Indian Journal of Orthopaedics (2020) 55:1410–1416
https://doi.org/10.1007/s43465-021-00513-3

REVIEW ARTICLE

Developmental Dysplasia of Hip and Post‑natal Positioning: Roleof Swaddling and Baby‑Wearing
Sandeep Vaidya1· Alaric Aroojis1· Rujuta Mehta1

Received: 12 August 2021 / Accepted: 2 September 2021 / Published online: 25 September 2021
© Indian Orthopaedics Association 2021

Abstract
Introduction Traditional swaddling, which implies restrictive immobilisation of the infant’s lower limbs with the hips inforced extension and adduction, has been shown to be a risk factor for Developmental Dysplasia of Hip (DDH).
Methods We reviewed the literature regarding the correlation between DDH and post-natal positioning by swaddling andbaby-wearing, to draw awareness of healthcare professionals towards an important risk factor for DDH that has often been
overlooked.
Results There is overwhelming evidence in the literature, by both experimental and clinical studies, that proves the close
association between improper post-natal positioning of the baby’s hips in extension-adduction and an increased incidenceof DDH. On the other hand, “hip safe” swaddling which allows unrestricted flexion-abduction movements of the infants’hips, and the use of baby-wearing devices which keep the lower limbs in an attitude of hip flexion-abduction and knee flexion, is optimal for hip development. Populations which practice these “hip-safe” techniques of infant immobilisation have alower incidence of DDH as compared to those which practice restrictive immobilisation. Furthermore, populations whichhave adopted “hip-safe” positioning have demonstrated a significant decrease in the incidence of DDH. Understanding thisassociation is vital, since this is a modifiable risk factor, rectification of which can decrease the incidence of DDH.
Conclusion Policy makers and governments must design educational campaigns tailored to their respective populations toincrease awareness regarding the benefits of “hip-safe” techniques of infant positioning, since this simple intervention has
the potential of decreasing the incidence of DDH.
Keywords Developmental dysplasia of hip · DDH · Swaddling · Baby-wearing · Hip-safe · Post-natal positioning

Introduction
Developmental dysplasia of hip (DDH) encompasses aspectrum of conditions including hip dysplasia, subluxation, dislocatable hip, reducible and irreducible dislocations.
First-born child, female sex, positive family history, oligohydramnios, twin pregnancy, uterine anomalies, post-maturity
birth, and birth weight > 4 kg are recognized risk factors for* Rujuta Mehta
rujutabos@gmail.com
Sandeep Vaidya
drsvvaidya@gmail.com
Alaric Aroojis
aaroojis@gmail.com
1

Department of Paediatric Orthopaedics, Bai Jerbai
Wadia Hospital for Children, Acharya Donde Marg,
Mumbai 40012, Maharashtra, India

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DDH [1–4]. Whereas female sex and family history indicate
the role of genetic and hormonal factors in the causationof DDH, all other risk factors implicate intra-uterine overcrowding and fetal positioning.
In addition to the above, post-natal positioning is now
recognized to be contributory to the causation of DDH [5].
Traditional infant swaddling methods or methods of baby
carrying, in which the infant’s lower limbs are forced into
hip extension-adduction and knee extension, are detrimental
and predispose to hip dysplasia [6–9]. On the other hand,“hip-safe” swaddling and carrying infants in baby-wearing
devices which permit unrestricted hip flexion-abduction andknee flexion, facilitates normal hip development [10–12].
Recognizing the association between post-natal positioning and the occurrence of DDH is especially important,because these are “modifiable” risk factors. Creating awareness amongst healthcare workers and caregivers regardingIndian Journal of Orthopaedics (2020) 55:1410–1416

1411“hip-safe” techniques of post-natal positioning can potentially decrease the incidence of DDH in society [13–15].
In this article, we review the literature on two widely
prevalent methods of post-natal positioning, namely, infant
swaddling and use of baby-wearing for infant carrying,in order to draw awareness of healthcare professionals
towards an important risk factor for DDH that has often
been overlooked.

no difference between the Pavlik harness and baby-wearing[21]. The authors concluded that baby-wearing plays a crucial role in preventing DDH. On the other hand, muscle
activity and hip position in the supine position in containerlike devices, such as car seats and cradle-boards, can negatively impact hip development and predispose to DDH.

Relevant Biomechanics of the Infant Hip

Swaddling is a practice followed across many cultures
through the millennia, in which the infant is wrapped in acloth [22]. This practice has been shown to have several
beneficial effects for the infant, including, better sleep patterns in the newborn by virtue of elimination of unnecessary movements, better thermoregulation, reduction in theincidence of sudden infant death syndrome (SIDS), fasterrecovery from painful stimuli and reduced crying [23, 24].
However, when done incorrectly, swaddling can be detrimental and cause overheating, increased respiratory infections when the chest is swaddled too tightly, sub-clinical
Vitamin D deficiency, and an increased incidence of SIDS
when swaddled infants are laid to sleep in the prone position [24]. From an orthopaedic viewpoint, the chief concern
is the association between the technique of swaddling andoccurrence of DDH [25–27].
Traditionally, the practice prevalent across many cultures
has been to swaddle the baby tightly, with the hips in tightextension and adduction [6, 13] (Fig. 1). This posturing
causes tightness in the iliopsoas, hamstrings and hip abductors, and, predisposes to hip dislocation. The tendency for
dislocation is even higher in children with pre-existing hip
dysplasia [28]. Cultures which practice “traditional” swaddling, with hips extended and adducted, have been shown tohave a higher incidence of DDH [9, 26, 29]. Consequently, ahistory of improper swaddling is included as one of the indications for referral for selective ultrasound screening before
6 months of age by the American Academy of Pediatrics(AAP) [5].
Recognition of the detrimental effects of traditional swaddling has led to evolution of the concept of “hip-safe” swaddling [30]. Hip-safe swaddling implies swaddling with theinfants’ lower limbs positioned in the so-called “froggy-leg
attitude”, with the hips in slight flexion and abduction andthe knees in slight flexion. Additionally, “hip-safe” swaddling should allow adequate space for the infants to movetheir hips and knees within the swaddle (Fig. 2). The International Hip Dysplasia Institute (IHDI) website describes indetail two different techniques of “hip-safe” swaddling: thediamond and square swaddle techniques [31].
Sleep sack swaddles are now commercially available.
They consist of body-binders at the top which can bewrapped around the chest and fastened with Velcro straps,

The attitude of the lower limbs of the foetus throughout
pregnancy is one of hip and knee flexion, except for the rare
frank breech presentation in which the hips are in flexion
and knees in extension. Due to this, all typically developing
infants have physiological flexion-external rotation contractures of the hips and flexion contractures of the knees atbirth. The hip flexion deformity ranges from 20° to 60° at
birth. These contractures gradually resolve spontaneously
and by the age of 4 months, the hips and knees can usually
be passively extended to neutral [16–18].
Attempts to forcibly correct the hip and knee physiological flexion contractures may predispose the infant’s hip to
DDH. Stretching of the contracted iliopsoas, hamstrings andhip abductors as they traverse the hip joint result in abnormal
joint reaction forces across the hip joint, which may resultin dysplasia. In an animal study performed on 85 growing
rabbits, Michelsson et al. [19] immobilised 1 or both knees
in extension. In almost all immobilised rabbits, subluxation,
dislocation or dysplasia of the hips, reminiscent of changesof DDH seen in humans, was observed. Rabbits in whom
the extension immobilisation was continued for a prolonged period developed permanent dislocation. However,changes in the hip failed to develop in a subgroup of animals
in whom the hamstrings were transected before extension
immobilisation of knees. These observations prompted theauthors to conclude that tension in hamstring group of muscles as they traverse the hip joints is responsible for dislocation or dysplasia of the hips [19].
In an experimental study conducted on a computationalmodel of a 1-year-old infant’s lower extremities, the joint
reaction forces across the hip joint in varying degrees offlexion and abduction were assessed [20]. At 60° abduction
and 120° flexion, the joint reaction forces measured 224 N,
which is closest to the value reported to be conducive tohealthy hip development. Since this position mimics the ‘M’position assumed by the infants’ hips in baby-wearing, theauthors concluded that baby-wearing is beneficial for normal
hip development.
Another study which employed surface EMG and markerbased motion analysis to track muscle activity and movements around the hip joint in various seating devices, foundSwaddling (“Traditional” Versus “Hip‑safe”)

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and, sleep sacks attached to the bottom which are roomy
enough to allow free flexion-abduction of the hips and flexion of the knees. They eliminate loose blankets in the crib,
since there is some concern that loose blankets may interferewith the baby's breathing and increase the risk of SIDS [32].

Baby‑Wearing
Baby-wearing is the practice of carrying an infant or toddler
by holding them close to the caregiver’s torso with the lower
limbs in an “M” position (hips flexed-abducted and knees
flexed), either at the front or back or side. This has beenachieved over centuries across several cultures by designing a simple swathe out of fabric, but now multiple designsof baby-carriers replete with fastening belts, cushions, andside-pockets are commercially available (Fig. 3).
A few disadvantages of baby-wearing, such as, increased
incidence of backache and an adverse impact on gait of thecare-givers have been noted [33]. Rare reports of infant
asphyxiation during baby-wearing, due to pressing of thenose and mouth against the caregiver’s body, have led torecommendations to keep the infant’s face visible, with thenose and mouth always free [34, 35]. The advantages ofbaby-wearing include improved bonding between the caregiver and infant, decreased crying, better breast-feeding,Fig. 1  Traditional hip swaddling with hips in extension-adduction
and knees in extension

Fig. 2  “Hip-safe” swaddling allows unrestricted hip flexion-abduction
and knee flexion

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Fig. 3  Infant placed in baby-wearing device with lower limbs in ‘M’position (hips flexed-abducted and knees flexed)Indian Journal of Orthopaedics (2020) 55:1410–1416

improved sleep patterns in the infant, and, freeing of handsof the caregiver for better multi-tasking [36–38].
From an orthopaedic viewpoint, baby-wearing is supposed to decrease the incidence of DDH. This is because, inbaby-wearing, the infant’s lower limbs are in the ‘M’ position with the knees in an attitude of flexion and the hips inflexion-abduction. For prevention of DDH, this is the safest
position and mimics the position of the hips during treatment
in a Pavlik harness or hip spica immobilization [21].

Scientific Evidence of the Association
Between DDH and Post‑natal Positioning
Epidemiological Evidence
The incidence of DDH shows wide geographic and culturalvariation. A meta-analysis of 422 studies published in 2011
reported an incidence ranging from 0.6/1000 in Africa to76.1/1000 in Native Americans [12]. Whereas part of thisvariation may be attributed to genetic factors, cultural differences in post-natal positioning is thought to be an important
contributory factor. Evidence that post-natal positioning may
be responsible for DDH comes in the form of a higher incidence of DDH seen in populations which practice restrictive
immobilization of the lower limbs of their infants. Czeizel
et al. [39] reported that out of 18,219 live births in Bekes
County, Hungary, between 1970 and 1972, 523 infants camefor treatment of developmental dysplasia of hip. Apart fromgenetic factors, the authors attributed this unusually highincidence of 28.7 per 1000 live births to unhealthy restrictive
swaddling practices then prevalent in the studied population.
Canadian Native Americans traditionally used cradle boards
to immobilize and carry their infants. A radiographic study
has shown that in cradle boards, hip abduction is restricted
to 15° with no further abduction possible [6]. Salter, in
1968, studied the incidence of DDH in Canadian infants
and reported a ten-fold higher incidence in infants in whom
cradle-board immobilization was used (250/2032 live births,
12.3%), as against an incidence of 17/1347 live births (1.2%)
in infants who were never immobilized on the cradle-board[27].
On the other hand, a lower incidence of DDH is seen in
populations which practise hip-safe post-natal positioning.
Graham et al. performed a retrospective review of 40,683
children under the age of 16 years treated at Beit CURE
International Hospital, Malawi, and reported a 0% incidenceof DDH [13]. The authors proposed that the low incidenceof DDH in the local population was the result of the practiceof back-carrying their infants in a position that is similar
to that of the Pavlik harness [1]. The lower incidence of
DDH in South China, among African Bantus, Thailand, Sri
Lanka and North Korea is believed to be due the practice of1413

not swaddling their infants in the hip-extended position [10,11]. The Inuit/Eskimos carry their infants in hooded jackets(Amauti), with the infants’ hips abducted around their backs.
A study of this population detected a low incidence of DDH(1.9 per 1000 live birth) [12].
A significant decrease in the incidence of DDH has been
observed in populations which have adopted “hip-safe” techniques of infant positioning. In a study conducted on 2300
Navajo subjects, Rabin et al. noted a higher prevalence of
DDH in the adult population as compared to the paediatricpopulation. This change in prevalence of DDH was attributed to decreased use of the Navajo cradle board, in which
the infant’s hips were swaddled in extension and adduction,
and wider usage of diapers which promoted hip abduction
over the preceding 30–50 years [6].
A few studies, however, have failed to conclusively
establish the protective effect of baby positioning against
the occurrence of DDH. Hoaglund et al. studied the epidemiology of DDH in South China between 1960 and 1975,
and reported an incidence of 0.005–0.009%, which wasmarkedly lower than the incidence reported in Caucasians.
Prima facie, this decreased incidence may appear to be dueto the South Chinese tradition of carrying their infants inthe “Hong Kong position” with hips flexed and abducted.
However, when a sub-group analysis was performed within
this population, DDH was found to occur with similar frequency in infants who were carried in “Hong Kong position”
as in those who were not carried in that position [40]. In
another study on 427 infants of the Cree-Ojabwa tribe withuntreated DDH, 113 including 21 with frank dislocation,
showed spontaneous improvement over a period of 1 year,
even though the infants were continued to be swaddled on
cradle-boards during this period [7]. A study from Saudi
Arabia, in which 50 children with established diagnosis of
DDH were compared with 414 children with normal hips,
demonstrated no significant statistical difference between
the incidence of restrictive swaddling in the two groups.
Nevertheless, the authors expressed the possibility of swaddling affecting the outcomes of affected hips unfavourably
and, therefore, recommended against the continuation of thispractice [8].

Ultrasound Evidence
Ultrasound studies have followed normal hip developmentfrom the late stages of foetal development to the post-natal
period [41]. The results of these studies suggest that, contrary to popular belief, the normally developing hip may
be well-formed prior to birth. However, there might be atransient decrease of α-angle (acetabular roof angle) in theearly post-natal period. Gardiner et al. proposed that greater
mechanical stresses placed on the new-born hips due toforceful post-natal positioning in extension and adduction

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contribute to the deterioration from mature hips in the third
trimester to immature hips in the early post-natal period. In
some cases, the deterioration may be severe enough to resultin dysplastic hips [41].
Harcke et al. [42] used ultrasonography to study the
impact of swaddling on hips of 30 infants with suspectedor documented DDH. When tight swaddling with a blanket
was applied, one unstable hip completely dislocated. On theother hand, no change of hip stability was observed whensafe swaddling techniques were employed. The authors alsostudied hip position following application of commerciallyavailable swaddling products which appeared to mildly
restrict leg motion. These products had an adverse effecton positions of three hips which were already under treatment with Pavlik harness. On the basis of these findings,
the authors concluded that safe swaddling techniques whichallow unrestricted hip motion should always be preferredover any form of swaddling which restricts hip motion [42].

Public Awareness
Awareness regarding the importance of hip-safe swaddlingis unfortunately lacking. In a survey conducted by the seniorauthors (AA and RM) at our institute, which is a tertiarycare, urban based paediatric hospital catering to a high volume patient base, only 3/45 (6.6%) paediatricians, 4/100(4%) caregivers and 0/219 (0%) nurses were aware of “hipsafe swaddling” [43]. This study revealed the need to train
nurses and paediatricians in hip-safe swaddling.
Campaigns aimed at creating public awareness regarding
the benefits of “hip-safe” infant positioning have the potential to decrease the incidence of DDH. An educational campaign against the harmful effects of restrictive lower limb
immobilisation was conducted in Kyoto, Japan, in 1973. A
study conducted in 1976 showed that the incidence of DDH
in Kyoto, after implementation of the programme, dropped
from 52.9/1000 in 1971–1973 to 5.6/1000 in 1974–1976[15]. Following its success, the programme was then implemented nation-wide which resulted in a decrease in theincidence of DDH in Japan from 3.5% before 1975 to lessthan 0.2% in 1984 [14]. Similar encouraging results werereported from Qatar, where implementation of a community
programme creating awareness regarding the harmful effects
of restrictive swaddling led to a drop in diagnosis rate of
DDH in selective ultrasound screening from 20 to 6% [16].

Conclusion
Of the various risk factors known to be responsible for thecausation of DDH, post-natal positioning is the only modifiable factor. It follows, therefore, that creating awareness13

Indian Journal of Orthopaedics (2020) 55:1410–1416

regarding the “hip-safe” positions for infant immobilisation
can decrease the incidence of DDH. Evidence that “hipsafe” positioning is beneficial comes in the form of a higher
incidence of DDH in populations which practice restrictive
lower limb immobilisation and a lower incidence in cultures
which have adopted “hip-safe” positioning. Additionally,
populations which have shifted to “hip-safe” positioning
following public awareness campaigns have demonstrated
significant decrease in the incidence of DDH. It is time forprofessional organizations in India, such as, the Indian Academy of Pediatrics (IAP), Paediatric Orthopaedic Society ofIndia (POSI), Federation of Obstetric and GynaecologicalSocieties of India (FOGSI) and others, to come together anddevelop a position statement and public awareness campaign
on the importance of ‘hip-safe’ swaddling and proper techniques of baby-carrying in order the reduce the incidence of
DDH in our country.
Author contributions SV conceptualised and designed the study. The
first draft of the manuscript was written and compiled by SV and editedby AA & RM. All authors commented on previous versions of themanuscript. All authors read and approved the final manuscript.
Funding Nil.

Declarations
Conflicts of interest The authors declare that they have no conflict ofinterest, financial or otherwise, relevant to this study.
Ethics approval and consent to participate No ethics approval was
required for this study since it is a narrative review of existing literature.
Informed consent For this type of study informed consent is not
required.

References
1. de Hundt, M., Vlemmix, F., Bais, J. M., Hutton, E. K., de Groot,
C. J., Mol, B. W., & Kok, M. (2012). Risk factors for developmental dysplasia of the hip: A meta-analysis. European Journal of
Obstetrics, Gynecology, and Reproductive Biology, 165(1), 8–17.
2. Fox, A. E., & Paton, R. W. (2010). The relationship between
mode of delivery and developmental dysplasia of the hip in breech
infants: A four-year prospective cohort study. The Journal of Boneand Joint Surgery (Br), 92(12), 1695–1699.
3. Hinderaker, T., Daltveit, A. K., Irgens, L. M., Udén, A., & Reikerås, O. (1994). The impact of intra-uterine factors on neonatal
hip instability: An analysis of 1,059,479 children in Norway. Acta
Orthopaedica Scandinavica, 65(3), 239–242.
4. Chan, A., McCaul, K. A., Cundy, P. J., Haan, E. A., & ByronScott, R. (1997). Perinatal risk factors for developmental dysplasiaof the hip. Archives of Disease in Childhood. Fetal and Neonatal
Edition, 76(2), F94–F100.

Indian Journal of Orthopaedics (2020) 55:1410–1416
5. Shaw, B. A., & Segal, L. S. (2016). Section on orthopaedics:
Evaluation and referral for developmental dysplasia of the hipin infants. Pediatrics, 138(6), e20163107.
6. Rabin, D. L., Barnett, C. R., Arnold, W. D., Freiberger, R. H.,& Brooks, G. (1965). Untreated congenital hip disease. A studyof the epidemiology, Natural history, and social aspects of thedisease in a Navajo population. American Journal of Public
Health and The Nation’s Health, 55(2), 1–44.
7. Walker, J. M. (1977). Congenital hip disease in a Cree-Ojibwa
population: A retrospective study. Canadian Medical Association Journal, 116(5), 501–504.
8. Abd el-Kader, A., & Shaheen, M. (1989). Mehad: The Saudi
tradition of infant wrapping as a possible aetiological factor incongenital dislocation of the hip. Journal of the Royal Collegeof Surgeons of Edinburgh, 34(2), 85–87.
9. Kutlu, A., Memik, R., Mutlu, M., Kutlu, R., & Arslan, A.
(1992). Congenital dislocation of the hip and its relation to
swaddling used in Turkey. Journal of Pediatric Orthopedics,
12(5), 598–602.
10. Corea, J. R. (1992). Is congenital dislocation of the hip rare in
Sri Lanka? The Ceylon Medical Journal, 37(3), 96.
11. Loder, R. T., & Skopelja, E. N. (2011). The epidemiology
and demographics of hip dysplasia. ISRN Orthopedics, 2011,
238607.
12. Graham, S. M., Manara, J., Chokotho, L., & Harrison, W. J.
(2014). Back-carrying infants to prevent developmental hip dysplasia and its sequelae: Is a new public health initiative needed?
Journal of Pediatric Orthopedics, 35(1), 57–61.
13. Yamamuro, T., & Ishida, K. (1984). Recent advances in theprevention, early diagnosis, and treatment of congenital dislocation of the hip in Japan. Clinical Orthopaedics and Related
Research, 184, 34–40.
14. Ishida, K. (1977). Prevention of the development of the typical dislocation of the hip. Clinical Orthopaedics and Related
Research, 126, 167–169.
15. Chaarani, M. W., Al Mahmeid, M. S., & Salman, A. M. (2002).
Developmental Dysplasia of the Hip before and after increasing community awareness of the harmful effects of swaddling.
Qatar Medical Journal Published Online. https://​doi.​org/​10.​5339/​qmj.​2002.1.​17
16. Forero, N., Okamura, L. A., & Larson, M. A. (1989). Normal
ranges of hip motion in neonates. Journal of Pediatric Orthopedics, 9(4), 391–395.
17. Haas, S. S., Epps, C. H., Jr., & Adams, J. P. (1973). Normal
ranges of hip motion in the newborn. Clinical Orthopaedics
and Related Research, 91, 114–118.
18. Hoffer, M. M. (1980). Joint motion limitation in newborns.
Clinical Orthopaedics and Related Research, 148, 94–96.
19. Michelsson, J. E., & Langenskiöld, A. (1972). Dislocation or
subluxation of the hip: Regular sequels of immobilization of theknee in extension of young rabbits. The Journal of Bone andJoint Surgery American, 54(6), 1177–1186.
20. Girish, G. (2017). Computational investigation of the biomechanics of babywearing in regards to developmental dysplasiaof the hip. ProQuest Diss Theses. Published online 2017, p. 68.
https://​commo​ns.​erau.​edu/​cgi/​viewc​ontent.​cgi?​artic​le=​1364&​
conte​xt=​edt.
21. Siddicky, S. F., Wang, J., Rabenhorst, B., Buchele, L., & Mannen, E. M. (2021). Exploring infant hip position and muscle
activity in common baby gear and orthopedic devices. Journalof Orthopaedic Research, 39, 941–949.
22. Lipton, E. L., Steinschneider, A., & Richmond, J. B. (1965).
Swaddling, a child care practice: historical, cultural and experimental observations. Pediatrics, 35, 519–567.
23. van Sleuwen, B. E., Engelberts, A. C., Boere-Boonekamp,
M. M., Kuis, W., Schulpen, T. W., & L’Hoir, M. P. (2007).

1415

24.

25.

26.
27.

28.

29.
30.
31.

32.
33.
34.

35.
36.

37.
38.
39.
40.
41.

Swaddling: A systematic review. Pediatrics, 120(4),e1097–e1106.
Gerard, C. M., Harris, K. A., & Thach, B. T. (2002). Physiologic
studies on swaddling: An ancient child care practice, which
may promote the supine position for infant sleep. The Journalof Pediatrics, 141(3), 398–403.
Record, R. G., & Edwards, J. H. (1958). Environmental influences related to the aetiology of congenital dislocation of thehip. British Journal of Preventive & Social Medicine, 12(1),
8–22.
Salter, R. B. (1968). Etiology, pathogenesis and possible prevention of congenital dislocation of the hip. Canadian Medical
Association Journal, 98(19), 933–945.
Wang, E., Liu, T., Li, J., Edmonds, E. W., Zhao, Q., Zhang,
L., Zhao, X., & Wang, K. (2012). Does swaddling influence
developmental dysplasia of the hip? An experimental study ofthe traditional straight-leg swaddling model in neonatal rats.
The Journal of Bone and Joint Surgery American, 94(12),1071–1077.
Suzuki, S., & Yamamuro, T. (1993). The mechanical cause ofcongenital dislocation of the hip joint: Dynamic ultrasoundstudy of 5 cases. Acta Orthopaedica Scandinavica, 64(3),303–304.
Mahan, S. T., & Kasser, J. R. (2008). Does swaddling influence developmental dysplasia of the hip? Pediatrics, 121(1),177–178.
Karp, H. N. (2008). Safe swaddling and healthy hips: Don’t toss
the baby out with the bathwater. Pediatrics, 121(5), 1075–1077.
International Hip Dysplasia Institute. (2021). Understanding
hip dysplasia. Infant and child: Healthy hip swaddling. https://​hipdy​splas​ia.​org/​infant-​child/​hip-​healt​hy-​swadd​ling/. Accessed
10 Aug 2021.
Sobaihi, M., Banjari, M. A., & Alahmadi, T. S. (2020). Implementation of safe sleep practice recommendations for infants ininpatient wards. Cureus, 12(10), e11155.
Williams, L., Standifird, T., & Madsen, M. (2019). Effects ofinfant transportation on lower extremity joint moments: Baby
carrier versus carrying in-arms. Gait & Posture, 70, 168–174.
Bergounioux, J., Madre, C., Crucis-Armengaud, A., BriandHuchet, E., Michard-Lenoir, A. P., Patural, H., Dauger, S.,
Renolleau, S., Teychéne, A. M., Henry, S., Biarent, D., Robin,C., Werner, E., & Rambaud, C. (2015). Sudden deaths in adultworn baby carriers: 19 cases. European Journal of Pediatrics,
174(12), 1665–1670.
Batra, E. K., Midgett, J. D., & Moon, R. Y. (2015). Hazards
associated with sitting and carrying devices for children two
years and younger. The Journal of Pediatrics, 167(1), 183–187.
Anisfeld, E., Casper, V., Nozyce, M., & Cunningham, N. (1990).
Does infant carrying promote attachment? An experimental
study of the effects of increased physical contact on the development of attachment. Child Development, 61(5), 1617–1627.
Little, E. E., Legare, C. H., & Carver, L. J. (2019). Culture,carrying, and communication: Beliefs and behavior associatedwith babywearing. Infant Behavior & Development, 57, 101320.
Hunziker, U. A., & Barr, R. G. (1986). Increased carrying
reduces infant crying: A randomized controlled trial. Pediatrics,
77(5), 641–648.
Czeizel, A., Szentpétery, J., & Kellermann, M. (1974). Incidence of congenital dislocation of the hip in Hungary. British
Journal of Preventive & Social Medicine, 28(4), 265–267.
Hoaglund, F. T., Kalamchi, A., Poon, R., Chow, S. P., & Yau, A.
C. (1981). Congenital hip dislocation and dysplasia in SouthernChinese. International Orthopaedics, 4(4), 243–246.
Gardiner, H., Clarke, N. M. P., & Dunn, P. M. (1990). A sonographic study of the morphology of the preterm neonatal hip.
Journal of Pediatric Orthopedics, 10(5), 633–637.

13

1416
42. Harcke, H. T., Karatas, A. F., Cummings, S., & Bowen, J. R.
(2016). Sonographic assessment of hip swaddling techniques in
infants with and without DDH. Journal of Pediatric Orthopedics, 36(3), 232–238.
43. Pinto, D. A., Aroojis, A., & Mehta, R. (2020). Swaddling practices in an indian institution: Are they hip-safe? A survey of
paediatricians, nurses and caregivers. Indian Journal of Orthopaedics, 55(1), 147–157.

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