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Parents are effective safety net in infant hip screening programme

A guide created by nurses is helping parents screen their infants for developmental dysplasia, preventing invasive surgery. Nurse consultant Angie Lee explains how parents can be a 'safety net'            

A guide created by nurses is helping parents screen their infants for developmental dysplasia, preventing invasive surgery. Nurse consultant Angie Lee explains how parents can be a 'safety net'

The importance of early identification of developmental dysplasia of the hip (DDH) is well documented, and there has been a national screening programme since the early 1960s. Until 2008, infants were checked at birth, then at 6 weeks and 8 months; the check at 8 months has since been discontinued.

However, DDH can present after 8 weeks and some children are not identified until walking age. Such late presentation can be costly in financial and emotional terms. The short-term management and long-term outcome for the child alters significantly if a diagnosis is made after the age of 10 months.

There is a higher

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A guide created by nurses is helping parents screen their infants for developmental dysplasia, preventing invasive surgery. Nurse consultant Angie Lee explains how parents can be a 'safety net' 


Nurse consultant Angie Lee inspects a child’s hips. Picture: Tim George

The importance of early identification of developmental dysplasia of the hip (DDH) is well documented, and there has been a national screening programme since the early 1960s. Until 2008, infants were checked at birth, then at 6 weeks and 8 months;  the check at 8 months has since been discontinued.

However, DDH can present after 8 weeks and some children are not identified until walking age.  Such late presentation can be costly in financial and emotional terms. The short-term management and long-term outcome for the child alters significantly if a diagnosis is made after the age of 10 months.

There is a higher risk of DDH for firstborns; parents may be less likely to recognise that symptoms are unusual.

A delayed diagnosis will mean open surgery is required. If DDH is detected early it  can be managed less invasively, through splintage or closed reduction of the hip and the application of a hip spica. 

Parent help

Our team was dealing with a lot of traumatised parents who had had to put their babies in harnesses.

Along with my colleague, clinical nurse specialist Nina Doherty, I observed that in the vast number of cases where a clinical sign was noted by a healthcare professional, the child’s parents had noticed it already, but did not recognise its significance.

We felt that parents could help to diagnose DDH by checking and screening their children’s hips early on, acting as a further safety net and reducing the later risk of joint surgery. So we developed a guide giving parents the knowledge they needed to identify and report issues with their child’s hips.

We discussed our idea with health visitors and GPs before launching the guide in our maternity unit, giving a copy to the parents of every newborn infant. We then extended it to large GP surgeries -  and now all local surgeries use the guide.  It is provided electronically and printed as needed, as part of the usual 6-8 week infant check.

Routine checks 

The screening guide for hip dislocation and hip dysplasia is distributed to parents in the catchment area of the Royal Berkshire NHS Foundation Trust in Reading, in addition to information provided in the child health book.

It highlights uncomplicated classic diagnostic signs that could be easily identified by parents or carers. The guide also highlights other risk factors that may not have been identified previously, such as a family history of hip dysplasia or breech position in pregnancy. 

It recommends that parents who identify a risk factor discuss it with their health visitor, who will refer to the GP where appropriate.

The guide's concept and its administration are simple, and that’s the key to its success. Consequently, there have been few challenges. The most difficult aspect was ensuring the guide was clear, and supported parents rather than alarming them. We found the best way to achieve this was to advise them to make hip checks part of routine nappy changes.

We have shared our findings and a template with a number of trusts, six of which now use the self-check guide. 

Ideally, we would like to see the guide adopted as a national resource. If parents are given information on how to make simple but diagnostically effective observations about their baby, it can help identify hip dysplasia at a stage where treatment is simpler. 

Using hospital data, we were able to identify infants who had been referred by their GP to an infant hip clinic due to parent concern. These parents were alerted through the identification of factors noted in the guide, and the patients were either directly referred to the clinic by a GP, or booked in through a hospital.

The anlaysis of the data showed parents had been effective in highlighting the risk factors in infants who who were found to require monitoring and/or treatment with splintage. Those infants who presented had not been identified at the neonatal or 6-week check, and without the parents' concern might have remained undetected, risking costly and invasive surgical management.

Screening opportunities

It is often said that parents are the best judge of their child’s health, and this scheme shows that to be true. With some guidance, parents have played a vital part in identifying a condition that if not treated early can lead to mobility issues, complex surgery and increased costs for an already struggling health service.

As for health professionals, they should be aware that detection of DDH can be as simple as spotting tight hips. Screening should not just be at fixed times, and all contact with a health visitor can be used as an opportunity.

What to check for during a nappy change:

  • Tightness when abducting the hip to clean the groin area.
  • ‘Clunks’ noted when moving the hip.
  • Bulky appearances of the fat fold in the upper thigh on one side. 
  • Asymmetrical creases/gluteal folds.

 


Angie Lee is nurse consultant, paediatric trauma and orthopaedics, at Royal Berkshire Hospital NHS Trust

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