How to use baby carriers safely from birth

Is your newborn or young baby more likely to accidentally suffocate if you use a carrier or sling?

If your baby was born prematurely, or has a low birth weight, please read about Kangaroo Mother Care here. From 2023, Kangaroo Mother Care, which is a form of baby wearing, is recommended by the World Health Organisation as the most evidence-based and effective care for prematurely born or low birth weight babies (who aren't critically ill), for eight hours daily or more, regardless of country of birth. You can find out why carrier use can help in the early weeks and months of parenting here, and the four main ways of carrying your baby here. You can find out about safe use of baby carriers here.

When you have a newborn (in the first month of life) or a young baby, it's easy and safe to use a soft fabric wrap carrier which

• Holds your baby vertically, facing in

• Exposes your baby's legs and holds his legs and hips in an 'M' shape

• Is sewn into broad and easy straps for tying

Examples are

• https://www.chekoh.com/collections/wraps

• https://ergobaby.com.au/collections/wrap-hip-seat

• https://www.stokke.com/FRA/fr-fr/porte-bebe/porte-bebes-pour-nourrissons-et-jeunes-enfants/6194.html

News of the death of a baby in a carrier spreads fast, even though these devastating events are very rare. As a result, I've found in recent years that some families have become too afraid to use a carrier in the first few months of life. But carrier use has been shown in the research to have significant benefits for both parents and babies from birth. Not being able to use a carrier only increases the burden of work placed upon the primary carer, often a woman, and doesn't protect babies overall. What matters is that you know how to wear your baby safely.

This is why health professionals in the UK came up with the acronym TICKS.

1. Tight
2. In view at all times
3. Close enough to kiss
4. Keep chin off chest
5. Supported back.

'Tight' really means sensibly firm and secure, rather than tight. Your baby's chest and tummy are against you and always vertical. It's best for your baby to have the capacity for some movement within the sling, including movement of her arms and legs, and the ability to move her little head. Having your baby too tightly held in a fabric sling means that she is more likely to have her circulation to cut off, resulting in pins and needles, with sudden screams and dialling up in the carrier. Take your baby out, anyway, if she starts to dial up.

Having your baby's face, nose and mouth 'in view at all times' allows you to check the baby's breathing, and to be aware of your baby's breathing subliminally, which is one of the ways the maternal brain works. This is the main reason why 'pouch' sling carriers, where babies lie horizontal or diagonal inside the sling, are dangerous. (Another reason is that they increase the risk of hip problems). The shaped and sewn fabric wraps that I've suggested above support your newborn in a vertical position, with face, nose and mouth free of cloth and exposed. Semi-structured buckle carriers do the same as your baby grows heavier and you need better hip support.

The advice about having your baby 'close enough to kiss' intends to make sure that babies don't slump down in the carrier, with their chin falling forward onto their chest in a way that blocks off the airway, or has their face pressing into the carer's body, which could cause suffocation.

'Keeping your baby's chin off his chest' prevents airway blockage, which happens if the little head falls forward and squashes his neck. TICK strategies 2 and 3 also ensure this can't happen.

'Supporting your baby's back' again makes sure that your little one can't curl forward into the foetal position inside the carrier, compressing his airways. Your baby's back will be adequately supported if you wear the carrier somewhat firmly (but not too tight).

Can babywearing give you low back or neck pain or make your back problems worse?

Infant carrying alters postural alignment of your spine and pelvis, and can trigger musculoskeletal pain for some, unless the added load is carefully distributed to your pelvis and legs. But babywearing is better for your body alignment than carrying a baby in arms, actually, because wearing your baby in a carrier on the front of your body is closer biomechanically to walking without a load, compared to carrying your baby in arms.

One of the side benefits of caring for a baby has to be the physical activity and the muscle strength, flexibility and conditioning work that come with it, in a society where so much of our paid work is sedentary. It's just a matter of being mindful about spinal alignment and weight distribution (same as in the gym). Musculoskeletal pain can be prevented or dealt with by

• Graduating your baby from a wrap carrier (which carries weight on your shoulders and upper spine) to a half or full buckled semi-structured carrier as soon as you can, which better distributes your baby's weight to your hips and legs

• Lowering the wearing height of the baby carrier so that the external load of your baby is almost entirely transferred through your hips to your legs, and not dragging on your shoulders

• Choosing a carrier which doesn't place the weight of the baby too far out from your body.

This is why the kiss the top of his head part of the TICK acronym doesn't work for certain body types, and can result in pain. Carrying the baby high enough on the chest to kiss increases the load on the shoulders and lumbar spine and risks pain or injury for taller parents. (I'm thinking this is probably why the dad in the hero image at the top of this page has his baby lower down his body.)

A tall parent, who needs to carry the load of the baby further down their chest for ergonomic safety, can ensure airway safety without needing to be able to comfortably kiss the top of baby's head.

Can carrier use increase your baby's risk of hip problems?

Yes, but only if the carrier isn't used properly. All baby carriers, whether fabric wraps, semi-structured carrier, or backpacks, need to be used so that your baby's legs are positioned into an 'M' or frog shape, with both the hips and knees bent and hips wide apart. The fabric or carrier material between her legs supports her thighs and bottom and spreads her legs into the 'M' shape.

Hip dysplasia in genetically susceptible babies can be triggered or worsened by carrying devices which keep the baby’s legs more closed together and straight. Although causes of Developmental Dysplasia of the Hips are not entirely clear, mechanical factors in early life have a role.

Some orthopaedic surgeons are suggesting that carriers (used properly, with the 'M' positioning) not only protect against hip problems, but might have a place in treatment for hip dysplasia.

Should you be waiting for your baby to have head control before using a carrier?

Parents often tell me they are worried about putting the baby into a carrier before their baby has developed head control. But your baby develops head control by responding to changes in the direction his little head rolls relative to gravity. Paradoxically, it seems that babies in cultures where there is less attention paid to head control may develop head control more quickly.

Of course it goes without saying that we don’t want to be rough with our precious little ones! We obviously don’t want to expose our babies' necks to even subtle injuries and airway protection is vital. But I have watched mothers handle their babies in more traditional cultures, including in my experiences with Australian First Nation’s Peoples, with a steady casual firmness, as if knowing that their baby has an endless hunger for touch and pressure and vestibular stimulation and the effects of gravity. Babies' little heads rolled around gently as they were picked up or transferred from place to place or carried, but no-one worried.

What if your baby isn't happy in the carrier?

Some babies love the carrier right from the very beginning. Other parents explain that their baby doesn't seem to be happy in the carrier, even though the evidence shows that babies who are worn in carriers a lot are more settled.

It's true that some newborns or even older babies who haven't been in a carrier previously might need to be gradually accustomed to it, by having a short experience with it once or twice each day. We don't want to develop a conditioned dialling up with the carrier, by keeping baby in it even when she's distressed. But you could practice putting her in, and then if your baby really isn’t happy, take her out. Try launching into a vigorous walk for a short way outside the home if you can, just as soon as you put her in it. It usually doesn't take babies long to work out that the carrier is a wonderful place to be.

• Older babies prefer to face outward, so they can see the world, and dial up if they are put into a carrier facing inwards because this diminishes their sensory experience. We can turn babies around in carriers to look out earlier than you might have heard, though there are some things to know about postural safety, which I discuss here.

• Rules about how old a baby needs to be before you can use a structured backpack carrier can also be unhelpful. I discuss these and also safety here.

Does it help to use the detachable fabric covers or roofs that come with some carriers?

Because sleep is under the control of sleep pressure, and will happen best in the midst of lots of daylight, noise, activity and movement which dials baby down, there is no reason to use the covers that sometimes come with semi-structured baby carriers to block out the light, even if your baby falls asleep.

These covers might also contribute to overheating of your baby. In a climate like mine, with intense sunlight which quickly burns delicate baby skin regardless of skin tone, sunscreen and protective hats are best, rather than covers. This way, your baby can still see out, or can feel the air on his skin, even when sleeping!

Recommended resources

Baby Wearing UK

Carrying Matters by Dr Rosie Knowles

Why baby wearing makes life easier (not harder)

Four ways of carring your baby from birth which make life easier not harder

What is sensory motor nourishment and why does it help with baby sleep?

Filling your baby's sensory tank

What your baby needs for best possible motor development

About positional plagiocephaly and motor development

The NDC evolutionary perspective on positional plagiocephaly, motor development and sleep

The holistic NDC or Possums 8-step approach to supporting baby's motor development

Selected references

Berecz B, Cyrille M, Casselbrant U, Oleksak S, Norholt H. Carrying human infants - an evolutionary heritage. Infant Behavior and Development. 2020;60:101460.

Bergounious J, Madre C, Crucis-Armengaud A. Sudden deaths in adult-worn baby carriers: 19 cases. European Journal of Pediatrics. 2015;174:1665-1670.

Conde-Agudelo A, L D-RJ. Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database of Systematic Reviews. 2016;2017(8):CD002771.`

Havens KL, Goldrdod S, Mannen EM. The combined influence of infant carrying method and motherhood on gait mechanics. Journal of Applied Biomechanics. 2023:https://doi.org/10.1123/jab.2023-0127.

Hunziker UA, Barr RG. Increased carrying reduces infant crying: a randomized controlled trial. Pediatrics. 1986;77(5):641-648.

Lee H-M, Galloway JC. Early intensive postural and movement training advances head control in very young infants. Physical Therapy. 2012;92(7):935-947.

Little EE, Legare CH, Carver LJ. Culture, carrying, and communication: beliefs and behavior associated with babywearing. Infant Behavior and Development. 2019;57:101320.

Moore ER, Berman N, Anderson GC, Medley N. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database of Systematic Reviews. 2016(Issue 11. Art. No.: CD003519):DOI: 10.1002/14651858.CD14003519.pub14651854.

Minckas N, Medvedev MM, Adejuyigbe EA. Preterm care during the COVID-19 pandemic: a comparative risk analysis of neonatal deaths averted by kangaroo mother care versus mortality due to SARS-CoV-2 infection. EClinicalMedicine. 2021;33:100733.

Riem M, ME, Lotz AM, Horstman LI. A soft baby carrier intervention enhances amygdala responses to infant crying in fathers: A randomized controlled trial. Psychoneuroendocrinology. 2021;132:105380.

Sidharthan S, Kehoe C, Dodwell E. Post-natal positioning through babywearing: what the orthopaedic surgeon needs to know. Journal of the Pediatric Orthopaedic Society of North America. 2020;2(3):https://doi.org/10.55275/JPOSNA-52020-55131

Sivanandan S, Sankar MJ. Kangaroo mother care for preterm or low birth weight infants: a systematic review and meta-analysis. BMJ Global Health. 2023;8:e0101728.

Wall-Scheffler CM, Geiger K, L S-NK. Infant carrying: the role of increased locomotory costs in early tool development. American Journal of Physical Anthropology. 2007;133:841-846.