Swaddling as a risk factor for developmental dysplasia of the hip: Perception and knowledge of family medicine and pediatric residents

Introduction

Developmental dysplasia of the hip (DDH) is a term used to describe the structural abnormalities that involve the growing hip, which might lead to dislocation or instability of the hip joint.^[1],[2] The incidence of DDH in Saudi Arabia varies greatly in different cities. It ranges between 3.8 and 36.5 cases per 1000 according to different studies in different years.^[3],[4],[5] Several nonmodifiable risk factors were associated with DDH including family history, female gender, breech presentation, and firstborn child; however, the most common modifiable risk factor is swaddling.^[1],[2] According to one prospective study done in Turkey, swaddling was associated with DDH more than all other risk factors, including family history, female gender, breech presentation, and firstborn child.^[6]

Swaddling represents a practice of wrapping a baby in a blanket so that limb movement is snugly restricted to provide warmth and security. Swaddling is a traditional practice among different societies with different techniques.^[7] According to a systematic review, DDH can be promoted by swaddling, especially when the legs are not free to bend and flex.^[7] The International Hip Dysplasia Institute and the Pediatric Orthopedic Society of North America recommended that infant hips should be positioned in slight flexion and abduction during swaddling with the knees in slight flexion.^[8] One of the most common techniques of swaddling used is with extended hips and knees, which is almost the opposite of Pavlik harness, the standard initial treatment of DDH worldwide.^{[9],[10],[11]}

A very high prevalence of hip dislocation was shown in different populations that used swaddling. For example, in some tribes of Native American Indians where they used to carry their babies on a “cradle board” with the hips and knees strapped in forced extension and adduction position. Similarly, in Japan, swaddling was a common practice before 1965, and the incidence of DDH was 1.5%–3.5%. This incidence decreased down to 0.2% when they implemented a national program to stop swaddling.^[8]

In Saudi Arabia, it is still a common practice and is known with different names, including “Mihad,” “Tagmeet,” and “Kawfala.” Although the number of cases presented with DDH is considered high and the swaddling practice is very popular in Saudi Arabia, the research publications in this field are extremely limited. One study in Saudi Arabia found that swaddling was used in almost 71% of the patients with DDH.^[12] They found that only 25% of those with DDH associated with swaddling were discovered in the 1^st month of life. Moreover, only 45% of all the cases were discovered by the family when they noticed an abnormality. These findings demonstrate the importance of swaddling as a risk factor and the lack of the public awareness about its complications.

Only one cross-sectional study found in Saudi Arabia aimed at evaluating the perception of mothers about swaddling techniques. They found that 91% of mothers used swaddling and most of them learned the technique from their relatives and only 4% were trained by a healthcare provider.^[13] Family physicians and pediatricians are usually the ones responsible for neonatal screening, well-baby clinic, and education.^[2],[11] Residents, in general, are usually the first-line encounter with patients. According to a study done in Los Angeles, USA, <50% of pediatricians educate parents of newborns about swaddling risks if not done properly.^[14]

Up to our knowledge, no local study has evaluated the effectiveness of an educational intervention on changing the attitude and perception of swaddling in relation to DDH. Thus, the aim of our study was to evaluate the awareness and perception of family medicine and pediatric residents toward swaddling techniques and their relationships to DDH. Moreover, we aimed to look for the effectiveness of an educational intervention on changing their attitude and perception regarding this topic.

Materials and Methods

This cross-sectional study was conducted in January 2019. The study aimed to assess the perception of family medicine and pediatric residents toward swaddling techniques and their relationships to DDH. The inclusion criteria for both groups were being a resident at the National Guard Hospital, Jeddah. Respondents were targeted during their scheduled mandatory weekly teaching. Each of the participants received a validated questionnaire composed of 17 questions to be filled in 10 min. Then, papers were collected in sealed envelopes in front of them. After that, a 20-min presentation was provided by a pediatric orthopedic consultant. The presentation was a PowerPoint presentation that included different aspects of DDH, including clinical presentation, risk factors including swaddling, diagnosis, and management. Pictures were provided during the presentation to illustrate the correct and wrong swaddling techniques. Next, they were provided with another questionnaire, with the same knowledge questions that they filled before the presentation and were given 5 min to answer. Then, prepresentation and postpresentation questionnaires were collected for every participant in a sealed envelope. The same steps were done for both groups; family medicine residents and pediatric residents.

The questionnaire was adapted mainly from two studies' questionnaires.^[13],[15] The face and construct validity of the questionnaire and the presentation were addressed through consultation with three pediatric orthopedic consultants from National Guard Hospitals in Riyadh and Jeddah, Saudi Arabia. Then, the questionnaire was modified according to their recommendations. After that, a pilot study was done on 11 orthopedic residents in the National Guard Hospital, Jeddah, Saudi Arabia, to explore if there were any remaining issues in the questionnaire. The questionnaire was further modified according to the difficulties that the participants faced. The presentation was reviewed by the same reviewers and modified accordingly.

The final questionnaire developed consisted of three sections. The first section was about the respondents' demographical data, which included questions regarding their age, gender, specialty (i.e., family medicine or pediatrics), practicing period, marital status, if they have a family history of DDH, or if they have children. The second section consisted of two parts. The first part will be filled if the respondent has children. It was composed of three multiple-choice questions: whether their children were diagnosed with DDH, or they practiced swaddling on them in addition to the method of the swaddling. The second part was a question about if they have ever done swaddling to any child, in addition to the method of the swaddling they practiced. The third section consisted of eight multiple-choice questions that assessed the knowledge of respondents toward DDH and swaddling as a risk factor.

All statistical procedures were performed using Statical package for IBM SPSS Statistics for Windows, Version 18.0. Chicago: SPSS Inc. IBM Corp. Quantitative variables were reported as a mean and standard deviation if normally distributed data or median and 25^th and 75^th percentile if data were skewed, while qualitative variables were reported as frequency and percentages. Analyses for associations between variables were performed using the Student's t-test and analysis of variance test. Paired t-test and McNemar's test were used to compare the scores difference between preintervention and postintervention results. Values <0.05 were considered statistically significant, with a confidence interval of 95%.

Results

Sixty-one participants were included in the study. Participants' age ranged from 25 to 30 years, with a median age of 26 years (interquartile range) = 2 years. Females presented 65.6% (40/61) of the total participants. In terms of marital status, 67.2% (41/61) were singles, 27.9% (17/61) were married, and 3.3% (2/61) were divorced. Family medicine residents constituted 63.9% (39/61) of the participants, while 36.1% (22/61) were pediatric residents. [Table - 1] illustrates the demographic characteristics of each specialty.

Table 1: Demographic data

Of the total participants, only 11.5% (7/61) had children; neither of these children was diagnosed with DDH nor had a family history with the disease. About 71.4% (5/7) of the parents had practiced swaddling on their children, and 34.4% (21/61) of the total participant had previously practiced it on other children. [Table - 2] summarizes the used swaddling techniques. There was no correlation between practicing swaddling on their children or any child and their knowledge score.

Table 2: Used swaddling techniques by participants

There was a significant correlation between the prelecture scores and the practicing period of the physicians (P = 0.003). Pediatricians had higher prelecture knowledge scores than family physicians (P = 0.033). Further, there was a weak positive correlation between the age and the knowledge scores (r² = 0.86, P = 0.031) [Table - 3].

Table 3: Correlation between demographic data and prelecture knowledge score

Knowledge score was calculated out of 8, with each question counts for 1. Results showed participants' mean knowledge score before the intervention was 3.801 ± 2.181, while after the intervention, the mean score increased to 6.903 ± 1.121. A repeated-measure t-test found this difference to be statistically significant, t = 11.683, df = 60, and P < 0.001. Knowledge questions were evaluated each one separately before and after the intervention, with a P < 0.001 in most questions [Table - 4].

Table 4: Pre- and post-lecture knowledge scores

Discussion

Awareness regarding swaddling techniques and their relation to DDH is suboptimal among the first-line encounters to these patients, as found by our results. Almost one-third of the participants have practiced swaddling on a child, with only 42% of them using the safe technique. Our study focused on family physicians and pediatricians as they are usually the first-line patients' encounter, and generally, education about these topics should be held with them. Hence, their perception and knowledge regarding this topic are essential.

Almost 50% of the questions regarding swaddling and its relation to DDH were answered incorrectly. Participants who practice for more than 2 years in their specialty had higher scores. The higher the age of the participants, the more answers were answered correctly, which could be attributed to more practicing period. There was no difference between males and females or those who are married or not in the knowledge scores. In addition, having children was not associated with higher knowledge scores. Moreover, there was no correlation between practicing swaddling before and their knowledge scores. Interestingly, pediatric residents had higher scores than family medicine residents.

Our intervention had a significant effect on the participants' total perception of DDH and the appropriate swaddling techniques. The average score after the intervention increased to 85% compared to <50% preintervention. There was a statistically significant difference in almost all questions from preintervention to postintervention.

One study done in Almadinah Almunawwarah, Saudi Arabia, on 2631 mothers showed that only <23% knew that there are some effects of swaddling on children's hips and <37% knew the correct and safe swaddling technique.^[12] Only 32% of the participants in our study knew that swaddling is a risk factor of DDH and 100% of them learned that it is a risk factor after the lecture. Remarkably, almost 51% of the participants thought that swaddling is a treatment of DDH, which was changed significantly after the educational intervention. In addition, more than 67% of the participants were not able to choose the correct safe swaddling technique. However, after the intervention, more than 91% were comfortable and sure about the correct safe method.

These data demonstrate that first-line physicians encountering DDH patients (family physicians and pediatricians) need educational sessions regarding this topic to deal with them safely. In addition, this will give them insight into how to educate their patients about the risks of swaddling and safe swaddling practices, and hopefully, they will practice that as initial encounter as pediatric residents early after birth or as family medicine residents in the well-baby clinic as a regular follow-up with each vaccination visit.

Limitations

The limitations were being a single-center study and with a small sample size and lack of long-term assessment of the effect on knowledge or on residents' behavior.

Conclusion

More than half of the participants had a lack of knowledge about swaddling and its relation to DDH, and about 22% of them had practice swaddling in an unsafe method. A longer practicing period was associated with more knowledge about the topic. The educational intervention significantly increased the knowledge and perception of the participants, regarding swaddling and its relation to DDH. More than 91% of the participants were able to identify the safe practice of swaddling after the educational intervention compared to 32.8% before it. This clearly means that first-line physicians encountering DDH patients (family medicine and pediatric residents) need educational sessions on this topic to deal with them safely and educate their parents about safe swaddling techniques.

Recommendations

Educational interventions regarding swaddling and its relation to DDH are of great value and can have a huge impact on prognosis of children and worsening of the hip dysplasia. Future studies with larger sample size are recommended. Practical intervention sessions could be more helpful and a subject for future research concerning DDH and other topics.

Ethical consideration

This study was approved by the Institutional Review Board of King Abdullah International Medical Research Center, National Guard Health Affairs, Jeddah, Saudi Arabia, with Memorandum Reference No. RYD-18-417780-130171, dated July 26, 2018. Participants were consented to participate in the study.

Acknowledgment

The authors want to thank the pediatric orthopedic consultants who reviewed the questionnaire and the lecture. The authors would also like to thank Nada Baatiah for her valuable contribution to data analysis. The authors would like to thank the participants.

Financial support and sponsorship

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflicts of interest

There are no conflicts of interest.

Authors' contributions

MNA has contributed with concepts, design, definition of intellectual content, manuscript preparation, editing, and review. AHK and MMA have contributed with literature search, data acquisition, manuscript preparation, editing, and review. SGQ and WHA have contributed with design, data acquisition, and manuscript review. All authors have critically reviewed and approved the final draft and are responsible for the content and similarity index of the manuscript.