Monday, December 22, 2014

Screening for developmental dysplasia of the hip: when organizations disagree

- Jennifer Middleton, MD, MPH

If your medical education was anything like mine, chances are you learned to incorporate hip testing into every newborn exam, but the evidence base to support that common practice is uncertain. "Common Questions About Developmental Dysplasia of the Hip," an article in the December 15 issue of AFP, includes a discussion about the varied hip dysplasia screening recommendations by the United States Preventive Service Task Force (USPSTF), the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP), and the Pediatric Orthopaedic Society of North America (POSNA).

The USPSTF gives screening for developmental dysplasia of the hip (DDH) an "I" recommendation:
There is poor evidence (poor quality studies) of the effectiveness of both surgical and non-surgical interventions; avascular necrosis of the hip (AVN) is reported in 0% to 60% of children who are treated for DDH. Thus, the USPSTF was unable to assess the balance of benefits and harms of screening for DDH but was concerned about the potential harms associated with treatment of infants identified by routine screening.
The AAFP concurs with the USPSTF:
The AAFP concludes that the evidence is insufficient to recommend routine screening for developmental dysplasia of the hip in infants as a means to prevent adverse outcomes. 
Although the AAP agrees that the quality of available studies was low, they came to a different conclusion:
There were few controlled trials and few studies of the follow-up of infants for whom the results of newborn examinations were negative. When the evidence was poor or lacking entirely, extensive discussions among members of the committee and the expert opinion of outside consultants were used to arrive at a consensus....All newborns are to be screened by physical examination. [emphasis in original]
And, the POSNA aligns with the AAP:
The Pediatric Orthopaedic Society of North America recommends that all health care providers who are involved in the care of infants continue to follow the clinical practice guideline for early detection of developmental hip dysplasia (DDH) outlined by the American Academy of Pediatrics. 
When medical organizations' recommendations differ, family physicians can be left wondering who to follow and what to do. Considering each organization's goals and process for developing recommendations can help. The USPSTF and AAFP typically will not make a recommendation in the absence of high-quality studies, therefore setting the bar high to receive anything but an "I" (insufficient evidence) recommendation. The AAP and Pediatric Orthopaedic Society, however, are more comfortable providing a recommendation based on expert opinion and lower-quality studies.

We strive, in this age of evidence based medicine (EBM), to base our clinical decisions on high-quality evidence. When high-quality evidence is lacking, however, we must rely on what we do have to make decisions; in this case, on expert opinion and lower-quality studies. In the absence of high-quality studies, reasonable physicians may also be expected to disagree about how to interpret what is available. The practice of EBM does not seek to eliminate individual clinician judgment, and each of us is left to determine how to put into practice what evidence and expert opinion currently exists. There's an AFP By Topic on Neonatology/Newborn Issues if you'd like to read more.

What is your practice regarding screening infants for DDH?