PEDIATRICS Vol. 121 No. 5 May 2008, pp. 1077 (doi:10.1542/peds.2008-0553)
LETTER TO THE EDITOR |
Safe Swaddling and Healthy Hips: Don't Toss the Baby out With the Bathwater: In Reply
Susan T. Mahan, MD, MPHJames R. Kasser, MD
Department of Orthopaedics,
Children's Hospital Boston,
Harvard Medical School,
Boston, MA 02115
We thank Dr Karp for his comments and input on our article "Does Swaddling Influence Developmental Dysplasia of the Hip?"1 We agree that plenty of anecdotal and scientific literature has shown the benefits of swaddling in neonates2–6 and appreciate his contribution to the recent popular surge of swaddling.2 Our concern, however, is to stress the relationship between swaddling and an increased risk of developmental dysplasia of the hip (DDH) and draw awareness to this potential problem.
We agree that much of the strong deleterious effect of swaddling on DDH was seen in cultures that swaddled with the hips adducted and extended.6–9 More modern swaddling technique allows the hips to be flexed and abducted.6,10 However, concerns of improper technique and the risk that this poses to the hips should be emphasized.
Swaddling can be most beneficial in the first 2 months or so of a neonate's life,11 and this is the same window of time in which DDH may resolve or persist. Prospective studies have shown that 17% of newborns have some degree of "immaturity" or dysplasia of their hips according to ultrasound.12 Although this resolves untreated in most hips by 2 to 3 months of age, the hips are very susceptible to improper positioning that could lead to long-term dysplasia and early arthritis. This overlapping window of time in which infants are swaddled and their hips are susceptible to positioning is a potential concern.
Although we respect the important impact of swaddling on decreasing crying and promoting sleep and the potential benefits that go with these effects,6 we wish to emphasize the risks to the hips that can occur with swaddling. We agree that not all swaddling techniques pose similar risks to the hips, and an emphasis on swaddling technique is important for avoiding the potential increases to DDH that could occur. Allowing the hips to be flexed and abducted (a neonate's natural hip position) within the swaddle allows normal hip development to be optimized.8,13,14
Our purpose is not to discourage swaddling; rather, it is to raise awareness of the potential impact of swaddling on neonatal hip development. Pediatricians who take care of these neonates should be aware of the risks to the hip with swaddling. Neonates who are at increased risk for hip dysplasia (because of family history of DDH and/or being born in breech position) should have a screening ultrasound at 6 to 8 weeks of age as is currently recommended by American Academy of Pediatrics clinical practice guidelines.15 Infants with dysplasia or hip dislocation probably should not be swaddled. Families who swaddle their neonate should understand the potential risk to the hip, and techniques that allow the hips to be flexed and abducted should be emphasized.
REFERENCES
- Mahan ST, Kasser JR. Does swaddling influence developmental dysplasia of the hip?
Pediatrics. 2008;121
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[Free Full Text] - Karp HN. The Happiest Baby on the Block. New York, NY: Bantam Dell; 2002
- Gerard CM, Harris KA, Thach BT. Spontaneous arousals in supine infants while swaddled and unswaddled during rapid eye movement and quiet sleep. Pediatrics. 2002;110 (6). Available at: www.pediatrics.org/cgi/content/full/110/6/e70
- Caiola E. Swaddling young infants can decrease crying time. J Pediatr. 2007;150 (3):320 –321[CrossRef][Medline]
- Franco P, Seret N, Van Hees JN, Scaillet S, Groswasser J, Kahn A. Influence of swaddling on sleep and arousal characteristics of healthy infants.
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[Abstract/Free Full Text] - van Sleuwen BE, Engelberts AC, Boere-Boonkamp MM, Kuis W, Schilpen TW, L'Hoir MP. Swaddling: a systematic review. Pediatrics. 2007;120 (4). Available at: www.pediatrics.org/cgi/content/full/120/4/e1097
- Coleman SS. Congenital dysplasia of the hip in the Navajo infant. Clin Orthop Relat Res. 1968;56 :179 –193[Medline]
- Yamamuro T, Ishida K. Recent advances in the prevention, early diagnosis, and treatment of congenital dislocation of the hip in Japan. Clin Orthop Relat Res. 1984;(184) :34 –40[Medline]
- Kutlu A, Memik R, Mutlu M, Kutlu R, Arslan A. Congenital dislocation of the hip and its relation to swaddling used in Turkey. J Pediatr Orthop. 1992;12 (5):598 –602[Web of Science][Medline]
- Gerard CM, Harris KA, Thach BT. Physiologic studies on swaddling: an ancient child care practice, which may promote the supine position for infant sleep. J Pediatr. 2002;141 (3):398 –403[CrossRef][Web of Science][Medline]
- van Sleuwen BE, L'Hoir M P, Engelberts AC, et al. Comparison of behavior modification with and without swaddling as interventions for excessive crying. J Pediatr. 2006;149 (4):512 –517[CrossRef][Web of Science][Medline]
- Rosendahl K, Markestad T, Lie RT. Ultrasound screening for developmental dysplasia of the hip in the neonate: the effect on treatment rate and prevalence of late cases.
Pediatrics. 1994;94
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[Abstract/Free Full Text] - von Rosen S. Diagnosis and treatment of congenital dislocation of the hip joint in the new-born. J Bone Joint Surg Br. 1962;44 :284 –291[Web of Science][Medline]
- Salter RB. Etiology, pathogenesis and possible prevention of congenital dislocation of the hip. Can Med Assoc J. 1968;98 (20):933 –945[Medline]
- American Academy of Pediatrics, Committee on Quality Improvement, Subcommittee on Developmental Dysplasia of the Hip. Clinical practice guideline: early detection of developmental dysplasia of the hip.
Pediatrics. 2000;105
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[Abstract/Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics
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