hip-healthy swaddling...of hip dislocation in tribes that carried babies on a “cradle board”...

©Copyright 2011 AAP News

Volume 32 • Number 9September 2011www.aapnews.org

Hip-healthyswaddling

New light is being shed on thelong-held practice of wrapping aninfant in a blanket snuggly with legsfully extended and together, whichexperts say can lead to hip sublux-ation and dislocation.

The AAP Section on Orthopae dicshas teamed up with the PediatricOrthopaedic Society of North Amer-ica and the International Hip Dys-plasia Institute to recommend swad-dling so that hips are free to moveand in safe abducted position.

Read the literature review andParent Plus information for distri-bution on page 11.

Photo courtesy of International Hip Dysplasia Institute

at Amer Acad of Pediatrics on September 8, 2011http://aapnews.aappublications.org/Downloaded from

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DOI: 10.1542/aapnews.2011329-112011;32;11AAP News

Charles T. Price and Richard M. SchwendImproper swaddling a risk factor for developmental dysplasia of hip

http://aapnews.aappublications.org/content/32/9/11.1World Wide Web at:

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2011 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397. Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright ©published continuously since 1948. AAP News is owned, published, and trademarked by the American AAP News is the official journal of the American Academy of Pediatrics. A monthly publication, it has been



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by Charles T. Price, M.D., FAAP, and Richard M. Schwend, M.D., FAAP

Swaddling has many benefits and has grownin popularity among U.S. parents. However,traditional swaddling as practiced in many cul-tures with the legs fully extended and wrappedtogether can cause hip subluxation and dislo-cation (see Figure 1). This has been known fordecades, long before swaddling was widely prac-ticed in North America.

The AAP Section on Orthopaedics hasteamed up with the Pediatric Orthopaedic Soci-ety of North America (POSNA) and the Inter-national Hip Dysplasia Institute (IHDI) to pro-mote “hip-healthy swaddling.”

The IHDI has issued the following statementwith support from POSNA, “It is the recom-mendation of the International Hip DysplasiaInstitute that infant hips should be positionedin slight flexion and abduction during swad-dling. The knees should also be maintained inslight flexion. Additional free movement in thedirection of hip flexion and abduction may havesome benefit. Avoidance of forced or sustainedpassive hip extension and adduction in the firstfew months of life is essential for proper hipdevelopment.”

A systematic review of swaddling noted thatdevelopmental dysplasia of the hip (DDH) ismore prevalent when the legs are bound so theyare not free to move (van Sleuwen BE, et al.Pediatrics. 2007;120:e1097-e1106).

Studies of Native American Indians prior tothe 1950s demonstrated a very high prevalenceof hip dislocation in tribes that carried babieson a “cradle board” with the hips and kneesstrapped in an extended and adducted position.The frequency of childhood hip dislocationdecreased dramatically among Navajos aftercloth diapers were introduced. This decreasewas attributed to the slightly flexed and abducted position from the bulky clothdiapers even when the infants were strapped on the cradle board. As the frequencyof cradle board use in Navajo society has diminished recently, the prevalence ofhip dysplasia has further decreased from a rate of six times the U.S. average toa similar prevalence.

A somewhat similar experience has been doc-umented in Japan where the incidence of DDHwas 1.5%-3.5% before 1965. Following imple-mentation of a national program to eliminateswaddling with the hips and knees in anextended position, the incidence of DDHdecreased to 0.2%. (Yamamuro T, Ishida K.Clin Orthop Relat Res. 1984;184:34-40).

A significant relationship between swaddlingand hip dysplasia also was identified in Turkey(Kutlu A, et al. J Pediatr Orthop.1992;12:598-602). Although the frequency of traditionalswaddling has been reduced in Turkey, tradi-tional swaddling during infancy still is the great-est risk factor for hip dysplasia compared tobreech birth, family history or gender (DogruelH, et al. Int Orthop. 2008;32:415-419).

Newborn infants have hip and knee flexioncontractures because of their normal intrauterineposition. These contractures resolve over timewith normal development. Animal studies haveshown that forced hip and knee extension inthe neonatal period leads to hip dysplasia anddislocation because of increased tension in thehamstring and iliopsoas muscles that stress thehip capsule, which can have underlying laxityor instability (see previously cited paper byYamamuro and Ishida in Clin Orthop Relat Res).

Comprehensive ultrasound screening duringthe immediate newborn period has demon-strated hip laxity in approximately 15% ofinfants (Rosendahl K, et al. Pediatrics.1994;94:47-52). The combination of capsularlaxity and abnormal muscle tension is the mostlikely mechanism of DDH for infants who aremaintained with the lower extremities extendedand wrapped together.

In contrast, cultures that carry their childrenin the straddle or “jockey” position, as seen inwarmer climates (Figure 2), have very low ratesof hip dislocation compared to cultures thatwrap their children tightly with the legs together

and extended (Salter RB. Can Med Assoc J. 1968;98:933-945). Harvey N. Karp, M.D., FAAP, has pointed out that contemporary methods

of swaddling emphasize upper extremity wrapping while allowing ample roomfor hip and knee flexion (Karp HN. Pediatrics. 2008;121:1075-1076) (see Figure3). However, that message may not have been clearly understood by parents

Figure 1: Traditional swaddling with the legs togetherand extended is associated with an increased risk ofhip dislocation. Figure 2: Cultures that carry theirchildren in the straddle position have very low ratesof hip dislocation. Figure 3: Contemporary swaddlingshould allow ample room for hip and knee flexion withfree movement of the legs.

1 2

3

Improper swaddling a risk factor fordevelopmental dysplasia of hip



who swaddle their children or by nurses who instruct parents at discharge fol-lowing birth.

Prevention of DDH should begin with encouragement of flexed and abductedhip positioning during early infancy. Infants who have been swaddled tightlywith the hips and legs bound together in extension should have focused attentionto their periodic clinical hip examination.

Dr. Price is a member of the AAP Section onOrthopa edics, past president of the PediatricOrthopaedic Society of North America anddirector of the International Hip DysplasiaInstitute. Dr. Schwend is chair of the Sectionon Orthopaedics Executive Committee.


Dr. Price Dr. Schwend

More information on hip-healthy swaddling and developmental dysplasiaof the hip can be found on the International Hip Dysplasia Institute Web site,www.hipdys plasia.org, and the American Academy of Orthopaedic SurgeonsWeb site, http://orthoinfo.aaos.org/topic.cfm?topic=A00347.

RESOURCES



DOI: 10.1542/aapnews.2011329-11a2011;32;11AAP News

Trisha KoriothPractice safe swaddling to protect baby's hips

http://aapnews.aappublications.org/content/32/9/11.2World Wide Web at:

The online version of this article, along with updated information and services, is located on the

2011 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397. Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright ©published continuously since 1948. AAP News is owned, published, and trademarked by the American AAP News is the official journal of the American Academy of Pediatrics. A monthly publication, it has been



Parent PlusAAP NewsINFORMATION FROM YOUR PEDIATRICIAN

©2011 American Academy of Pediatrics. This information may be freely copied and distributed with proper attribution.



Practice safe swaddling to protect baby’s hipsMany babies take comfort in being swaddled in a blanket.However, swaddling the wrong way can cause hip dislocation.

The cozy feeling of a blanket snugly wrapped around thebaby’s body resembles the mother’s womb. The AmericanAcademy of Pediatrics supports safe swaddling of infantsthat leaves the hips and legs free to move. Studies havefound that straightening and tightly swaddling a baby’s legscan lead to hip dislocation or hip dysplasia, an abnormalformation of the hip joint where the top of the thigh bone isnot held firmly in the socket of the hip.

When swaddling a baby, use the following techniquesfrom the International Hip Dysplasia Institute:

• Swaddle the baby on a square blanket. Place thebaby’s head above the middle of one edge, tuck the rightarm down and fold the right side of the blanket over thebaby between the left arm and under the left side. Then tuckthe left arm down and fold the left edge of the blanket overthe baby and under the right side. Fold or twist the bottomof the blanket up and loosely and tuck it under one side ofthe baby.

• Swaddle a baby using the diamond shape tech-nique. Fold one corner of a square blanket down and placethe baby with its head in the center above the folded corner.Straighten the right arm and fold the right corner of the blan-ket over the baby between the left arm and under the leftside. Then tuck the left arm down and fold the left cornerof the blanket over the baby and under the right side. Foldor twist the bottom of the blanket loosely and tuck it underone side of the baby.

Legs should be able to bend up and out. When using acommercial swaddling blanket, make sure it is loose aroundthe baby’s hips and legs.

To reduce the chance of sudden infant death syndrome,parents should place babies on their backs to sleep andkeep loose bedding and soft objects out of the crib.

— Trisha Korioth



hip-healthy swaddling...of hip dislocation in tribes that carried babies on a “cradle board”...

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