Traditional swaddling, which implies restrictive immobilisation of the infant’s lower limbs with the hips in forced extension and adduction, has been shown to be a risk factor for Developmental Dysplasia of Hip (DDH).
We reviewed the literature regarding the correlation between DDH and post-natal positioning by swaddling and baby-wearing, to draw awareness of healthcare professionals towards an important risk factor for DDH that has often been overlooked.
There is overwhelming evidence in the literature, by both experimental and clinical studies, that proves the close association between improper post-natal positioning of the baby’s hips in extension-adduction and an increased incidence of DDH. On the other hand, “hip safe” swaddling which allows unrestricted flexion-abduction movements of the infants’ hips, and the use of baby-wearing devices which keep the lower limbs in an attitude of hip flexion-abduction and knee flexion, is optimal for hip development. Populations which practice these “hip-safe” techniques of infant immobilisation have a lower incidence of DDH as compared to those which practice restrictive immobilisation. Furthermore, populations which have adopted “hip-safe” positioning have demonstrated a significant decrease in the incidence of DDH. Understanding this association is vital, since this is a modifiable risk factor, rectification of which can decrease the incidence of DDH.
Policy makers and governments must design educational campaigns tailored to their respective populations to increase awareness regarding the benefits of “hip-safe” techniques of infant positioning, since this simple intervention has the potential of decreasing the incidence of DDH.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
de Hundt, M., Vlemmix, F., Bais, J. M., Hutton, E. K., de Groot, C. J., Mol, B. W., & Kok, M. (2012). Risk factors for developmental dysplasia of the hip: A meta-analysis. European Journal of Obstetrics, Gynecology, and Reproductive Biology, 165(1), 8–17.
Fox, A. E., & Paton, R. W. (2010). The relationship between mode of delivery and developmental dysplasia of the hip in breech infants: A four-year prospective cohort study. The Journal of Bone and Joint Surgery (Br), 92(12), 1695–1699.
Hinderaker, T., Daltveit, A. K., Irgens, L. M., Udén, A., & Reikerås, O. (1994). The impact of intra-uterine factors on neonatal hip instability: An analysis of 1,059,479 children in Norway. Acta Orthopaedica Scandinavica, 65(3), 239–242.
Chan, A., McCaul, K. A., Cundy, P. J., Haan, E. A., & Byron-Scott, R. (1997). Perinatal risk factors for developmental dysplasia of the hip. Archives of Disease in Childhood. Fetal and Neonatal Edition, 76(2), F94–F100.
Shaw, B. A., & Segal, L. S. (2016). Section on orthopaedics: Evaluation and referral for developmental dysplasia of the hip in infants. Pediatrics, 138(6), e20163107.
Rabin, D. L., Barnett, C. R., Arnold, W. D., Freiberger, R. H., & Brooks, G. (1965). Untreated congenital hip disease. A study of the epidemiology, Natural history, and social aspects of the disease in a Navajo population. American Journal of Public Health and The Nation’s Health, 55(2), 1–44.
Walker, J. M. (1977). Congenital hip disease in a Cree-Ojibwa population: A retrospective study. Canadian Medical Association Journal, 116(5), 501–504.
Abd el-Kader, A., & Shaheen, M. (1989). Mehad: The Saudi tradition of infant wrapping as a possible aetiological factor in congenital dislocation of the hip. Journal of the Royal College of Surgeons of Edinburgh, 34(2), 85–87.
Kutlu, A., Memik, R., Mutlu, M., Kutlu, R., & Arslan, A. (1992). Congenital dislocation of the hip and its relation to swaddling used in Turkey. Journal of Pediatric Orthopedics, 12(5), 598–602.
Corea, J. R. (1992). Is congenital dislocation of the hip rare in Sri Lanka? The Ceylon Medical Journal, 37(3), 96.
Loder, R. T., & Skopelja, E. N. (2011). The epidemiology and demographics of hip dysplasia. ISRN Orthopedics, 2011, 238607.
Graham, S. M., Manara, J., Chokotho, L., & Harrison, W. J. (2014). Back-carrying infants to prevent developmental hip dysplasia and its sequelae: Is a new public health initiative needed? Journal of Pediatric Orthopedics, 35(1), 57–61.
Yamamuro, T., & Ishida, K. (1984). Recent advances in the prevention, early diagnosis, and treatment of congenital dislocation of the hip in Japan. Clinical Orthopaedics and Related Research, 184, 34–40.
Ishida, K. (1977). Prevention of the development of the typical dislocation of the hip. Clinical Orthopaedics and Related Research, 126, 167–169.
Chaarani, M. W., Al Mahmeid, M. S., & Salman, A. M. (2002). Developmental Dysplasia of the Hip before and after increasing community awareness of the harmful effects of swaddling. Qatar Medical Journal Published Online. https://doi.org/10.5339/qmj.2002.1.17
Forero, N., Okamura, L. A., & Larson, M. A. (1989). Normal ranges of hip motion in neonates. Journal of Pediatric Orthopedics, 9(4), 391–395.
Haas, S. S., Epps, C. H., Jr., & Adams, J. P. (1973). Normal ranges of hip motion in the newborn. Clinical Orthopaedics and Related Research, 91, 114–118.
Hoffer, M. M. (1980). Joint motion limitation in newborns. Clinical Orthopaedics and Related Research, 148, 94–96.
Michelsson, J. E., & Langenskiöld, A. (1972). Dislocation or subluxation of the hip: Regular sequels of immobilization of the knee in extension of young rabbits. The Journal of Bone and Joint Surgery American, 54(6), 1177–1186.
Girish, G. (2017). Computational investigation of the biomechanics of babywearing in regards to developmental dysplasia of the hip. ProQuest Diss Theses. Published online 2017, p. 68. https://commons.erau.edu/cgi/viewcontent.cgi?article=1364&context=edt.
Siddicky, S. F., Wang, J., Rabenhorst, B., Buchele, L., & Mannen, E. M. (2021). Exploring infant hip position and muscle activity in common baby gear and orthopedic devices. Journal of Orthopaedic Research, 39, 941–949.
Lipton, E. L., Steinschneider, A., & Richmond, J. B. (1965). Swaddling, a child care practice: historical, cultural and experimental observations. Pediatrics, 35, 519–567.
van Sleuwen, B. E., Engelberts, A. C., Boere-Boonekamp, M. M., Kuis, W., Schulpen, T. W., & L’Hoir, M. P. (2007). Swaddling: A systematic review. Pediatrics, 120(4), e1097–e1106.
Gerard, C. M., Harris, K. A., & Thach, B. T. (2002). Physiologic studies on swaddling: An ancient child care practice, which may promote the supine position for infant sleep. The Journal of Pediatrics, 141(3), 398–403.
Record, R. G., & Edwards, J. H. (1958). Environmental influences related to the aetiology of congenital dislocation of the hip. British Journal of Preventive & Social Medicine, 12(1), 8–22.
Salter, R. B. (1968). Etiology, pathogenesis and possible prevention of congenital dislocation of the hip. Canadian Medical Association Journal, 98(19), 933–945.
Wang, E., Liu, T., Li, J., Edmonds, E. W., Zhao, Q., Zhang, L., Zhao, X., & Wang, K. (2012). Does swaddling influence developmental dysplasia of the hip? An experimental study of the traditional straight-leg swaddling model in neonatal rats. The Journal of Bone and Joint Surgery American, 94(12), 1071–1077.
Suzuki, S., & Yamamuro, T. (1993). The mechanical cause of congenital dislocation of the hip joint: Dynamic ultrasound study of 5 cases. Acta Orthopaedica Scandinavica, 64(3), 303–304.
Mahan, S. T., & Kasser, J. R. (2008). Does swaddling influence developmental dysplasia of the hip? Pediatrics, 121(1), 177–178.
Karp, H. N. (2008). Safe swaddling and healthy hips: Don’t toss the baby out with the bathwater. Pediatrics, 121(5), 1075–1077.
International Hip Dysplasia Institute. (2021). Understanding hip dysplasia. Infant and child: Healthy hip swaddling. https://hipdysplasia.org/infant-child/hip-healthy-swaddling/. Accessed 10 Aug 2021.
Sobaihi, M., Banjari, M. A., & Alahmadi, T. S. (2020). Implementation of safe sleep practice recommendations for infants in inpatient wards. Cureus, 12(10), e11155.
Williams, L., Standifird, T., & Madsen, M. (2019). Effects of infant transportation on lower extremity joint moments: Baby carrier versus carrying in-arms. Gait & Posture, 70, 168–174.
Bergounioux, J., Madre, C., Crucis-Armengaud, A., Briand-Huchet, E., Michard-Lenoir, A. P., Patural, H., Dauger, S., Renolleau, S., Teychéne, A. M., Henry, S., Biarent, D., Robin, C., Werner, E., & Rambaud, C. (2015). Sudden deaths in adult-worn baby carriers: 19 cases. European Journal of Pediatrics, 174(12), 1665–1670.
Batra, E. K., Midgett, J. D., & Moon, R. Y. (2015). Hazards associated with sitting and carrying devices for children two years and younger. The Journal of Pediatrics, 167(1), 183–187.
Anisfeld, E., Casper, V., Nozyce, M., & Cunningham, N. (1990). Does infant carrying promote attachment? An experimental study of the effects of increased physical contact on the development of attachment. Child Development, 61(5), 1617–1627.
Little, E. E., Legare, C. H., & Carver, L. J. (2019). Culture, carrying, and communication: Beliefs and behavior associated with babywearing. Infant Behavior & Development, 57, 101320.
Hunziker, U. A., & Barr, R. G. (1986). Increased carrying reduces infant crying: A randomized controlled trial. Pediatrics, 77(5), 641–648.
Czeizel, A., Szentpétery, J., & Kellermann, M. (1974). Incidence of congenital dislocation of the hip in Hungary. British Journal of Preventive & Social Medicine, 28(4), 265–267.
Hoaglund, F. T., Kalamchi, A., Poon, R., Chow, S. P., & Yau, A. C. (1981). Congenital hip dislocation and dysplasia in Southern Chinese. International Orthopaedics, 4(4), 243–246.
Gardiner, H., Clarke, N. M. P., & Dunn, P. M. (1990). A sonographic study of the morphology of the preterm neonatal hip. Journal of Pediatric Orthopedics, 10(5), 633–637.
Harcke, H. T., Karatas, A. F., Cummings, S., & Bowen, J. R. (2016). Sonographic assessment of hip swaddling techniques in infants with and without DDH. Journal of Pediatric Orthopedics, 36(3), 232–238.
Pinto, D. A., Aroojis, A., & Mehta, R. (2020). Swaddling practices in an indian institution: Are they hip-safe? A survey of paediatricians, nurses and caregivers. Indian Journal of Orthopaedics, 55(1), 147–157.
Conflicts of interest
The authors declare that they have no conflict of interest, financial or otherwise, relevant to this study.
Ethics approval and consent to participate
No ethics approval was required for this study since it is a narrative review of existing literature.
For this type of study informed consent is not required.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Vaidya, S., Aroojis, A. & Mehta, R. Developmental Dysplasia of Hip and Post-natal Positioning: Role of Swaddling and Baby-Wearing. JOIO (2021). https://doi.org/10.1007/s43465-021-00513-3
- Developmental dysplasia of hip
- Post-natal positioning