DEVELOPMENTAL DYSPLASIA OF THE HIP BEFORE AND AFTER INCREASING COMMUNITY AWARENESS OF THE HARMFUL EFFECTS OF SWADDLING

Chaarani M.W., Al Mahmeid M.S. and Salman A.M.
Orthopedics Section, Department of Surgery, Hamad Medical Corporation, Doha, Qatar

Abstract:

Qatar is a small country with a population of around 580,000. Over a period of 14 months a study was conducted on 520 infant hips to compare the results of ultra sound scanning of 260 “high risk” babies; half of them (130) scanned before and the others scanned after increasing public awareness of the possible serious consequences of swaddling on neonate hips. Before this public awareness, of 130 babies scanned in a six months period 26 showed a form of acetabular dysplasia (20%), eighteen mild, four moderate and four severe. Two months after the public was made aware that swaddling could cause harmful effects on infants’ hips, 130 babies were scanned in a six months period. The number of babies with hip dysplasia was reduced to eight (6%), six mild, one moderate and another had severe acetabular dysplasia.

Key Words: Developmental Dysplasia of the Hip (DDH), before swaddling, after swaddling, ultrasound scanning of the hips.

Introduction:

The habit of swaddling is a common tradition in the Middle East that goes back hundreds of years. It is done by wrapping the baby either with many bandages or garments or with a long strip of material wrapped around the baby’s body (Figure 1). Both methods fix the hips in an extended and adducted position that can seriously affect the development of the acetabulum. The extension and adduction position may lead to hip dislocation during the neonatal period(1) as shown experimentally in animal hips(2). Epidemiological studies performed in countries such as Japan(3), Turkey(4) and an observation made in the Eastern province of Saudi Arabia(5) correlated a high incidence of dislocated hip with the use of swaddling for the newborn.

Figure 1: Swaddling with a long strip

Although it is quite clear in the literature that swaddling is harmful to babies with acetabular dysplasia it is surprising that clinicians who are aware of this increased incidence do not warn parents of the disadvantages of this practice.

The term “Developmental Dysplasia of the Hip“ (DDH) has replaced the term “Congenital Dislocation of the Hip” because a hip put under unfavorable conditions can deteriorate. That is why communities that practice swaddling have a higher rate of DDH as swaddling may prevent the acetabulum from correct development. If there is muscle imbalance leading to persistent hip adduction of an otherwise normal hip can change gradually into a subluxed and dislocated hip, as is very common in neuromuscular disorders such as cerebral palsy(6). In neonates the majority of dysplastic and dislocated hips can improve to normal under favorable conditions (flexion and abduction) such as the position in a Pavlik harness(7). Most hips that have minor acetabular dysplasia during the neonatal period recover spontaneously within a few weeks(8,9). The aim of this prospective study was to show the importance of public awareness that swaddling has harmful effects on infant hips and to show the immediate reduction of the number of infants with acetabular dysplasia after mothers became aware of the harmful effects of swaddling.

Method:

An ultrasound clinic for hip scanning was held one morning a week to cater for the many mothers bringing high risk babies for examination. For the last two years a Pediatric Orthopaedic surgeon has been present and most babies at risk were given an ultrasound appointment after an average of six to eight weeks.

After birth the babies were examined clinically by a neonatologist and all hips were routinely screened for DDH. All those with hips at risk were referred for ultrasound screening. The risk factors included breech presentation, family history of DDH, hips clicking, limited hip abduction and some other rare indications.

The ultrasound machine was a Real Time Siemens Sonoline SL 1 with a 5 MHz linear transducer. A black and white thermal paper video printer was used for documentation of the results. The babies were examined using the technique described by Graf(10, 11) to obtain a standard static sonographic plane of section for hips documented by pictures of right and left hips and graded according to Graf’s classification(12).

The orthopaedic surgeon noticed that, even though swaddling was a common practice in the region, families who had babies at risk were not warned of the hazards. Many of these swaddled babies had hip problems ranging from mild acetabular dysplasia to complete hip dislocation.

The awareness of the neonatologists of the serious consequences was increased by a lecture (MW Chaarani: Surgical Neonatology Symposium, 3rd May 2001, Qatar) and a memo requesting improved public education. A common reaction from mothers (and particularly from grandmothers) was that swaddling was an ancient practice that had not harmed them, so why should it harm their offspring? Patience, trust, and obvious concern for their babies was necessary to win them over. Some refused point blank to change the practice. Others appeared to understand and would express agreement and gratitude for the advice even while they were swaddling their babies ready to leave the clinic!

Of 520 infant hips from 260 “high risk” babies examined and scanned by ultrasound over a period of 14 months, 130 babies (50%) were scanned before and the remainder after attempts to increase public awareness of the consequences of swaddling.

Results:

One hundred and thirty babies with hips at risk had ultra sound examination of their hips in a six month period from 16th October 2000 to 16th April 2001. Twenty six babies had a form of acetabular dysplasia, (20%), eighteen of these were mild, four moderate and four severe (Table 1). Seventeen were Qatari and nine various other nationalities. Two months after the consequences had been publicized another 130 babies were studied and scanned by ultrasound during the six month period from 2nd July 2001 to 7th January 2002. Eight of these babies (six Qatari, two non-Qatari) had a form of acetabular dysplasia (6%), showing a 14% drop in the incidence of acetabular dysplasia between the first and second groups. Six were mild, one moderate and one severe (Table 2).

Discussion:

The acetabulum of an infant is formed of two parts, an inner bony part and an outer cartilaginous. If the hip is put into extension and adducted, the femoral head will press on the cartilaginous part of the acetabulum, possibly affecting its growth and ossification and leading to acetabular dysplasia, hip subluxation and dislocation. In the literature there appears to be no disagreement that swaddling can cause further deterioration of hips at risk. Swaddling alone does not cause hip dislocation but it can have an unfavorable effect on the future progress of a dysplastic hip, i.e. swaddling can be only a contributing factor in the development of congenital hip pathology after birth if some abnormality of the hip or the area around the hip already exists at birth(13).

It is necessary to differentiate between risk factors of acetabular dysplasia in utero and extra-uterine (perinatal) risk factors. If perinatal risk factors are favorable the hip will have a better chance to grow to normal, if unfavorable there can be serious deterioration(14, 15).

The regular presence of an orthopaedic surgeon in the ultrasound clinic had many advantages. Parents of affected babies could be given immediate instructions and a management plan tailored according to the severity without waiting for outpatient orthopaedic appointments. That families with babies at risk of acetabular dysplasia were not being warned of the hazards of swaddling was an important observation by the orthopedic surgeon which led to this study.

Publicity appeared to produce good results. Within a few months swaddling became occasional rather than common, and ultrasound screening showed a sharp decline in the number of dysplastic hips. When asked why their babies are not swaddled mothers were likely to reply that they had heard that the practice was not good. However, Qatar is a relatively small community and news spreads very quickly. In other areas more intensive efforts might be necessary if swaddling is to become past history not only for Qatar but for the whole of the Middle East. It is not news that swaddling has an adverse effect on developmental acetabular dysplasia but this pilot study shows how an immediate improvement can be achieved when mothers are made fully aware of the serious consequences.

Conclusion:

We recommend immediate national campaigns. Already one is planned in Qatar in conjunction with the Health Media and Public Relations Department of Hamad Medical Corporation using material prepared in English and Arabic, and possibly later in other commonly used expatriate languages. We look forward to the golden sands of the desert soon covering the age-old tradition of swaddling.

Acknowledgement:

We thank both the late Dr. William M. George for his assistance and Mrs. Deepa Sasidharan, Orthopedic Secretary, for her patience and cooperation while preparing this manuscript. We also thank Health Media and Public Relations Department, Hamad Medical Corporation, for their understanding and help in persuading the community to abandon swaddling.

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