Keyvan Hadad, MD, MHSc, FRCPC (biography and disclosures)
What is the question
Developmental dysplasia of the hips (DDH) is one of the more common congenital defects. Hip dysplasia can lead to degenerative hip disease and is a leading cause of early arthritis of the hip. Risk factors for this condition include female gender, breech delivery and positive family history. Some recent data has shown a significant increase in the prevalence of this condition (1).
The age-old practice of swaddling has regained popularity in recent years to improve uninterrupted sleep and reduce crying in newborns. The effectiveness of this technique has been questioned with the majority of studies showing some improvement in sleep and crying (2). There is ongoing debate over the role of swaddling in risk of respiratory infection and in SIDS prevention (2).
With the increase in popularity of swaddling, there is concern among pediatricians and pediatric orthopedic surgeons that swaddling has led to an increased risk of DDH.
What is the evidence
So, is there a relationship between newborn swaddling and an increased risk of DDH?
A number of epidemiological studies from around the world have confirmed that improper swaddling of babies with lower limbs in extension is associated with an increased risk of DDH (3). In cultures where tight swaddling with the lower limbs in extension is particularly common, significantly higher rates of DDH have been reported (2).
In Japan, at a time when traditional swaddling was used to keep the newborn’s lower limbs in extension, the incidence of DDH was around 5%. A public campaign to switch to wrapping techniques that encouraged hip flexion and abduction led to DDH rates falling to less than 0.4% (4).
In South Australia, in the last decade, there has been a threefold increase in the rate of late-diagnosed DDH at or after 3 months of age. During this period, there has been no change in screening practices or demographics. Of these babies, 79% were tightly swaddled (1).
Practical tips in managing this problem
Improper swaddling is a risk factor for developmental dysplasia of the hips. If families wish to swaddle their infant, they need to be aware of the need to allow flexion and abduction of the hips. This will provide protection for the safe development of hips. Physicians should ask about swaddling practices and pay close attention to the hip examination of babies who are tightly swaddled. For families who wish to swaddle, there is an excellent video of hip-friendly swaddling techniques at http://www.hipdysplasia.org/%20developmental-dysplasia-of-the-hip/hip-healthy-swaddling by the International Hip Dysplasia Institute (IHDI).
New guidelines are expected in the next few months on which babies need to be routinely screened for DDH with a hip ultrasound. At the present, at BC Women’s Hospital, pediatricians screen all babies born breech and all those with a strong family history of DDH with a hip ultrasound. This is, of course, in addition to the newborn exam for all newborns. The ideal time for a hip ultrasound is six weeks of age. Hip ultrasound is useful until about 4 months of age, following which a hip x-ray becomes the investigation of choice. If DDH is identified or suspected, an orthopedics referral is necessary.
References:
- Azzopardi T, VanEssen P, Cundy PJ. Late diagnosis of developmental dysplasia of the hip: an analysis of risk factors. J Pediatr Orthop B 2011; 20: 1-7. (View with CPSBC or UBC)
- vanSleuwen BE, Engelberts AC, Boere- Boonekamp MM, et al. Swaddling: a systematic review. Pediatrics 2007; 120: e1097-e1106. (View)
- Mahan ST, Kasser JR. Does swaddling influence developmental dysplasia of the hip? Pediatrics 2008; 121: 177-178. (View)
- Yamamuro T, Ishida K. Recent advances in the early diagnosis, and treatment of congenital dislocation of the hip in Japan. Clin Orthop Relat Res 1984; (184): 34-40. (Request from CPSBC)
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how reliable is hip ultrasound in the screening of patients with possible
DDH when used in addition to the physical examination?
interesting to hear swaddling is making a comeback. I thought we were more successful in explaining the risk. Time to revisit this during pregnancy.
Useful reminder to discuss and review techniques of swaddling, rather than just the fact of it…especially with the increasing use of swaddling and the variety of swaddling techniques and materials/devices on the market and promoted through cultural practices or the “mom and baby” business.
If the baby has a clearly abnormal hip examination, I would suggest referring straight to orthopedics.
If the baby has an equivocal hip examination and/or significant risk factors as outlined in the review, ultrasonography is a reliable investigation.
I had not noticed an increase in this type of swaddling so I will ask and watch more carefully
As a matter of curiosity, has anyone looked into the incidence of DDH in the Inuit. Most Inuiit children are carried in their mothers’ amautis ( a rather convenient sort of child carrier come Parka) until they are three years old or even more. The kids seem to sit in there with their hips (and knees) flexed and externally rotated. I couldn’t help but wonder
if this contributed to the incredible flexibility of Inuit women’s hips which I noted in the deliver room. What about other “squatting cultures”?