The Health Information and Quality Authority (HIQA) has published an evidence review of universal ultrasound screening for developmental dysplasia of the hip (DDH) in infants in Ireland. The review was requested by the National Screening Advisory Committee (NSAC).



DDH is a congenital disease where the ‘ball and socket’ joint of the hip does not properly form in babies and young children. DDH can affect one or both hips, and is more common in girls, firstborn children and babies born in the breech position. In mild cases, the symptoms (for example, pain) may resolve without treatment. However, for those with more severe DDH, early intervention is needed, as DDH can result in long-term pain, early osteoarthritis of the hip and back, and the need for hip replacements.



Routine health checks of infants look for physical signs of DDH, but these checks will not identify all cases. Examining ultrasound images of an infant’s hips shortly after birth can allow more children with DDH to be identified. Ultrasound screening for DDH can be broadly categorised as universal or selective. Universal ultrasound screening involves screening every infant. Selective screening involves screening only some infants, based on risk factors. In Ireland, there is no universal screening programme in place; instead, infants who are at greater risk of DDH may be selected for ultrasound examination.



As requested by NSAC, HIQA examined the evidence on the effectiveness of universal ultrasound screening compared to selective ultrasound screening for DDH. Few studies were identified that compared these two forms of screening, and the high quality evidence that was found came from a very small number of older studies, the applicability of which may be limited given changes in healthcare. Therefore the effectiveness of universal ultrasound screening, versus selective screening, remains unclear. The available evidence suggested that universal ultrasound screening could potentially lead to an increase in unnecessary treatment of children. However, it is not possible to determine the extent of this from the current evidence.



In 2017, recommendations were published for a selective ultrasound screening programme for DDH in Ireland. It is unclear the extent to which these recommendations have been applied across hospitals in Ireland. It is possible that a better understanding of current practice for the identification of DDH in infants would help with future implementation of the 2017 recommendations; this would be with a view to a formal screening programme with appropriate oversight, end-to-end care, quality assurance, and monitoring of outcomes.



Dr Máirín Ryan, Director of HTA and Deputy CEO of HIQA, said: “We found that the evidence relating to the effectiveness of universal compared to selected ultrasound screening for DDH was too limited to allow us to make a clear conclusion on the added value of universal screening. As a result, there is a lot of uncertainty around whether or not introducing a universal ultrasound screening would be beneficial.”



ENDS



Further information:

Marty Whelan, Head of Communications and Stakeholder Engagement 085 805 5202 / mwhelan@hiqa.ie



Notes to Editor:

• The Health Information and Quality Authority (HIQA) has today published the following document:
  • Evidence review of universal ultrasound screening for developmental dysplasia of the hip (DDH) in infants in Ireland
• In 2017, recommendations for a selective ultrasound screening programme in Ireland were published. The implementation pack is available here.
• The incidence of DDH varies internationally, in part due to different definitions of the condition. In Ireland, there is no national centralised database of cases of DDH so it is difficult to understand how common the condition is. Published estimates from one hospital indicated that the number of infants with DDH ranged from 7 cases per 1,000 infants to 31 cases per 1,000 infants over time. However, these estimates may not be nationally representative of practice or case numbers in the rest of Ireland.
• A review of ultrasound screening in 18 countries found that universal ultrasound screening for DDH was nationally implemented in two countries (Austria and Germany), while 14 have selective ultrasound screening, that is, screening based on clinical signs and or risk factors.
• Treatment of DDH aims to align the ‘ball’ of the hip joint properly in the hip socket to allow for normal continued hip development and to prevent impairment. In infants aged up to six months, DDH is most commonly treated using a splint called the Pavlik harness. In children aged six to 18 months, the ball of the hip is placed back into the hip socket and a plaster cast may be used to keep the legs and hips in position during healing. Avascular necrosis (loss of blood supply) of the femoral head is a potential risk of these treatments. In some cases (typically more advanced), surgery may be required to place the ball of the hip joint back into the socket.