Table 14.

Recommendations, Evidence, and Consensus of the Subcommittee

Index to
Diagram
RecommendationEvidenceConsensus
1NB screenDirect (arc 1 → 3); although orthopaedic screening would be optimal, it is doubtful that such a strategy widely practiced would give the same good results as those of pediatric orthopaedic study centers.      Strong
1Post-NICU examinationDirect; there is some suggestion that NICU infants may be at higher risk.      Strong
Examination by properly trained personnelDirect (arc 1 → 3); a number of studies performed by properly trained nonphysicians report results indistinguishable from those performed by physicians.      Strong
Do not perform US for all infantsIndirect (arc 1 → 4 plus decision model); that strategy results in no lower postneonatal DDH rates and may result in higher AVN rates.      Strong
4PE ++: refer to orthopaedistDirect (arc 3 → 5)      Optional
4PE ++: follow-up in 2 wkDirect (target article 96)      Strong
PE ++: do not order US nowDirect (arc 3 → 4)      Strong
PE ++: do not order radiographsDirect (not from our review); radiographs are too insensitive at this age owing to lack of calcification.      Strong
PE ++: do not triple diaperIndirectStrong; a true positive examination should be actively managed, and triple diapering is not an effective treatment modality.
PE positive or negative: triple diaperIndirectOptional; diapering may communicate a sense of concern and may promote compliance.
5If PE positive or negative, follow-up in 2 wk3 → 4 (target article 96); 80% resolves spontaneously      Fair
6If PE positive at 2-wk follow-up, refer to orthopaedist now or perform US at 3 wkIndirect because rate decreases from 10/1000 to a lesser number, but DDH does not resolve (target article 38)      Strong
7If PE negative, continue with periodicity examinationsDirect; diagnosis before 6 mo decreases AVN/DDH morbidity      Strong
12Risk factorsDirect; the evidence is strongest for family history, female sex, and breech presentation. Other risk factors include left hip involvement and prematurity. We do not include left hip because no one will examine one hip and not the other. We do not include prematurity because the overall data are unclear about its implications.      Strong
13If family history positive, perform periodic examinationsAbsolute risk is 9–44/1000Strong; consensus threshold for imaging is 50/1000
13If girl, perform periodic examinationsAbsolute risk is 12–19/1000      Strong
10If boy breech, perform periodic examinations, with optional imagingAbsolute risk is 17–26/1000      Strong
8If girl breech, refer to orthopaedist immediately or perform US at 3–6 wkAbsolute risk is 70–120/1000      Strong
9If periodic examination positive, refer to orthopaedist immediately or image (US if <5 mo or radiographs if >4 mo)Indirect; imaging may be acceptable if imager has requisite experience in interpreting results.Strong for referral; fair for imaging
  • NB indicates newborn; NICU, neonatal intensive care unit; US, ultrasonography. Two plus signs indicate strongly positive.