Closed consultation

NIPE hip screening pathway changes for consultation

Published 16 May 2018

Managing ‘clicky hips’

The expert working group is proposing the addition of clear national guidance regarding the management of babies found to have ‘clicky hips’ and no follow-up or referral for ultrasound scan for ‘clicky hips’.

Current national guidance wording

Babies who have no predisposing risk factors and are found to have ‘clicky hips’ on physical examination should be managed and referred as per local arrangement and should not be included in NIPE screening programme key performance indicator (KPI) data.

Proposed new wording

A true ‘click’ in a hip that is stable on examination should not be treated as screen positive. Babies who have no national hip risk factors and are found to have ‘clicky hips’ on physical examination should not undergo hip ultrasound scan.

This is based on evidence that there is no clinical benefit in undertaking hip ultrasound in these babies. However, if the NIPE practitioner is unsure of their findings, the clinical examination should be repeated by an experienced clinician.

Consultation question 1

What is your view on the proposal to reinforce national guidance for managing ‘clicky hips’ by removing reference to local management?

Timing of hip ultrasound examination

The expert working group is proposing that there should be no differentiation in timeline for scan completion for babies requiring referral for ultrasound scan with screen positive findings or risk factors.

Current national guidance wording

Babies who are found to have dislocated or dislocatable hips, positive Ortolani or Barlow manoeuvre on newborn physical examination (screen positive) should be referred and undergo hip ultrasound within 2 weeks of age.

Babies who have risk factors but a normal newborn physical examination should be referred and undergo hip ultrasound within 6 weeks of age.

Screen positive following 6 to 8 week infant examination infants should be referred directly to orthopaedic surgeon for urgent expert opinion and be seen by 10 weeks of age.

Proposed new wording

All non-premature babies (screen positive and risk factor referrals) should have had an ultrasound scan and either be discharged or have entered the orthopaedic treatment pathway (seen by the specialist orthopaedic practitioner) by 6 weeks of age.

Consultation question 2

2a. What is your view of the proposal that babies who are screen positive on newborn examination or who have risk factors should be treated the same in terms of the timing of their ultrasound examination?

2b. What is your view of the proposal that all non-premature babies who are screen positive on newborn examination or who have risk factors should either be discharged or in the treatment pathway by the age of 6 weeks?

Timing of hip ultrasound examination

There is currently no national guidance on the upper or lower limit for timing of hip ultrasound examination.

The expert group is proposing that the hip ultrasound scan should not be undertaken earlier than 3 weeks of age because it may not give a reliable result at an earlier age.

This is based on level 5 evidence (expert orthopaedic surgeon / designated specialist practitioner and imaging professional’s opinion) of the optimum time to enter into orthopaedic treatment pathway (6 weeks) with no difference in treatment pathways after abnormal ultrasound scan whether referred due to screen positive hip examination or risk factors. In addition, level 1 evidence suggests that a large proportion of early abnormalities resolve and do not need treatment.

In the randomised control trial (‘Immediate Treatment Versus Sonographic Surveillance for Mild Hip Dysplasia in Newborns’ Pediatrics 125(1), 2010), excluding fixed dislocations, less than half of those that were initially abnormal required treatment after 6 weeks as they resolved spontaneously.

Please note that if a ‘one stop shop’ model is not in place, the ultrasound scan may need to be undertaken by 4 weeks of age at the latest to allow time for the referral to take place, the specialist orthopaedic practitioner appointment to be arranged and any treatment pathway to be started by 6 weeks of age.

Proposed new national guidance wording

Hip ultrasound scan should not be undertaken earlier than 3 weeks of age (because it may not give a reliable result at an earlier age).

Consultation question 3

What is your view of the proposal that babies should not have hip ultrasound scan undertaken earlier than 3 weeks of age?

Review of hip ultrasound result following positive newborn clinical examination

There is no specific current guidance regarding post ultrasound management.

Proposed new national guidance

Babies who have an abnormal newborn clinical examination but normal ultrasound should be discharged without the need to see an orthopaedic surgeon or specialist practitioner.

Consultation question 4

What is your view on the proposal that babies who have an abnormal newborn examination but normal ultrasound can be discharged without need to see orthopaedic surgeon / specialist practitioner?

Risk factors

There is no specific current guidance regarding post ultrasound management risk factors.

Proposed new national guidance

Babies who have hip risk factors identified but normal ultrasound should be discharged without the need to see an orthopaedic surgeon or specialist practitioner.

Consultation question 5

What is your view on the proposal that babies who have hip risk factors identified but normal ultrasound should be discharged without the need to see an orthopaedic surgeon or specialist practitioner?

Preterm babies – eligibility

Current national guidance

There is no current national guidance based on gestational age. All babies are eligible for newborn examination unless too unwell to be screened.

It is acknowledged that some babies in neonatal units may be too ill at the time the examination is due and the NIPE screen is not appropriate.

Proposed new national guidance wording

Where a baby is born prematurely (before 36 completed weeks) the clinical examination of the hips should be delayed until they reach 36 completed weeks gestation or are discharged, whichever is earlier. The ultrasound scan target date would be based on date of examination for these babies.

Consultation question 6

6a. What is your view on the proposal that there should be an allowance for prematurity in deciding at what age a baby’s hips should be examined?

6b. What is your view on the proposal that 36 completed weeks gestation is the correct age cut-off for eligibility for the NIPE hip examination?

Preterm babies risk factors

Risk factors are currently applied if there is breech presentation at birth at any gestation (including very preterm).

The expert working group is proposing that breech presentation / breech birth should only be considered a risk factor at or after 28 weeks gestation.

Current national guidance wording

Hip risk factors: breech presentation at or after 36 completed weeks of pregnancy, irrespective of presentation at delivery or mode of delivery, or breech presentation at delivery if this is earlier than 36 weeks.

Proposed new national guidance wording

Breech presentation at birth should only be considered a risk factor if this is at or after 28 weeks gestation.

Consultation question 7

What is your view on the proposal to only apply breech birth/presentation as a risk factor at or after 28 weeks gestation?

Clinical guidance on undertaking hip screening examination

The expert group is proposing the removal of reference to ventral suspension in the guidance.

Current national guidance wording

Observation:

• symmetry of skin folds in the groin when baby is in ventral suspension
• symmetry of leg length
• level of knees when hips and knees are both flexed
• if legs can be fully abducted

Consultation question 8

What is your view on the proposal to remove the above reference to ventral suspension?

Screen positive criteria

Current national guidance wording

Screen positive:

• difficulty in abducting the hip to 90 degrees
• difference in leg length
• knees at different levels when hips and knees are bilaterally flexed
• asymmetry of groin skins folds
• palpable ‘clunk’ when undertaking either the Ortolani or Barlow manoeuvres.

Consultation question 9

Do you think any changes need to be made to the screen positive criteria?