Is screening for hip dysplasia in newborns after breech (breach) delivery often inadequate?

Inadequate Screening for Hip Dysplasia in Breech Deliveries

Yes, there is evidence of inadequate screening for developmental dysplasia of the hip (DDH) in newborns after breech delivery, with studies showing that up to 29% of breech infants with initially normal ultrasound screenings may later develop hip dysplasia requiring treatment. 1

Risk Factors for DDH in Breech Deliveries

Breech positioning is one of the most significant risk factors for DDH, carrying a 3.8-5.7 times increased risk compared to normal presentation 2, 3. This occurs because:

• Breech positioning causes extreme hip flexion with knee extension
• This leads to shortening and contracture of the iliopsoas muscle
• The positioning promotes femoral head dislocation 4, 2

Other important risk factors that often coexist with breech presentation include:

• Female gender (2.5-3.8 times increased risk)
• Positive family history (1.4 times increased risk)
• Left hip (three times more frequently affected) 4, 2

Current Screening Recommendations and Gaps

The American Academy of Pediatrics (AAP) and American College of Radiology (ACR) recommend:

• Clinical examination at every well-baby visit through 12 months 4, 2
• Ultrasound screening at 6 weeks for breech females (mandatory) and breech males (optional) 5
• Radiographic evaluation after 4-6 months of age 4, 2

However, significant gaps in screening practice exist:

1. Incomplete adherence to guidelines: Not all pediatricians follow the AAP guidelines for ultrasound screening of breech infants 5

2. Inadequate follow-up: Many breech infants with normal initial ultrasounds are discharged without further imaging, despite evidence showing late dysplasia can develop 1, 6

3. False reassurance from normal ultrasound: A normal ultrasound at 6 weeks does not rule out later development of dysplasia 1

Evidence of Inadequate Screening

Research demonstrates concerning rates of missed diagnoses:

• A study of 300 breech infants found that 29% of those with normal ultrasounds at 6 weeks later developed dysplasia requiring treatment at 4-6 months follow-up 1

• Another study found a 7.4% rate of radiographic dysplasia at 13 months in breech babies who had normal initial clinical and ultrasound screening 6

• Some practitioners skip ultrasound screening entirely, with one study showing 35% of breech infants with normal physical exams did not receive recommended ultrasound screening 5

Optimal Screening Protocol for Breech Deliveries

Based on the evidence, the optimal screening protocol should include:

1. Thorough newborn physical examination focusing on Barlow and Ortolani tests

2. Ultrasound screening at 6 weeks for all breech infants (mandatory for females, recommended for males)

3. Radiographic follow-up at 4-6 months even with normal ultrasound findings 1

4. Continued clinical monitoring through 12 months of age 4, 2

Common Pitfalls in DDH Screening for Breech Infants

1. Premature discharge from follow-up after normal ultrasound at 6 weeks

2. Reliance solely on clinical examination without imaging follow-up

3. Failure to recognize that the Ortolani and Barlow tests become less sensitive after 2-3 months due to increased tightening of the hip capsule 4

4. Missing subtle radiographic signs of dysplasia at follow-up (blunting of sourcil, abnormal acetabular index, asymmetry)

5. Inadequate communication between different healthcare providers about the need for continued monitoring

Consequences of Missed Diagnosis

Unrecognized and untreated DDH can lead to:

• Early degenerative joint disease
• Abnormal gait and decreased strength
• Up to one-third of all total hip arthroplasties in patients under 60 years 4, 2

The evidence clearly supports the need for comprehensive screening protocols and diligent follow-up for all breech infants, even those with normal initial examinations and ultrasounds.