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Ultrasound Examination for Infants Born Breech by Elective Cesarean Section With a Normal Hip Exam for Instability
Matthew J Pacana1, William L Hennrikus, Jennifer Slough
1Department of Orthopedics, Penn State College of Medicine, Hershey, PA.
Insights
Ultrasound screening for breech infants with normal exams is often unnecessary. A normal physical exam in breech infants may not require ultrasound (US) hip imaging, suggesting a more selective approach could be cost-effective.
Area of Science:
- Pediatric Orthopedics
- Neonatal Care
- Diagnostic Imaging
Background:
- The American Academy of Pediatrics (AAP) recommends ultrasound (US) hip screening for breech infants due to developmental dysplasia of the hip (DDH) risk.
- This recommendation applies to breech females and optionally to breech males, even with a normal physical examination.
- This study evaluates US findings and outcomes in breech infants presenting with a normal physical exam.
Purpose of the Study:
- To report on the results of hip ultrasounds (US) and subsequent follow-up for infants born in a breech presentation but with a normal physical examination.
- To assess the utility and outcomes of routine US screening in this specific infant population.
Main Methods:
- A retrospective review of electronic medical records for infants born breech between 2008 and 2011 at a single hospital.
- Data collected included infant demographics, birth details, US and x-ray results, clinical follow-up, and associated costs.
- Study design classified as Level III, a case-control investigation.
Main Results:
- Out of 237 breech infants with normal exams, 151 (64%) underwent precautionary hip US at approximately 7 weeks of age.
- The vast majority of ultrasounds (140/151, 93%) were normal, with no cases of dislocated hips identified.
- Only two infants showed laxity on US despite a normal physical exam and were treated with a Pavlik harness; others with subtle findings were monitored.
Conclusions:
- Current AAP guidelines for routine US screening of breech infants with normal physical exams may lead to unnecessary imaging.
- The study suggests that the decision for US screening should be individualized by the examining physician.
- A more cost-effective approach might involve skipping routine US and opting for an AP pelvis X-ray at 4 months if the physical exam is normal.
Introduction:
Because of the risk of developmental dysplasia of the hip in infants born breech-despite a normal physical exam-the American Academy of Pediatrics (AAP) guidelines recommend ultrasound (US) hip imaging at 6 weeks of age for breech females and optional imaging for breech males. The purpose of this study is to report US results and follow-up of infants born breech with a normal physical exam.
Methods:
The electronic medical record for children born at 1 hospital from 2008 to 2011 was reviewed. Data were analyzed for sex, birth weight, breech position, birth order, ethnicity, US and x-ray results, follow-up, and cost.
Results:
A total of 237 infants were born breech with a normal physical examination, all delivered by cesarean section. Of the infants, 55% were male and 45% female. About 151 breech infants (64%) with a normal Barlow and Ortolani exam had a precautionary hip US as recommended by the AAP performed at an average of 7 weeks of age. Eighty-six breech infants (35%) did not have an US and were followed clinically. Of the 151 infants that had an US, 140 (93%) were read as normal. None had a dislocated hip. Two patients had a normal physical exam but laxity on US. These 2 patients were the only infants treated in a Pavlik harness. A pediatric orthopaedic surgeon followed those with subtle US findings and no laxity until normal.
Conclusions:
The decision by the AAP to recommend US screening at 6 weeks of age for infants with a normal physical exam but breech position was based on an extensive literature review and expert opinion. Not all pediatricians are following the AAP guidelines. The decision to perform an US should be done on a case-by-case basis by the examining physician. A more practical, cost-effective strategy would be to skip the US if the physical exam is normal and simply obtain an AP pelvis x-ray at 4 months.
Level Of Evidence:
Level III-this is a case-control study investigating the outcomes of infants on data drawn from the electronic medical record.
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