Swaddling: IHDI Position Statement

Summary Statement: Swaddling infants with the hips and knees in an extended position increases the risk of hip dysplasia and dislocation. It is the recommendation of the International Hip Dysplasia Institute that infant hips should be positioned in slight flexion and abduction during swaddling. The knees should also be maintained in slight flexion. Additional free movement in the direction of hip flexion and abduction may have some benefit. Avoidance of forced or sustained passive hip extension and adduction in the first few months of life is essential for proper hip development.

Scientific Rationale: There are many benefits of swaddling,[1, 2] but improper swaddling increases the risk of hip dysplasia and hip dislocation.[3, 4] A leading proponent of swaddling, Harvey Karp, M.D., has stated, “Contemporary swaddling techniques…permit infants to be snugly wrapped with their hips being safely flexed and abducted.”[5] This position should be encouraged. An alternative method is to swaddle only the upper extremities and allow the lower limbs to move freely.[1, 2]

Mechanical factors in development of hip dysplasia The etiology of hip dysplasia in otherwise healthy infants is multifactorial, but mechanical factors play an important role.[6] Studies of hip development have been conducted using ultrasonography during late stages of fetal development prior to delivery and also in pre-term infants.[7, 8] These studies indicate that the normally developing hip is well-formed prior to birth. An unpublished study by Judy Estroff, M.D. at Harvard evaluated 451 fetal hip ultrasound studies. All hips were noted to be mature and well-formed near term. A published study of fetal ultrasonography also reported, “Prenatally, the mean ?-angles were above the level that corresponds to a mature hip joint.”[8] The acetabular roof angle decreased after birth in normal infants suggesting post-natal influences on developmental dysplasia. The same study evaluated pre-term infants and noted that ß-angles were greater in term infants than pre-term infants. This suggests that mature infants had greater displacement of the lateral soft tissues than pre-mature infants.[7] Dissections in deceased newborn infants with hip dislocation have not always demonstrated primary acetabular dysplasia.[9] Thus, the concept of “immature hip” should be re-considered with regards to anatomical development. These observations suggest that the hip may be more “mature” prior to birth and become more dysplastic around the time of birth.   Gardiner, Clarke and Dunn postulated that transient ligamentous laxity from maternal relaxin and greater mechanical pressures around the time of birth may contribute to soft tissue deformation in the mature infant.[7] It is known that normal infants have an average hip flexion contracture of 28° that decreases to 19° at six weeks and 7° at three months of age.[10, 11] Hip flexion contractures of 50° to 120° and knee flexion contractures of up to 35° have also been noted in otherwise healthy newborn infants.[12] These improve rapidly in the newborn period and gradually resolve following the assumption of upright posture.[11, 12]  Several authors have cautioned against extension of the hip during the neonatal period as this may contribute to subluxation, dislocation, or dysplasia of the joint.[11, 13, 14] Also, hip dysplasia has been shown to develop in  animal studies, when the lower extremities were immobilized with the hips or knees in extension.[14-16] In these studies the incidence of hip dislocation was also increased by addition of maternal progesterone that promotes hip joint laxity and the effect was greater on females than males.[15, 16]   There is evidence in humans that post-natal positioning influences the development of hip dysplasia. Hip dysplasia has been associated with abduction contracture of the contralateral hip.[17] Positioning the thighs together uncovers the femoral head and stretches of the hip capsule on the side opposite the abduction contracture. Protecting both hips with abduction bracing while implementing stretching exercises resulted in resolution of dysplasia.[17] It has also been noted that hip dysplasia is rare in cultures that carry their infants with the hips abducted.[4, 13] A study of Canadian First Nations demonstrated a ten-fold increase in the incidence of hip dislocation in tribes that carry babies on a “cradle board” with the hips strapped in an extended and adducted position.[13]. A high incidence of hip dislocation was noted in Navajo Indians who strapped their infants to a cradle board.[18] However the incidence of complete dislocation in Navajo Indians decreased dramatically in the 1940s when diapers were introduced instead of moss to absorb excreta. The reduction in the rate of dislocations was attributed to the use of diapers that kept the hips slightly abducted and flexed even when strapped in the cradle board. A somewhat similar experience has been documented in Japan.[15] In 1975 a national program was initiated in Japan to avoid swaddling infants with the hips and knees in extension. Prior to that initiative, the incidence of infantile dislocation of the hip was as high as 3.5%. Following that initiative, the incidence dropped to less than 0.2%.[15] A significant relationship between swaddling and hip dysplasia has also been found in Turkey.[19]   Swaddling is increasing in frequency in the USA to promote improved sleep habits.[1] The benefits of this practice may be offset by higher rates of developmental hip dysplasia and dislocation if infants are swaddled incorrectly.   Caution when swaddling has been recommended to allow the hips to move freely to avoid increasing the risk of developmental dysplasia.[1, 3]    
1. van Sleuwen, B., Engelberts AD, Boere-Boonekamp MM, Kuis W, Schulpen TWJ, L’Hoir MP,, Swaddling: a systematic review. Pediatrics, 2007. 120: p. e1097-e1106.
2. Gerard, C., Harris KA, Thach BT, Physiologic studies on swaddling: an ancient child care practice, which may promote supine position for infant sleep. J. Pediatr., 2002. 141: p. 398-403.
3. Mahan, S., Kasser JR, Does swaddling influence developmental dysplasia of the hip? Pediatrics, 2008. 121: p. 177-8.
4. Salter, R., Etiology, pathogenesis and possible prevention of congenital dislocation of the hip. Can. Med. Assoc. J., 1968. 98: p. 933-45.
5. Karp, H., Safe swaddling and healthy hips: don’t toss the baby out with the bathwater. Pediatrics, 2008. 121: p. 1075-6.
6. Bowen, J., Kotzias-Neto A, Etiology, in Developmental Dysplasia of the Hip, J. Bowen, Kotzias-Neto A, Editor. 2006, Data Trace: Brooklandville, MD. p. 18-21.
7. Gardiner, H., Clarke NMP, Dunn PM, A sonographic study of the morphology of the preterm neonatal hip. J. Pediatr. Orthop., 1990. 10: p. 633-7.
8. Stiegler, H., Hafner E, Schuchter K, Engel A, Graf R,, A sonographic study of prenatal hip development: from 34 weeks of gestation to 6 weeks of age. J. Pediatr. Orthop., 2003. 12B: p. 365-8.
9. McKibben, B., Anatomical factors in the stability of the hip joint in the newborn. J. Bone Joint Surg., 1970. 52B: p. 148-59.
10.Haas, S., Epps CH, Adams JP, Normal ranges of hip motion in the newborn. Clin. Orthop. Rel. Res., 1973. 91: p. 114-8.
11.Coon, V., Donato G, Houser C, Bleck EE, Normal ranges of hip motion in infants six weeks, three months, and six months of age. Clin. Orthop. Rel. Res., 1975. 110: p. 256-60.
12.Hoffer, M., Joint motion limitation in newborns. Clin. Orthop. Rel. Res., 1980. 148: p. 94-96.
13. Salter, R., Role of Innominate osteotomy in the treatment of congenital dislocation and subluxation of the hip in the older child. J. Bone Joint Surg., 1966. 48A: p. 1413-39.
14. Suzuki, S., Yamamuro T, The mechanical cause of congenital dislocation of the hip joint. Acta Orthopaedica Scand., 1993. 64: p. 303-4.
15. Yamamuro, T., Ishida K, Recent advances in the prevention, early diagnosis, and treatment of congenital dislocation of the hip in Japan. Clin. Orthop. Rel. Res., 1984. 184: p. 34-40.
16. Wilkinson, J., and Carter C, Prime factors in the etiology of congenital dislocation of the hip. J. Bone Joint Surg., 1963. 45B: p. 268-83.
17. Green, N., Griffin PP, Hip dysplasia associated with abduction contracture of the contralateral hip. J. Bone Joint Surg., 1982. 64: p. 1273-81.
18. Pratt, W., Freiberger RH, Arnold WD, Untreated congenital hip dysplasia in the Navajo. Clin. Orthop. Rel. Res., 1982. 162: p. 69-77.
19. Kutlu, A., Memik R, Mutlu M, Kutlu R, Arslan A, Congenital dislocation of the ip and its relationship to swaddling used in Turkey. J. Pediatr. Orthop., 1992. 12: p. 598-602.  

Clinical Practice Guidelines

Clinical Practice Guidelines have been developed by the American Academy of Pediatrics for early diagnosis of Hip Dysplasia. Information on this website is presented in an effort to help pediatricians with the difficult task of diagnosis and appropriate treatment or referral of patients wtih hip dysplasia. PEDIATRICS Vol. 105 No. 4 April 2000, pp. 896-905 American Academy of Pediatrics: Clinical Practice Guideline: Early Detection of Developmental Dysplasia of the Hip Committee on Quality Improvement, Subcommittee on Developmental Dysplasia of the Hip Developmental dysplasia of the hip is the preferred term to describe the condition in which the femoral head has an abnormal relationship to the acetabulum. Developmental dysplasia of the hip includes frank dislocation (luxation), partial dislocation (subluxation), instability wherein the femoral head comes in and out of the socket, and an array of radiographic abnormalities that reflect inadequate formation of the acetabulum. Because many of these findings may not be present at birth, the term developmental more accurately reflects the biologic features than does the term congenital. The disorder is uncommon. The earlier a dislocated hip is detected, the simpler and more effective is the treatment. Despite newborn screening programs, dislocated hips continue to be diagnosed later in infancy and childhood,1-11 in some instances delaying appropriate therapy and leading to a substantial number of malpractice claims. The objective of this guideline is to reduce the number of dislocated hips detected later in infancy and childhood. The target audience is the primary care provider. The target patient is the healthy newborn up to 18 months of age, excluding those with neuromuscular disorders, myelodysplasia, or arthrogryposis.