Current Concept Review

Post-Natal Positioning through Babywearing:
What the Orthopaedic Surgeon Needs to Know
Sreetha Sidharthan, MD; Clare Kehoe, BS; Emily Dodwell, MD, MPH
Hospital for Special Surgery, New York, NY

Abstract: Babywearing is the practice of using a swathe of fabric or purpose-built carrier to hold an infant or
toddler close to the caregiver’s torso for multiple hours of the day. The child’s legs are often positioned in an “M”
shape, with hips and knees flexed and the hips abducted. There is increasing interest in the potential forbabywearing to assist in hip development, as the “M” position assumed in most carriers is similar to the position
achieved in harnesses/braces used in the treatment of developmental dysplasia of the hip (DDH). The association
between low incidence of DDH in babywearing populations suggests this may play a role in optimal hip
development. The purpose of this review is to present epidemiological, comparative, biomechanical, and imaging
studies that investigate the potential impact of babywearing on hip development while outlining other benefits suchas caretaker-infant responsiveness, attachment and bonding, and potential parental benefits such as decreased
crying, improved breastfeeding, caregiver multi-tasking, as well as potential complications and impact on gait andposture for those supporting an infant.
Key Concepts:• Babywearing involves using a swathe of fabric or purpose-built carrier to hold an infant or toddler close to the
caregiver’s torso for multiple hours of the day.
• Observational population studies demonstrate an association between babywearing and low incidence of DDH,
although genetic factors may also play a role.
• Babywearing in an “M” position with hips flexed and abducted mimics the position obtained in a Pavlik
harness and is theorized to promote hip development.
• Non-orthopaedic benefits of babywearing include stimulating caretaker-infant responsiveness, improving
attachment and bonding, promoting language development, decreasing infant crying, supporting breastfeeding,Introduction
Babywearing is the practice of using a swathe of fabricor purpose-built carrier to hold an infant or toddler close
to the caregiver’s torso, be it the front, back or side
(Figure 1). The child is close enough to feel the parent’s

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warmth, and hear their heartbeat, voice, and breathing.
Often, the infant’s legs are positioned in an “M” shape,with hips and knees flexed and the hips abducted.
Babywearing has been used for thousands of years in1

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some cultures, keeping the child close,
warm, calm, and allowing the caregiver’s
arms to be free for other work. Babywearing
involves carrying the baby for multiple hours
in the day by a parent or caregiver. It has
also been trending in recent years,
concurrent with parental interests in
attachment parenting (promoting theattachment of parent and infant not only by
maximal parental empathy andresponsiveness but also by continuous bodily
closeness and touch). Multiple carriers exist,
ranging from a simple piece of fabric that istied about the body to custom made carriers
with extensive fastening clips, cushions, andpockets. Families are using baby carriers,and orthopaedic surgeons need to know theorthopaedic and non-orthopaedic benefits
and potential complications of this form of
post-natal positioning.

Figure 1. Contemporary babywearing with the hips inthe “M” position

The etiology of DDH has not been fully elucidated but a
combination of genetic, hormonal, and mechanicalfactors may play a role in its development. Whileassociations with positive family history1 and female
sex2 may be due to genetic and hormonal factors, therisks associated with first borns,3 post-maturity birth,2
birth weight >4 kg,2,4 oligohydramnios,5 breech position4
in utero, and vaginal birth of breech babies all seemconsistent with abnormal peri-natal mechanics. Postnatal positioning has also been implicated. In particular,
swaddling and carrying practices that restrict hip andknee flexion are believed to increase the risk for DDH,6
while the “M” position is hypothesized to beprotective.7

hip position and anatomy during babywearing. The
secondary objective is to contrast these findings withother forms of post-natal hip positioning and theirassociations with hip development. Practical information
on non-orthopaedic benefits and potential complications
are also provided.

Association Between
Babywearing and DDH
A systematic review of 422 articles focusing on theepidemiology and demographics of DDH reported anincidence ranging from 0.06/1000 in Africa to 76.1/1000
in Native Americans.8 The significant variability inincidence within these racial and geographic groups
could be genetic but may also be influenced bycultural/ethnic post-natal positioning practices.

The primary objective of this review is to provide
comprehensive and up-to-date information on
babywearing and its impact on hip position anddevelopment, focusing on reports of DDH incidence in
cultures that practice babywearing as well as studies thatutilize imaging and biomechanical models to investigate
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A retrospective review of medical records between 1960
and 1975 reported an incidence of 0.005-0.009% of
DDH in Southern China, approximately 10 times lessthan that found in Caucasians.10 In Southern China,

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Table 1. Incidence of DDH by Infant Hip Position in Communities that Practice Babywearing
Authors

Study Population

Infant Hip Position

Incidence of DDH

Graham 20159

Malawi, November 2002September 2012

Back-carry infants for first 2-24
months in “M” hip position

0% (0/40683)

Hoaglund 198110

Southern China, 1968-1974

Back-carry infants in “M” hipposition (~50% of the population)

0.005-0.009%

Western Australia, 1981-1983

No direct measurement of babycarrying; Aboriginal infants are
0.37% (Aboriginal)
known to spend a large proportion
0.66% (non-Aboriginal)of their lives being carried with
their hips abducted by mother orother family member

Bantu people, 35 years

Traditional Bantu infant carrying
method, “M” hip position

Bower 198711

Roper 197614

0.0025% (1/40000)

was observational and speculative; there was no direct
measurement of babywearing in either group.

infants are traditionally held in the “Hong Kong”
position, on their mothers’ backs with hips flexed andabducted. Of those with hip dislocations, 41% werecarried in the “Hong Kong” position during the first 6
months of life compared to 49% in a control group
without DDH.10 During the first 2 years of life, 67%with DDH were held in the “Hong Kong” position
compared to 54% in the control group. There was nodifference in the number of hours of carrying between
the DDH and control groups. The authors concluded thatwhile the Hong Kong position could be beneficial, otherfactors such as genetics likely account for the rarity of
DDH in Southern China.

Inuit living around the North Pole commonly carry theirinfants in a hood (amauti) inside their parkas.12 This
practice abducts the infant’s hips by straddling themother’s back. Despite a genetic origin believed to be
similar to Native Americans who have a high incidenceof DDH, Inuit’s practice back-carrying are reported tohave a significantly lower incidence of DDH compared
to Caucasians.12,13 Of note, the original article that wascited documenting the incidence in this population could
not be obtained and checked for accuracy.13

A population-based study of children born in Western
Australia in 1981 to 1983 showed low rates of DDH
among infants born to Aboriginal mothers, with a rate of
3.7/1000 births in Aboriginal women compared to
6.6/1000 births in non-Aboriginal women.11 The authors
reported that Aboriginal infants spend a large proportionof their early lives being carried with their hips
abducted, either by their mother or members of theextended family. This cultural practice was hypothesized
to be the primary explanation for the differences in DDH
incidence. However, this relationship with babywearing

Several case series have commented on the low rates of
DDH among African cultures. Many Central andSouthern African populations traditionally back-carry
their infants. Roper et al.14 observed the rarity of DDH in
the Bantu population; in an estimated total of 40,000
patients seen over 35 years, there was only one reported
case of typical DDH. Due to the concurrent low
incidence of osteoarthritis in the Bantu adults, Roper andcolleagues believed genetics to be the greatest protective
factor in this population.14 Griffiths15 and van
Meerdervoort16 also presented cases of infants from

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Table 2. Incidence of DDH by Infant Hip Position in
Communities that Practice Swaddling and Use Cradleboards
Authors

Ishida 197732

Yamamuro 198433

42

Mellbin 1962
and Getz 195543

Salter 196840

Rabin 196541

Study Population

Infant Hip Position

Incidence of DDH

Kyoto City, Japan,
1971-1976

Tight swaddling was used before a
local campaign emphasized theimportance of preventing DDH.
In 1973, the educational program
included recommendations to avoid
prolonged extension of the hip andknee during early postnatal life.

5.3% in 1971–1973 versus
0.6% in 1974–1976

Japan, 1975

Tight swaddling was used before a1975 national Japanese campaign
with recommendations to avoid
prolonged extension of the hips andknees of infants during the early
postnatal period

3.5% before 1975
campaign versus less than
0.2% after 1975 campaign

Sámi, indigenous people of
Sápmi, the circumpolar areas
Europe (Sweden, Norway,
Finland, Kola Peninsula of
Russia)Cradleboard (gietka or komse)
hollowed from a log tightly
swaddling the lower extremities andallowed for minimal movement

2.5% (Mellbin)
4.0% (Getz)

Canadian Indian Tribes, 1963

Cradleboard (Tikonagan) with hips
in extension and adduction

12.3% (250/2032 live
births with cradleboarduse) vs. 1.2% (17/1347
live births without
cradleboard use)

Navajos born 1910-1930 and
1955-1961

Cradleboards were traditionallyused, with hips in extension andadduction. Diapers were introduced
before 1955 leading to a decreased
use of cradleboards

2.6% (1910-1930) versus
0.7% (1955-1961)

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Hip Biomechanics in Babywearing

Central and Southern Africa with DDH; however, theysuggested that back-carrying is an important
preventative measure in addition to genetic factors.

Recent studies on hip biomechanics suggest thatbabywearing is beneficial to hip development. A
computational model of a 1-year-old infant’s lower
extremities was constructed with modeling software toinvestigate the relationship between babywearing
positions and hip joint reaction forces.17 The model was
subjected to a range of hip flexions and abductions,while keeping external rotation fixed at 10 degrees. At
60 degrees of abduction and 120 degrees of flexion, theinfant right hip model produced a joint reaction force of
244 N, closest to the value reported to be beneficial for
healthy hip development and to the in vivo joint reaction
forces known to be present with a standing leg raise.17
The authors concluded that babywearing in the “M”
position with hips abducted and flexed is conducive tohealthy hip development.

To further investigate this hypothesis, a recent review
and retrospective cohort examined the diagnosis andmanagement of all infants seen at the Beit CURE
International Hospital in Malawi and its mobile clinics,
from November 2002 to September 2012. In a
population of 40,683 children, Graham et al.9 found nopatients with a diagnosis of DDH. The majority of
mothers in Malawi back-carry their infants for the first 2
to 24 months in the “M” position; the authors believed
this was primarily responsible for the low incidence of
DDH in Malawi.9
The low incidence of DDH in Africa (weighted average
0.06/1000) and the higher incidence of DDH among
Blacks in the United States (weighted average 0.40/1000)
is of interest.8 Between 1977 and 1982, the incidence of
DDH at a single institution in Louisiana was reported tobe 1.5/1000 among White children and 0.46/1000 among
Black children. A retrospective review at a single
institution in Indiana assessed the race distribution ofpatients with DDH to the race distribution of live births.12
They found that 4.0% of infants with DDH were Black,
while Black babies made up 11.7% of the live births. In
comparison, 80.8% of infants with DDH were White,while White babies made up 77.0% of live births. Overall,the incidence of DDH among Blacks in the United States
is higher than in Africa but lower than for Whites in the
United States. The authors believed the etiology of thesedifferences to be multifactorial and related to both genetic
heterogeneity (intermarriage of Blacks and Whites in the
United States) and to cultural baby transporting practices.
It was hypothesized that Black infants in North America
are more likely to be transported in baby strollers and carseats, rather than carried with the hips in an abducted
position.12

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In another study, lower-extremity muscle activity andhip position was measured in 20 healthy full-term infants
positioned in a Pavlik harness, a rigid hip abduction
brace, an inward-facing soft-structured baby carrier, astandard car seat, and held in arms.18,19 Surface EMG
was used to record muscle activity and marker-based
motion capture was used to track lower extremity
motion. The authors found no difference in hip flexion,
abduction, external rotation, and lower limb muscle
activity between the Pavlik harness and the baby
carrier.18,19 In contrast, having the infant in a car seat
resulted in approximately half of mean adductor andquadriceps muscle activity compared to the Pavlik
harness. The authors suggested that baby carriers could
play a crucial role in preventing DDH and/or
supplementing the treatment of DDH.18,19

Hip Ultrasound While Babywearing
Imaging has also been utilized to characterize hip
position while babywearing. Fontecha et al. used
ultrasound to assess whether three different baby-carriers
ranging from a loose semi-flexed “M” position (original
Baby Bjorn, BabyBjörn, Lanna, Sweden) to a moderate5

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“M” position (Baby Bjorn One, BabyBjörn, Lanna,
Sweden) to a more extreme hyper-flexed “M” position(Manduca, Wickelkinder GmbH, Marburg, Germany)
could influence the femoral head position (alpha angle
and % acetabular coverage) while in the carriers.20
Fifteen healthy infants aged 1.5 to 3.5 months underwent
bilateral on-table static diagnostic ultrasounds, and wereconfirmed to have Graf 1 (normal) hips. Right hip static
ultrasounds in the three baby-carriers were then obtained
and no difference in alpha angle, acetabular coverage, or
distance to the pubis was identified. The authors
concluded the infants’ hip maintains normal ultrasoundparameters when placed in the tested baby-carriers, withthe caveat that dysplastic hips may react differently. Itshould be noted that this was immediate testing, and theauthors did not investigate the effects of long-term
positioning in these carriers.

strong correlation between incidence of DDH and the
traditional use of swaddling for newborn infants.31
Public health campaigns educating patients on the
problems associated with swaddling in extension havebeen utilized to reduce the incidence of DDH. In
Kyoto, Japan, the incidence of DDH dropped from52.9/1000 in 1971–1973 to 5.6/1000 in 1974–1976
after an educational campaign against tight lower
extremity swaddling.32 The results from Kyoto led to anational Japanese education and prevention programwith similarly striking reductions in incidence of
DDH: from 3.5% before 1975 to less than 0.2%
following the national program.33 In Turkey, the odds
ratio of DDH in swaddled children compared to nonswaddled children has been reported to range from 2.9
to 6.134,35 and one study found that 98% of DDH
patients were swaddled compared to 87.1% of nonDDH patients (p<0.05).36 Despite efforts in Turkey toeducate parents about the risks of tight swaddling oflower extremities, one institution reported thatapproximately 75% continued to swaddle their babies
with legs extended.37 In Qatar, the implementation of
a community awareness program demonstrating theharmful effects of swaddling reduced the incidence ofultrasonographic dysplasia in children at high risk for
DDH from 20% to 6%.38

Other Post-Natal Positioning andEffects on Hip Development
In contrast to the “M” hip position, swaddling the legs
in an extended and adducted position is a risk factor forDDH (Table 2). DDH is rare in cultures where
swaddling is not used (Southern Chinese,10 African
Bantu,14 Thailand,21,22 North Korea,23 Sri Lanka24). In
contrast, communities with prevalent swaddlingpractices have higher incidences of DDH. In Saudi
Arabia, studies have demonstrated that swaddling is an
important factor in the etiology of DDH.25,26 The highincidence of DDH in Arabic peoples in Western
Galilee27 and Iraqi immigrants in Israel28 has been
attributed to this practice. In Hungary,29 swaddling was
believed to account for the high incidence (28.7/1000)of DDH which is much greater than incidences incountries of Western Europe and North America. A
retrospective cohort of 392 patients from a multicenter
database in the United States reported that babies witha history of swaddling have a 2x greater odds ofdeveloping late-presenting DDH compared to babies
who were not swaddled.30 A systematic review cited 11
additional epidemiologic studies that have shown a

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Ultrasound has also been used to evaluate hip joint
stability in infants who were swaddled by the traditionaltight method, safe blanket techniques, and commercial
devices.39 Harcke et al. compared 16 infants in a Pavlik
harness “treatment group” and 14 infants in a “nontreatment” group. They reported that tight swaddling
restricts range of motion in comparison with range of
motion allowed by safe (allowing hip flexion andabduction) swaddling methods.39 Safe swaddling does
not affect hip position; no stable or unstable hip
exhibited an immediate position change in comparison
with the initial sonogram. Lastly, they concluded thatsafe swaddling does not affect stable hips in a Pavlik
harness but can affect unstable hips.39

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Table 3: Reported Benefits and Risks of Babywearing
Benefits of Babywearing

Risks and Complications
Associated with BabywearingHip development (does not harm and may improve)Sudden infant death/asphyxia

Promotes caretaker-infant responsiveness, attachment,
and bonding

Falls/trauma

Baby-carrier purpura

Language development

Impact on caregiver energy expenditure and fatigue



Decreases infant cryingImpact on caregiver gait and posture, low back painImproves breastfeedingConvenient (allows for multi-tasking)Peninsula of Russia), the cradleboard (gietka or komse)
was believed to account for the high incidence (24.6 to40/1000) of DDH.43,44 The gietka is a cradle hollowedfrom a log and where the child is placed with tightswaddling of the lower extremities and allowing only forminimal movement. This cradle was practical in the
Sámi nomadic culture and lifestyle, allowing mothers tocarry the cradle across their shoulders, or onto areindeer’s pack saddle.43 As nomadic reindeer herding
culture and lifestyles have changed, the prevalence of
DDH in the Sámi has fallen.45,46

Cradleboards have been used in some cultures forkeeping children warm, still, away from hazards such as
open fires, and for transportation. Similar to traditionalswaddling, cradleboards typically restrict the legs in astatic extended position. In Canada, the Cree of northernQuebec used cradleboards until 1.5 years of age.40 This
population was noted to have a high burden of DDH. In
addition to the use of cradleboards, they were noted tohave significant multidirectional ligamentous laxity of
the hips, and femoral anteversion, with preferred W
sitting.40 Due to spontaneous normalization of somehips, the author hypothesized that much of the hip
dysplasia was due to hip adduction forces caused by thecradleboards, and the hips normalized once these forceswere discontinued. Similarly, a 10-fold increase in DDH(12.3% versus 1.2%) was reported in Canadian First
Nations people from Ontario who used the cradleboard
compared to those who did not.41 In the United States, a
study of approximately 2,300 Navajos42 found hip
dislocation to be more prevalent in adults than children(2.6% versus 0.7%, p<0.01). The authors postulated thatthe decreased dislocation in children was due to thetransition from exclusive use of the Navajo cradleboard
to the more frequent use of diapers, which had not
traditionally been used, and may have resulted incomparatively greater hip abduction.

Non-Orthopaedic Benefitsof Babywearing
In addition to the potential positive effects on hipdevelopment, babywearing has been shown to haveseveral other benefits (Table 3). Babywearing allows
frequent close physical contact between the caregiver andinfant, thereby promoting caregiver responsiveness,secure attachment, and bonding.47,48 Hours spent
babywearing has also been positively correlated withsecure attachment and negatively correlated withdisorganized attachment in a cohort of infants born toadolescent mothers, a population that is at particularlyhigh risk of developing insecure attachments andattachment disorders into adulthood.49,50 Babywearing
may also stimulate infant language development51 while
decreasing infant crying. In a randomized control trial,
infants exposed to increased carrying throughout the day

In Sámi, indigenous people of Sápmi, the circumpolar
areas of Europe (Sweden, Norway, Finland, Kola

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cried 43% less than infants in the control group at
6 weeks.52 Whilst babywearing, it is possible to position
the infant to facilitate breastfeeding. Baby wearing
increases the likelihood of responsive breastfeeding,feeding that is initiated in response to an infant’s early
hunger cues. Mothers who self-reported responsive
feeding were more likely to exclusively breastfeed for the
first 6 months and breastfeed more frequently throughout
the day.53 Practically speaking, babywearing also allows
caregivers to engage in day-to-day activities while staying
in close proximity to their infants. Caregivers can walkand multi-task, all while the infant remains close-by.
Additionally, babywearing is thought to have a positive
impact on maternal emotional well-being.

without the use of a sling has been shown to increase themechanical load placed on the knee and hip joints in thefrontal plane; however, babywearing with an anteriorlyworn carrier (with the infant facing the caregiver) was
shown to more closely resemble unloaded walking.64
Finally, infant carrying can also alter posture and thebiomechanical alignment of the mother’s trunk, which
may constitute a potential risk factor for development ofmusculoskeletal pain.69, 70 67–71,72 In caregivers withlumbar pain, the authors recommended lowering thewearing height of the baby carrier to pelvic level so thatthe external load could be transferred to the lower
extremities.72 (Table 3).

Conclusion

Risks and Complications of Babywearing

This review presents comprehensive evidence on theassociation between babywearing and improved hip
development, as well evidence demonstrating
diminished hip development (dysplasia) with alternate
post-natal positioning (swaddling and cradleboards).
Incidence of DDH is low amongst people who practice
babywearing, including Southern China, Aboriginal
people of Western Australia, Central and Southern
Africa, Malawi, and the Inuit of the circumpolar north.
Incidence of hip dysplasia is higher in American Indians
and Sámi populations where cradleboards havetraditionally been used. Granted, it is difficult to parseout the genetic versus environmental contributory
factors. Biomechanical studies demonstrate thatbabywearing in the “M” position provides a healthy hip
position, with similar positioning and muscle activationas achieved in a Pavlik harness. In addition to potentiallypromoting healthy hip development, babywearing
stimulates caretaker-infant responsiveness, improvesattachment and bonding, promotes language
development, decreases infant crying, supports
breastfeeding, and allows for caregiver multi-tasking.
Caregivers must be aware of the rare but important risksof babywearing including asphyxia, falls/trauma, andbaby-carrier purpura, all of which most commonly occur
due to improper use or positioning.

Suffocation has been reported while babies have been
positioned in carriers.54,55 Poor positioning in a sling or
carrier, such that the infant’s face is covered by fabricand the nose and mouth are pressed against the adult’s
body can increase the risk of asphyxiation.56 Parents
should be educated on proper babywearing, with
infant’s face and head visible at all times, nose andmouth free, and avoidance of the flexed chin-on-chest
position. Falls and trauma to infants in carriers havealso been reported.57,58,59 Modes of injury included:
cloth tearing, zippers coming undone or separating,hooks or fastening rings breaking, infants fallingthrough leg openings, straps breaking, stitchingunraveling, clasps or brackets breaking, and parents
falling while carrying their child.
Rumpel-Leede phenomenon associated with baby
carriers has also been described in the literature.60 Thisphenomenon is characterized by petechiae and purpura
localized to the lower extremities due to tourniquet-likeforces from the cinching of the baby carrier tightly
around the extremities. “Baby carrier purpura” is benign
and lesions spontaneously resolve in a few weeks.
Babywearing increases caloric output61 and can also alter
gait and walking speed.62,63 Carrying an infant in arms

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Acknowledgements

Dysplasia and its Sequelae. J Pediatr Orthop.
2015;35(1):57-61. doi:10.1097/BPO.0000000000000234

We would like to thank Bridget Jivanelli, MLIS andSarah Page for their assistance with the literature searchstrategy and procurement. We also thank Joanna
McNeilly of the Center for Babywearing Studies forproviding images of babywearing.

8. Loder RT, Skopelja EN. The Epidemiology and
Demographics of Hip Dysplasia. ISRN Orthop.
Published online 2011. doi:10.5402/2011/238607
9. Graham SM, Manara J, Chokotho L, Harrison WJ.
Back-carrying infants to prevent developmental hip
dysplasia and its sequelae: Is a new public healthinitiative needed? J Pediatr Orthop. Published online
2015. doi:10.1097/BPO.0000000000000234

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