Baby Hats: Wasted Wool

For years, requests have popped up on social media, on posters in antenatal waiting rooms and via the Knitting Networks. “Volunteers needed to knit baby hats for newborns in the maternity unit”. Such requests are a godsend for folks like me – yarn lovers who, given half a chance, would coat their homes and all who are in it with crocheted or knitted coverings. Giving us an outlet for our passion is like offering a dog a bone. We’ll take it, we’ll run with it and we will make vast numbers of baby hats.

So let’s just stop for a moment and ask some questions about these newborn baby hats. Why are we being asked to make hats for babies? When are they being used and why? What are the risks and benefits?

Policies differ from Trust to Trust, and it is always important to remember that it is the mother or birth parent who gets to ultimately decide whether or not her baby wears a hat. So how do mothers decide whether they want to allow it or not?

Why may hats be recommended?

Babies have a disproportionately larger head to body ratio compared to older children and adults, and because of this it is theorised that they will lose more heat through their head than they will as they grow bigger. For this reason, hats are sometimes recommended for newborn babies.

What does the evidence say?

A study in 2018 aimed to determine whether low birth weight babies wearing hats would retain more heat than similar babies who were not wearing hats¹. 300 mothers and babies were randomly assigned to Kangaroo Mother Care² either with or without a woolly hat. Regular temperature checks were taken over the course of a week, and it was determined that the hat did not help babies to maintain their body temperature.

Another study in 2004³ looked at whether a cotton head covering (draping a cotton nappy over the head) worked better or worse at maintaining a baby’s body temperature than a woollen hat. This study did not compare these findings with babies wearing no hat. While they decided that wool hats worked better than a cotton nappy, their data showed that babies staying skin to skin with their mother was the most effective way to keep babies warm.

This data tells us that encouraging, supporting and not inhibiting women and people holding their babies skin to skin is likely to be far more important for keeping babies warm than a hat.

The importance of skin to skin

Not only does skin to skin contact help babies to thermoregulate (stay the right temperature), it also helps the placenta to separate faster which can reduce the numbers of women having problematic heavy bleeding after birth (PPH)⁴, increases breastfeeding rates⁵ and helps with bonding⁵. Skin to skin also triggers important physiological processes in the baby which includes thermoregulation, but also instincts such as seeking the breast, calming the baby and ‘seeding’ the baby’s microbiome with beneficial bacteria⁵.

Could there be risks to using hats?

When midwives and doctors focus on using hats to try to help babies to thermoregulate, they may be less focused on what really works – skin to skin with their birth parent, or someone else if the birth parent is not well enough. Not supporting skin to skin, or even in some cases discouraging it (for instance, by putting a baby under a heat lamp if they are a little cold, rather than keeping baby skin to skin and covering baby up more) can be harmful in a number of ways, as outlined above.

Even if parents are holding their baby skin to skin, a hat can cause problems. For instance, it can get in the way of the baby trying to learn to latch to the breast. It can be harder for the mother to see what’s going on when trying to breastfeed a newborn, and they can just be a nuisance to a baby who is doing a breastcrawl⁷.

There is actually evidence that hats could be harmful to babies by causing over-heating⁸. Given that hospitals can often be warmer than many people’s homes, this needs to be carefully considered.

But one of the most beautiful things about a newborn baby becomes hidden under the hat. A newborn baby’s scent is not only one of the world’s delights, it is an important trigger for a mother or birth parent’s oxytocin system. Anyone who has had a baby will know that while other babies smell delicious, none of them smell quite as lovely as their own baby. Most mammals use smell as part of the way to identify their own offspring, and humans are no different. It’s an important element in bonding and connecting, as well as having positive physiological effects on our body, such as triggering uterine contractions to help release the placenta, as smelling our babies increases oxytocin flow.

Are home made hats safe?

Hats donated by knitting and crochet enthusiasts like me are not subject to quality controls. We may be putting hats on babies which were made in homes where there is a smoker. It’s possible that the yarn that is used is not suitable for a baby’s skin. Wool can trigger allergies, for instance. Infection control issues abound.

These hats are also not safe for the environment. Although made with great love, they are not chosen by the parents and for many, they will simply end up in the bin. This will be even more likely with the dreaded ‘traffic light hats’ (see below). Who wants to have a reminder of their baby’s ‘health status’ at birth, especially if it related to a traumatic experience?

What about traffic light hats?

Some hospitals have decided to request donated hats in three different colours: red, orange/amber and green. The idea is to give an instant visual clue as to which babies are in need (red) or may be in need (orange) of additional care.

These traffic light hats have all the same risks as outlined above, but also have other problems.

• Hats can be removed at any time, which immediately removes that visual clue for staff
• Parents can always decline the hat, again removing the visual clue
• Parents may become distressed at the idea that their baby has an orange or red hat, and worry about what is wrong with their baby

In summary, there is no evidence that using a hat on a newborn is the best way of keeping them warm, and there is much evidence about the importance of skin to skin contact with, ideally, their mother or birth parent, or if this is not possible, someone else.

Wise midwife words are, “no hatting, patting or chatting”. Let’s not interfere with the precious newborn period by hatting babies, patting mothers or chatting with parents who are discovering the new life that they have created together. We know how important this time after birth is, so let’s support physiology, follow evidence based practice, and ditch the hats.

References:

• Cavallin et al 2018, Thermal Effect of a Woolen Cap in Low Birth Weight Infants During Kangaroo Care: https://pubmed.ncbi.nlm.nih.gov/29789445/
• Kangaroo Mother Care: https://kangaroomothercare.com/
• Lang et al 2004, The effect of wool vs. cotton head covering and length of stay with the mother following delivery on infant temperature: https://pubmed.ncbi.nlm.nih.gov/15476757/
• Saxton et all 2015, Does skin-to-skin contact and breast feeding at birth affect the rate of primary postpartum haemorrhage: Results of a cohort study: https://pubmed.ncbi.nlm.nih.gov/26277824/
• World Health Organisation, Skin-to-skin contact helps newborns breastfeed: https://www.who.int/westernpacific/news/feature-stories/detail/skin-to-skin-contact-helps-newborns-breastfeed
• UNICEF Skin to Skin Contact: https://www.unicef.org.uk/babyfriendly/baby-friendly-resources/implementing-standards-resources/skin-to-skin-contact/#:~:text=Skin%2Dto%2Dskin%20contact%20is%20usually%20referred%20to%20as%20the,until%20after%20the%20first%20feed.
• Breast crawl: http://breastcrawl.org/
• Elabbassi et al 2002, Head insulation and heat loss in naked and clothed newborns using a thermal mannequin: https://pubmed.ncbi.nlm.nih.gov/12094978/