Developmental dysplasia of the hip: Risk markers, clinical screening and outcome

Background: Early detection, diagnosis and treatment of developmental dysplasia/dislocation of hip (DDH) are essential in preventing further disability and quality of life impairment in children. DDH risk markers and association between the age of clinical screening and outcome, were evaluated.
Methods: Clinical screening at ages birth, 6 and 13 weeks was performed in 8145 infants by pediatricians. Infants suspected for DDH were referred to the community hospital clinic for clinical evaluation by a pediatric orthopedic surgeon, imaging procedures and follow up. Demographic and perinatal characteristics of the children with suspected ( n = 77) and diagnosed DDH ( n = 51) were compared to matched controls ( n = 154).
Results: The rate of suspected DDH was 0.95% and that of diagnosed DDH was 0.63%. Female gender, firstborn child and breech presentation were significantly more frequent among cases versus controls (odds ratio [OR]: 4.3, 2.7, and 6 respectively; P < 0.05). The highest positive predictive value (95.5%) in physical evaluation was any evidence of a dislocatable hip. The proportion of DDH among infants referred from the newborn department was significantly higher (OR, 4.4). DDH diagnosis after 6 weeks of age was associated with a higher likelihood of subsequent surgery and motor disability. Untoward outcome was significantly associated with increasing age of referral both at ages of 6 and 13 weeks ( P < 0.05).
Conclusions: Children with DDH have certain specific demographic and perinatal risk markers. Clinical screening targeted towards early diagnosis may lessen the need for surgical intervention and the risk of disability or motor handicap.     

The contribution of developmental surveillance to early detection of cerebral palsy

Abstract A retrospective study of the contribution of examinations at Child Health Centres (CHC) for early detection of cerebral palsy (CP) was performed in 23 924 children, born in 1986-90, in the south-western part of Stockholm County. The outcome assessed was age of referral to a habilitation unit. A total of 66 children with CP (2.76/1000) were identified through the register at the responsible habilitation unit. The age of referral was, median 8 months, mean 12.4 months and range 0.5–54 months. A peak of referrals at 8–9 months was produced by CHC checks at 6 months of age. No other examination at the CHC resulted in a significant number of referrals. Nineteen records from CHC concerning moderate and severe cases were reviewed. Out of all examinations with aberrant findings only 11/20 resulted in referrals or further examinations. No child with moderate or severe CP was referred due to developmental screening test findings only.     

Screening for developmental dysplasia of the hip: Results of a 7-year follow-up study

BACKGROUND: Screening for developmental dysplasia of the hip (DDH) is widely recommended for all infants to prevent disability from late diagnosis of dislocation of the hip. The present study evaluates the results of screening for developmental dislocation of hip in a clinic in Turkey over the course of 7 years. METHODS: Hospital records of 5798 infants who were examined regularly until walking age at Gazi University well child clinics between January 1995 and December 2001 were reviewed. Infants with known risk factors for DDH such as breech presentation, family history of DDH or swaddling, and of infants with physical examination findings suggestive of DDH, were referred to orthopedic surgeons for diagnosis. Based on this final diagnosis, sensitivity, specificity, positive and negative predictive values of risk factors and physical examination findings were calculated. RESULTS: Of the 5798 infants, risk factors were detected in the medical history of 111 infants, and in 14 infants a musculoskeletal deformity was detected. In 606 infants the physical examination findings were suggestive of DDH. Ten patients were subsequently diagnosed with DDH. The sensitivity, specificity, positive predictive value and negative predictive values of having a risk factor for DDH in history were 10.0%, 98.1%, 0.9%, 99.8%, and having abnormal hip examination findings were 100.0%, 88.9%, 1.6% and 100.0%, respectively. CONCLUSIONS: A careful history and physical examination is the cornerstone of DDH screening. Serial hip examinations performed during health examination visits provide an opportunity to identify DDH cases. The sensitivity of risk factors in history and physical examination findings together is high enough to be accepted as a screening tool.     

Screening infants for hearing loss.

A computerised child health register was used to study the coverage, referral rate, and false positive rate of the eight month hearing distraction test in a cohort of 1990 births to residents of one district during an eight month period. Coverage by the age of 9 months was under 60% and varied with ethnic group and immunisation record. The true problem rate among those referred was 48%. None of the three children in the cohort who had a sensorineural hearing loss was picked up by screening, although it did identify children with conductive loss. The findings question the value of the distraction test as currently used, and underline the usefulness of computerisation, even if limited to child registration, in the evaluation of screening tests.     

发育性髋关节发育不良发病危险因素的研究进展

发育性髋关节发育不良(developmental dysplasia of the hip,DDH)是小儿骨科常见的下肢发育畸形,严重危害患者及其家长身心健康。影响DDH发病的因素可大致分为两部分,即遗传因素和环境因素。随着20世纪80年代高检出率髋关节超声的应用及国家二胎政策的开放,可预见未来一段时期内DDH患者数量将会增加。早诊断、早治疗是该病国内外公认的诊治原则,0~6月龄更是其治疗的黄金时期。但目前其发病的确切病因、发病机制尚不完全清楚,因此对婴儿进行早期筛查和及时干预,对早期诊治意义重大。笔者通过简要综述发育性髋关节发育不良发病危险因素的研究进展,以期为DDH早期筛查和诊断提供参考。     

Factors Associated With Early Intervention Referral and Evaluation: A Mixed Methods Analysis

ObjectiveTo identify parent, child, community, and health care provider characteristics associated with early intervention (EI) referral and multidisciplinary evaluation (MDE) by EI.MethodsWe conducted a mixed methods secondary analysis of data from a randomized controlled trial of a developmental screening program in 4 urban primary care practices. Children <30 months of age not currently enrolled in EI and their parents were included. Using logistic regression, we tested whether parent, child, community, and health care provider characteristics were associated with EI referral and MDE completion. We also conducted qualitative interviews with 9 pediatricians. Interviews were recorded, transcribed, and coded. We identified themes using modified grounded theory.ResultsOf 2083 participating children, 434 (21%) were identified with a developmental concern. A total of 253 children (58%) with a developmental concern were referred to EI. A total of 129 children (30%) received an MDE. Failure in 2 or more domains on developmental assessments was associated with EI referral (adjusted odds ratio [AOR] 3.15, 95% confidence interval [CI] 1.89–5.24) and completed MDE (AOR 2.16, 95% CI 1.19–3.93). Faxed referral to EI, as opposed to just giving families a phone number to call was associated with MDE completion (AOR 2.94, 95% CI 1.48–5.84). Pediatricians reported that office processes, family preference, and whether they thought parents understood the developmental screening tool influenced the EI referral process.ConclusionsIn an urban setting, one third of children with a developmental concern were not referred to EI, and two thirds of children with a developmental concern were not evaluated by EI. Our results suggest that practice-based strategies that more closely connect the medical home with EI such as electronic transmission of referrals (eg, faxing referrals) may improve completion rates of EI evaluation.     

When and by whom is concern first expressed for children with neuromotor problems?

OBJECTIVE: To describe when and by whom concern is first expressed for children referred to rehabilitation because of neuromotor problems. STUDY DESIGN AND SETTING: We conducted a survey of parents of 92 children (aged 0-6 years) who were on the waiting list for physical or occupational therapy services at rehabilitation centers in Montréal, Québec. We compared age of child at initial concern with who first expressed concern for children who were considered at risk due to their perinatal history of prematurity and those who were not born prematurely but were later diagnosed as having neuromotor problems. INTERVENTION: Parents were interviewed regarding their child's medical history and utilization of health care services. RESULTS: Parents were concerned later than physicians were regarding their child's development (mean difference, 8.2 months; 95% confidence interval [CI], 3.7-12.6 months). There was no significant difference in time of recognition of problems between the premature (10.2 months) and full-term (11.9 months) groups. Even after controlling for risk group, parental concern occurred later than physician concern (beta coefficient, 7.3; 95% CI, 2.5-12.2). The child's age at the time of initial concern was associated with the child's age at referral to rehabilitation (beta coefficient, 0.04; 95% CI, 0.01-0.06). CONCLUSIONS: Early recognition is important if a child is to benefit from early rehabilitation. It may be important to improve primary care screening of children for neuromotor problems and to increase parental awareness regarding normal motor development of their children. Prompt, simultaneous referral to medical evaluation and rehabilitation resources may decrease delays in rehabilitation.     

Services provided for preschool-aged children with suspected amblyopia

BACKGROUND: Little is known about the pattern and variation of care offered to preschool-aged children who have had an abnormal vision screening test. PURPOSE: To evaluate the variations in pediatric eye care services and availability of optometrists and ophthalmologists for preschool-aged patients, referral patterns, and barriers to providing care as perceived by eye care specialists. METHODS: A survey was mailed to 542 ophthalmologists and a random sample of 501 optometrists actively practicing in Michigan. RESULTS: The response rate was 65% (optometrists, 75%; ophthalmologists, 57%). More optometrists than ophthalmologists evaluated preschool-aged children (97% vs 79%; P < .001). Of these, most managed amblyopia (80% vs 77%; P = .372) and strabismus (89% vs 80%; P = .002) themselves. Fewer optometrists than ophthalmologists dilated eyes routinely during the first evaluation of a preschool-aged child (39% vs 93%; P < .001). The leading barrier to care for preschool-aged children reported by both optometrists and ophthalmologists was difficulty of the examination (25% vs 23%; P = .501). Optometrists reported that most of their patients were referred from community-based screening programs or by parent self-referral. Ophthalmologists reported that most of their preschool-aged patients were referred from primary care providers. CONCLUSIONS: There are different sources of referrals for optometrists and ophthalmologists. Although most eye care specialists treat amblyopia, the types of care offered by optometrists and ophthalmologists differ. Future studies should address the impact that these patterns have on outcomes and cost. The results of these studies should be shared with those responsible for screening.     

Unequal cardiac care for children with Down's syndrome

We reviewed the course of all 36 new patients with complete atrioventricular canal defect (CAVC) seen in a regional center from 1977 through 1982. Of this group of 36 patients, 28 had Down's syndrome. The eight children without Down's syndrome were all referred before 1 year of age. Surgical intervention was possible for each child. Of the 28 with Down's syndrome, 18 were referred before 1 year of age. Surgery intervention was possible in 17 (94%) of 18. Of the ten children with Down's syndrome referred after 1 year of age, surgical therapy was not possible in five because of pulmonary vascular obstructive disease (PVOD). Since CAVC is known to progress to PVOD at an early age, it is not surprising that half of those patients referred after 1 year of age had become inoperable because of this complication. We therefore concluded that in spite of the severity of CAVC some children with Down's syndrome and this heart condition are being denied standard cardiac care by the process of late referral.     

新生儿髋关节筛查资料分析

目的 探讨超声及临床髋关节检查在新生儿发育性髋关节发育不良（DDH）早期筛查中的意义.方法 采用前瞻性的方法,分两阶段对我院2011年8月1日至2013年3月29日出生的新生儿分别进行髋关节临床检查和超声检查,并对筛查结果进行分析.第一阶段为2011年8月1日至2013年1月29日,筛查出生3 ～ 10天的新生儿,了解我院新生儿DDH的患病率、DDH发生的高危因素,以及髋关节超声筛查和临床物理检查两者之间的吻合度等.第二阶段为2013年1月30日至2013年3月29日,对初诊与复诊的一致性及灵敏度和特异度进行调查.结果 第一阶段共筛查5193例新生儿,临床髋关节检查阳性616例（11.86％）,超声检查阳性556例（10.71％）.男、女超声阳性率分别为6.41％和15.78％.臀位及羊水量少的新生儿超声检查阳性率分别为10.55％和13.00％.男、女左、右髋超声分度比较和男、女左髋、右髋、双髋超声检查比较显示,女婴、臀位、羊水量少、右髋发生DDH的风险高,差异有统计学意义（P＜0.05）.第二阶段共筛选出符合超声初查和复查双条件的新生儿108例,初诊与复诊结果差异无统计学意义（P＞0.05）.ROC曲线下面积为0.675（95％ CI：0.183～1.000）.阳性预测值5.88％,阴性预测值98.90％.灵敏度及特异度的95％可信区间分别为50.00％ （95％ CI：1.26％ ～ 98.70％）,84.90％（95％ CI：76.60％ ～91.10％）.结论 超声进行新生儿髋关节DDH检查排除性诊断的意义大.运用髋关节临床及超声检查筛查新生儿DDH简便、安全,可早期发现可疑及异常病例,有利于门诊随访和早期干预.     

VISUAL DISORDERS IN 7-YEAR-OLD CHILDREN WITH AND WITHOUT PREVIOUS VISION SCREENING

ABSTRACT. An analysis of visual defects among 310 children referred from a vision screening of 2178 7-year-old children revealed a 50% frequency of significant eye defects among the referrals (7% of screened children). Of the screened children, one group (1530 children) had previous visual screening three years earlier. The other group (648 children) had no previous vision screening until the age of seven. A comparison between the two groups showed that the risk of finding a new significant eye disorder in a school entrant was more than 6 times greater for a child who was not examined in his preschool years, and the risk of finding an ambiyopic child was more than 10 times greater. The results do indicate the need for continuation of the present vision screening program of pre-school children.     

Visual disorders in 7-year-old children with and without previous vision screening

An analysis of visual defects among 310 children referred from a vision screening of 2 178 7-year-old children revealed a 50% frequency of significant eye defects among the referrals (7% of screened children). Of the screened children, one group (1 530 children) had previous visual screening three years earlier. The other group (648 children) had no previous vision screening until the age of seven. A comparison between the two groups showed that the risk of finding a new significant eye disorder in a school entrant was more than 6 times greater for a child who was not examined in his preschool years, and the risk of finding an amblyopic child was more than 10 times greater. The results do indicate the need for continuation of the present vision screening program of pre-school children.     

PHYSICAL EXAMINATION OF FOUR-YEAR-OLD CHILDREN

An unselected population of 2 447 four-year-old children in two communities in southern Sweden underwent a physical examination as part of a general health control. The general health was very good, mean weight was 17.2 kg, mean height 104.2 cm, mean Hb 12.7 g/ 100 ml. Anaemia (<11 g/100 ml) was detected in 20 children (0.9%). The mean blood pressure was 100/54. No child with persistently elevated blood pressure was found. Practically all serious handicaps were detected and already taken care of before the age of 4 years. Altogether 164 children (6.7%) were referred to specialists for newly detected deviations, and 144 (5.9%) were reported back. In 52 children, 2.2%, minimal brain dysfunction was diagnosed, half of them having other neurological disturbances besides clumsiness and hyperactivity. Five children (0.2%) had other neuro-muscular deviations, such as myo-pathia, hemiplegia, polyneuropathia. Including children already under professional care, 3% showed a significant degree of motor dysfunction. The cardiac findings were sparse; the prevalence of heart diseases at this age was about 6/1 000, all already detected. Phimosis was the cause of referral in 12 boys (0.9%). The prevalence of retentio testis was 0.9% at this age. The orthopaedic findings were also confined to minor disabilities with little influence on the child's development and well-being: 31 children (1.3%) had pronounced flat-feet with complaints from the feet or the legs. Another 5.2% were already under current care for flat-feet. From a questionnaire to the parents, some children could be designated as having neurological disorders, but the information was not selective enough to be of practical value as a screening instrument.     

Are we ready for universal school-based asthma screening?: An outcomes evaluation

BACKGROUND: Asthma is the most common chronic condition of childhood and a common reason for school absenteeism and use of school health services. Unrecognized but symptomatic childhood asthma may be adding to this school burden. OBJECTIVE: To evaluate the effectiveness of school-based asthma screening in identifying children at high risk for unrecognized asthma and facilitating new asthma diagnoses. METHODS: A controlled trial of school-based asthma screening using mailed parent surveys and medical record review to estimate outcomes of interest, specifically numbers of new asthma diagnoses. RESULTS: Most parents (80%, N = 5116) responded to the asthma screening survey. About 1 in 5 (19.4%, n = 994) parents reported that their children had previously been diagnosed with asthma or reactive airway disease. Letters recommending further evaluation for symptoms suggestive of possible asthma were sent to the parents of 388 children (7.6% of respondents) without known asthma. About half of parents returned postcards stating their intended reaction to the referral recommendation including 52 parents (13.4% of those referred) who thought no further action was necessary. Parent-initiated physician visits occurred in 45 (11.6%) of the 388 referred children. Overall, there were 57 (0.9%, 57/6401) new physician diagnoses of asthma among the screened children in the 6 months following screening: 16 in the referred group and 41 in the group not referred, including 20 in the group whose parents said they had known that their child had asthma, but had no medical record documentation of an asthma diagnosis. The incident asthma diagnosis rate was 1.2% (34/2906; P =.25) in a comparable control group that did not participate in screening. CONCLUSIONS: School-based asthma screening did not increase the incident rate of asthma diagnoses in this community. Parents participated in the screening process, but the percentage of referred children with follow-up medical visits was low.     

Identification and management of psychosocial problems by preventive child health care

OBJECTIVES: To assess the degree to which physicians and nurses working in preventive child health care (child health professionals [CHPs]) identify and manage psychosocial problems in children, and to determine its association with parent-reported behavioral and emotional problems, sociodemographic factors, and general and mental health history of children. DESIGN: The CHPs examined the child and interviewed parents and child during their routine health assessments. The parents completed the Child Behavior Checklist. SETTING: Nineteen child health care services across the Netherlands, serving nearly all school-aged children routinely. SUBJECTS: Of 4970 children aged 5 through 15 years, eligible for a routine health assessment, 4480 (90.1%) participated. MAIN OUTCOME MEASURES: Identification and management of psychosocial problems by CHPs. RESULTS: In 25% of all children, CHPs identified 1 or more psychosocial problems. One in 5 identified children were referred for further diagnosis and treatment. Identification of psychosocial problems and subsequent referral were 6 times more likely in children with serious parent-reported problem behavior according to the Child Behavior Checklist total problem score (8% of total sample). However, CHPs identified no psychosocial problems in 43% of these children and therefore undertook no action. Other child factors associated with CHPs' identification and referral were past treatment for psychosocial problems, life events, and academic problems. After adjustment for these, sociodemographic characteristics did not predict referral. CONCLUSIONS: The CHPs identify psychosocial problems in school-aged children frequently and undertake actions for most of them. Screening for psychosocial problems may be a promising option to reduce these problems, but accurate identification should be enhanced.     

Parental perception of weight and weight-related behaviour in 2- to 4-year-old children in the eastern part of the Netherlands

Parental perception of weight status and weight-related behaviour of their toddler was determined through a questionnaire survey in child health care centres (CHCs). Complete data on weight, length, sex and age were available for 635 of 682 children (93.1%). The median age of the children was 37.0 months (range 24–56 months). Of all 635 children, 76.5% were normal weight, 16.2% underweight and 7.2% overweight. Parents’ perception of the weight of their child compared with their peers was moderately related to the actual weight status. Of the parents of overweight and underweight children, 87.0% and 89.3%, respectively, were not concerned. Only the parents’ perception of the amount of food eaten by their child was significantly related to the weight status. The primary goal of CHC workers should be to create parental awareness in case of their child being overweight or underweight and to support them in accomplishing a healthy lifestyle. An erratum to this article can be found at     

Growth monitoring and diagnostic work-up of short stature: an international inventorization

BACKGROUND/AIMS: Growth monitoring is almost universally performed, but few data are available on which referral criteria and diagnostic work-up are used worldwide for children with short stature. METHODS: A short questionnaire, containing questions on auxological screening and on diagnostic criteria for short stature, was sent to all members of the European Society of Paediatric Endocrinology (ESPE) and to several pediatric endocrinologists outside Europe. RESULTS: Responses were received from 36 countries. In 27 (75%) a child health care program existed and in 14 (39%) there was a protocol for referral of children with growth retardation. Height for age was mostly used as a referral criterion. Sixteen countries (45%) reported having a guideline in secondary health care for diagnostic work-up. Although all countries agreed on having biochemical, radiological and/or genetic tests in the diagnostic work-up, there was a wide variety of recommended tests. CONCLUSIONS: There is little consensus on referral criteria and diagnostic work-up of children with short stature among industrialized countries. There is a need to establish evidence-based guidelines.     

Health of Australian children in out-of-home care: needs and carer recognition

Aim: Following research highlighting high levels of health need in New South Wales children in out‐of‐home care, this study aimed to quantify health need in a sample of Queensland children in care based on multidisciplinary child health assessments. The study also sought to examine the concordance between foster carers' health concerns for children for whom they are providing care and health need as established through referrals made as a result of health assessment. Methods: Children entering out‐of‐home care in the north Brisbane area within the previous month were referred for baseline child health assessment. Child health was assessed by paediatricians and clinical nurses utilising a pro forma‐based methodology. Analysis of initial carer concerns, health referrals and immunisation status in the sample was undertaken. Results: Of the 63 children assessed, 70% were found to require multiple referrals to various health services. The most frequently made referrals included paediatrician follow‐up (41% of children), counselling services (30%) and audiology (26%). Only 68% of the sample was found to be fully immunised. A discrepancy was noted between foster carers' child health concerns and level of referral need established during assessment. Conclusions: Queensland children in care have high health needs similar to those evidenced by children in care in other areas of Australia. Foster carers appear to underestimate the health needs of children in their care, demonstrating the necessity of multidisciplinary health screens and foster carer training in order to detect child health problems in this population.     

Frequency of digital rectal examination in children with chronic constipation

OBJECTIVES: To determine the frequency of performance of digital rectal examination by primary care practitioners on children with chronic constipation and to assess its effect on therapy. PATIENTS AND METHODS: One hundred twenty-eight children referred for chronic constipation to the Division of Pediatric Gastroenterology at Schneider Children's Hospital, New Hyde Park, NY, as well as their parents were questioned as to whether a digital rectal examination was ever performed prior to referral. All children underwent subsequent digital rectal examination by a pediatric gastroenterologist and recommended treatment regimens were compared with pretreatment regimens. The patients evaluated were a mix of private-insurance and Medicaid patients referred by pediatricians in the general community. RESULTS: Ninety-eight (77%) of the children referred for chronic constipation were found to have never had a digital rectal examination performed prior to referral. Fifty-three (54%) of these children were found to have fecal impaction. Only 19 (21%) were found to have minimal to no stool retention on digital examination. Enema therapy had been infrequently used to "clean out" the colon in referred children. Seventy percent were treated with multiple enema therapy following digital rectal examination. Organic causes of constipation were identified in 3 patients. CONCLUSIONS: Digital rectal examination is often not performed in the examination of the child with chronic constipation. The digital examination can help differentiate functional constipation from an organic process and may alter the course of therapy.     

Identification and management of psychosocial problems among toddlers in Dutch preventive child health care

OBJECTIVES: To assess the degree to which preventive child health professionals (CHPs) identify and manage psychosocial problems among preschool children in the general population and to determine the association with parent-reported behavioral and emotional problems, sociodemographic factors, and mental health history of children. DESIGN: The CHPs examined the child and interviewed the parents and child during their routine health assessments. The Child Behavior Checklist (CBCL) was completed by the parents. SETTING: Sixteen child health care services across the Netherlands that routinely provided well-child care to nearly all preschool children. PATIENTS: Of 2354 children aged 21 months to 4 years who were eligible for a routine health assessment, 2229 (94.7%) participated. MAIN OUTCOME MEASURES: Identification and management of psychosocial problems by CHPs. RESULTS: In 9.4% of all children, CHPs identified psychosocial problems. Two in 5 of the CHP-identified children were referred for additional diagnosis and treatment. Identification of psychosocial problems and subsequent referral were much more likely in children with a clinical CBCL total problems score than in others (identification: 29% vs 7%; odds ratio [95% confidence interval], 5.40 [3.45-8.47]; referral: 15% vs 3%; odds ratio [95% confidence interval], 6.50 [3.69-11.46]). CONCLUSIONS: The CHPs frequently identify psychosocial problems in preschool children, although less than among school-aged children, but they miss many cases of parent-reported problems as measured by a clinical CBCL score. This general population study shows substantial room for improvement in the early identification of psychosocial problems.