complicated medical problems and invasive treatments and examinations that premature infants undergo. I also observed nurses use swaddling as a nonpharmacological measure to soothe these babies. In particular, Halo

SleepSack Swaddles were used when swaddling. These swaddles have been approved by

SMBHWN NICU because of their safe design and superior quality and have been recognized and endorsed by leading safe sleep and safety organizations in the United States and Canada

(Halo Innovations, 2015-a; Personal Communication, Rochelle Sey, SMBHWN NICU Clinical

Nurse Specialist, March 4, 2016). However, when babies are discharged from the NICU, the hospital does not provide their parents/caregivers with a Halo SleepSack Swaddle, or any other swaddle (Personal Communication, Rochelle Sey, SMBHWN NICU Clinical Nurse Specialist,

March 4, 2016).

In discussion with other medical professionals who serve this unique population, I was informed that there was literature that indicated swaddling had health benefits for preterm infants. Also, other hospitals throughout the United States offer swaddles to their newborn infants upon discharged. After reviewing the literature on swaddling and specifically swaddling premature infants, I was impressed by the plethora of literature supporting the use of swaddling as a heath care intervention for these infants. For that reason, I developed the idea to write a THE BENEFITS OF SWADDLING PRETERM INFANTS 40 grant proposal to Halo Innovations, seeking Halo SleepSack Swaddles for every premature baby who is discharge from the NICU.

Social Justice

Because premature infants are born three or more weeks before their due date, they are at risk for many health challenges (U.S. National Library of Medicine, 2014). Swaddling is a technique that has been identified in research as having several health benefits for preterm infants (Van Sleuwen et al., 2007). Even though all parents/caregivers are educated on the benefits of swaddling and safe swaddling and sleep practices for their preterm infant, by nurses in SMBHWN NICU using Halo SleepSack Swaddles, some parents/caregivers may not be able to afford the cost of a $28.95 swaddle. Many of these families that have premature infants hospitalized at the NICU come from an underserved population, have low incomes, and/or are insured by Medi-cal. These families may be only left with the option to either opt out for a cheaper swaddle, not only in price but quality, or not purchase a swaddle at all.

It is the responsibility of social workers to promote social justice on behalf of vulnerable individuals and groups of people and to encourage responsiveness of organizations, communities, and other social institutions to individuals’ needs and social problems (NASW,

2008, p. 1, 5). Also, social workers strive to ensure that all people have equal access to needed information, services, and resources (NASW, 2008, p. 5). Promoting social justice for these pre- term infants and their parents/caregivers who already face many challenges means recognizing the barriers that might keep them from having the best possible experience upon discharge. This includes supporting them in implementing best swaddling and sleep practices with their premature infant, and finding resources that can eliminate the financial barriers that might keep them from doing so. In order to promote social justice at SMBHWN, it is important that all THE BENEFITS OF SWADDLING PRETERM INFANTS 41 parents/caregivers with premature infants in the NICU are provided with supports to help their infants thrive outside the hospital setting after they are discharged, including having the use of a safe swaddle, regardless of ability to pay.

Implications for Social Work Practice

This grant proposal for Halo SleepSack Swaddles is one small piece in helping future parents/caregivers who have premature babies in SMBHWN NICU continue safe sleep and swaddling practices and experience the health benefits of swaddling when in their homes. Grant seeking and writing skills can be an effective tool for social workers to support their agencies with providing additional resources to vulnerable and oppressed populations that may experience barriers and challenges in obtaining needed resources. This is an important way for social workers to draw on their knowledge, values, and skills to help individuals and organizations obtain resources that they may not be able to acquire on their own. Furthermore, this project has shown me another creative but effective way for social workers to impact the agencies or communities they serve.

Implications for Research

There are several studies that show swaddling is a technique that has many health benefits for preterm infants. However, many of these studies are conducted in a hospital setting or the NICU. On the other hand, there is minimal research on how this intervention benefits premature infants or even what types of swaddles are more useful for the parents/caregivers and their infants after they are discharged home. There is some literature that discusses the advantages of swaddling term infants outside a hospital setting. For example, term infants who were swaddled were aroused less while sleeping, slept longer, cried less, and were soothed when in pain (Van Sleuwen et al., 2007). Future research could focus on whether parents/caregivers THE BENEFITS OF SWADDLING PRETERM INFANTS 42 and their premature infants are benefiting from the use of swaddling when discharged home, and if so, the nature of those benefits. Also, future research might examine whether there are differences between different brands of swaddling blankets.

THE BENEFITS OF SWADDLING PRETERM INFANTS 43

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Appendix A

Parents/caregivers use/satisfaction of the swaddles Survey

How long did you used the swaddle in the past three months for your premature infant’s needs? (Choose best answer)

o Never o One month o Two months o Three months How often did you used the swaddle for you premature infant’s needs? (Choose best answer)

o Daily o At least once a week o At least once a month o Never What was the most common reason for using the swaddle for you premature infant’s needs? (Choose best answer)

o Calming your fussy baby o Swaddle bathing o Safe sleep o Keeping you infant warm o Other Overall, how satisfied were you with the swaddle for you premature infant’s needs?

o Not at all satisfied o Somewhat Satisfied o Satisfied o Very Satisfied

THE BENEFITS OF SWADDLING PRETERM INFANTS 49

Appendix B

Halo Innovations, Inc. Grant Proposal Cover Letter

April 22, 2016

Ms. Christine Andersen HALO Innovations, Inc. Office Administrator 111 Cheshire Lane Suite 700 Minnetonka, MN 55305

Dear Ms. Andersen:

Aligned with Halo Innovations’ efforts to keep all babies safe while they sleep, I would like to request an in-kind donation of swaddles on behalf of the Clinical Counseling Department for the Neonatal Intensive Care Unit (NICU) at Sharp Mary Birch Hospital for Women &Newborns (SMBHWN). I am a Medical Social Work Intern and am seeking this in-kind donation to start the first swaddle project for premature infants who are discharged from the NICU at SMBHWN. Sharp HealthCare is a not-for-profit integrated regional health care delivery system, and SMBHWN is one of the acute-care hospitals for this organization. The mission of Sharp HealthCare is to improve the health of those we serve, with a commitment to excellence in all that we do, with the goal of offering quality care and programs that set community standards, exceed patients' expectations and are provided in a caring, convenient, cost-effective and accessible manner. For over 60 years, Sharp HealthCare has provided care for all people, with special concern for the underserved and San Diego’s diverse population, and has served everyone regardless of their ability to pay. In 2014, SMBHWN provided more than $17 million in unreimbursed community benefits, programs and services, including charity, uncompensated and under-compensated care. The NICU at SMBHWN ranks among the top four centers in the nation for NICU infection prevention and provides highly-skilled medical care for newborns who are born prematurely, underweight, or with other serious health problems. Our main objective with this project is to encourage parents/caregivers to continue healthy sleep and safe swaddling habits after their premature baby is discharged from the hospital, while they are celebrating the birth of their baby and the health challenges he/she has overcome. We thank you for your consideration of this grant request for an in-kind donation of Halo SleepSack Swaddles. This donation will support our efforts to help future parents/caregivers who have premature babies in SMBHWN NICU continue safe sleep and swaddling practices and experience the health benefits of swaddling when in their homes. We appreciate Halo THE BENEFITS OF SWADDLING PRETERM INFANTS 50

Innovations’ amazing twenty-year dedication to putting the health, safety and well-being of babies first. Please find a description of our hospital’s NICU, proposed project, and request for in-kind donations attached. Should you have any questions or concerns, please do not hesitate to call Karen Anderson, Supervisor for the Clinical Counseling Department at SMBHWN at (858) 939- 4130 or via email at [email protected]. Regards,

Nycole De La Torre, MSW Intern Medical Social Worker Intern Sharp Mary Birch Hospital for Women & Newborns

THE BENEFITS OF SWADDLING PRETERM INFANTS 51

Appendix C

Halo Innovation, Inc. Grant Proposal Form

Neonatal Intensive Care Unit Swaddle Project

The Neonatal Intensive Care Unit (NICU) is an essential resource for families, providing skilled medical care for newborns that are born premature, underweight, or with other serious health problems. Sharp Mary Birch Hospital for Women & Newborns (SMBHWN) has a level three NICU that cares for up to 84 infants at a time. In addition to the NICU babies born at SMBHWN, more than 130 babies are transferred from other area hospitals each year. The medical team in the NICU consists of neonatologists, specialized nurses, lactation specialists, neonatal nurse practitioners, nutritionists, occupational and physical therapists, research specialists, respiratory care practitioners and medical social workers who work together to help the babies heal and support their families during this difficult time. More babies are born at SMBHWN than any other hospital in San Diego County and even in the state of California. An average of 130 infants are discharged from the NICU each month.

Premature infants are born three or more weeks before their due date and are at risk for many health challenges and swaddling is a technique that has been identified in research as having several health benefits for these infants. At SMBHWN, parents or caregivers who have a premature baby in the NICU are properly educated by the nurses on safe swaddling and sleep practices with Halo SleepSack Swaddles. However, the hospital currently does not have a project that offers a free Halo SleepSack Swaddle to the parents/caregivers of these infants who are discharged from the hospital. These parents/caregivers may not be able to afford the cost of this swaddle or may opt out for a cheaper swaddle, not only in price but quality. As a result, parents/caregivers and their infants may not be able to experience all the benefits that Halo SleepSack Swaddles have to offer.

On behalf of the Clinical Counseling Department, I am a Medical Social Work Intern, seeking in-kind donations to start the first Swaddle Project for the infants that are discharged from SMBHWN NICU, in hopes of encouraging parents/caregivers to continue healthy sleep and safe swaddling habits after their baby goes home.

Objective This grant proposal is seeking an in-kind contribution of Halo SleepSack Swaddles from Halo Innovations, Inc. in order to provide one swaddle for every premature baby who is discharged from the NICU for the calendar year beginning January 1, 2017 and ending December 31, 2017. Parents/caregivers of these infants will be offered one free Halo SleepSack Swaddle after they have been properly educated on safe swaddle and sleep practices by the NICU nurses.

Evaluation of Swaddle Project A pre-stamped mail-in survey will be sent to the parents or caregivers of each discharged infant from the NICU three months after discharge. The survey will consist of four questions that will inquire about parents/caregivers use of and satisfaction with the swaddles. Use/satisfaction will be measured by how long they have used the swaddle during three months post-discharge, how THE BENEFITS OF SWADDLING PRETERM INFANTS 52 frequently they used the swaddle, the reason for using the swaddle, and parents/caregivers’ overall satisfaction with the swaddle. After 12 months of distributing the swaddles, all returned surveys will be analyzed and a written report outlining the findings will be presented to Halo Innovations, Inc.’s corporate office.

Sustainability The social work department at Sharp Mary Birch Hospital for Women & Newborns will accept responsibility for sustaining the Halo SleepSack Project after the 2017 calendar year. The information from the patient use and satisfaction surveys will be used to assess benefit, and if the project goes as expected, to convince other outside funders of the benefits of the swaddle project to infants, parents and caregivers. The social work department will first look for outside funders that support baby friendly incentives to fund the entire cost of the Halo SleepSack project for the following year. In particular, attempts will be made to use sources that have funded previous grant proposal submitted by the department. As an alternative, the social work department will also seek funders who will do a matching grant.

Budget Request In SMBHWN NICU, there are an average number of 130 infants discharged every month. The total projected number of Halo SleepSack Swaddles needed for the entire calendar year beginning January 1, 2017 and ending December 31, 2017 is 1,560.

Halo Innovations, Inc. SleepSack Swaddle Grant Request Qty Unit Cost Halo SleepSack Swaddle 1 $28.95 Total Request For Halo SleepSack Swaddles For One Month 130 $3,763.50 Total Request For Halo SleepSack Swaddles For One Year 1,560 $45,162

The total dollar value for this in-kind donation request for one year: $45,162

Charitable Contribution Information If we do receive in-kind donations of Halo SleepSack Swaddles from your company for this project, please send it to:

Sharp HealthCare Foundation Attn: Susan Ressmeyer 8695 Spectrum Center Blvd. San Diego, CA 92123

Be sure to attach a message or note that the in-kind donations are earmarked for the Swaddle Project at Sharp Mary Birch Hospital for Women & Newborns Neonatal Intensive Care Unit.

THE BENEFITS OF SWADDLING PRETERM INFANTS 53

Appendix D

501(c)(3) Letter

THE BENEFITS OF SWADDLING PRETERM INFANTS 54