Screening programmes for developmental dysplasia of the hip in newborn infants (Review)

Shorter D, Hong T, Osborn DA

The Cochrane Collaboration and published in The Cochrane Library
2011, Issue 9. http://www.thecochranelibrary.com

Background
Uncorrected developmental dysplasia of the hip (DDH) is associated with long term morbidity such as gait abnormalities, chronic pain and degenerative arthritis.
Objectives
To determine the effect of different screening programmes for DDH on the incidence of late presentation of congenital hip dislocation.
Search methods
Searches were performed in CENTRAL (The Cochrane Library), MEDLINE and EMBASE (January 2011) supplemented by searches of clinical trial registries, conference proceedings, cross references and contacting expert informants.
Selection criteria
Randomised, quasi-randomised or cluster trials comparing the effectiveness of screening programmes for DDH.
Data collection and analysis
Three independent review authors assessed study eligibility and quality, and extracted data.
Main results
No study examined the effect of screening (clinical and/or ultrasound) and early treatment versus not screening and later treatment.
One study reported universal ultrasound compared to clinical examination alone did not result in a significant reduction in late diagnosed DDH or surgery but was associated with a significant increase in treatment.
One study reported targeted ultrasound compared to clinical examination alone did not result in a significant reduction in late diagnosed DDH or surgery, with no significant difference in rate of treatment.
Meta-analysis of two studies found universal ultrasound compared to targeted ultrasound did not result in a significant reduction in late diagnosed DDH or surgery. There was heterogeneity between studies reporting the effect on treatment rate.
Meta-analysis of two studies found delayed ultrasound and targeted splinting compared to immediate splinting of infants with unstable (but not dislocated) hips resulted in no significant difference in the rate of late diagnosed DDH. Both studies reported a significant reduction in treatment with use of delayed ultrasound and targeted splinting.
One study reported delayed ultrasound and targeted splinting compared to immediate splinting of infants with mild hip dysplasia on ultrasound resulted in no significant difference in late diagnosed DDH but a significant reduction in treatment. No infants in either group received surgery.
Authors’ conclusions
There is insufficient evidence to give clear recommendations for practice. There is inconsistent evidence that universal ultrasound results in a significant increase in treatment compared to the use of targeted ultrasound or clinical examination alone. Neither of the ultrasound strategies have been demonstrated to improve clinical outcomes including late diagnosed DDH and surgery. The studies are substantially underpowered to detect significant differences in the uncommon event of late detected DDH or surgery. For infants with unstable hips or mildly dysplastic hips, use of delayed ultrasound and targeted splinting reduces treatment without significantly increasing the rate of late diagnosed DDH or surgery.

School-based programmes for preventing smoking..

Cochrane Database Syst Rev. 2013 Apr 30;4:CD001293. doi: 10.1002/14651858.CD001293.pub3.

Thomas RE, McLellan J, Perera R.
Department of Family Medicine, Faculty of Medicine, University of Calgary, Calgary, Canada. rthomas@ucalgary.ca.

Abstract

BACKGROUND:

Helping young people to avoid starting smoking is a widely endorsed public health goal, and schools provide a route to communicate with nearly all young people. School-based interventions have been delivered for close to 40 years.

OBJECTIVES:

The primary aim of this review was to determine whether school smoking interventions prevent youth from starting smoking. Our secondary objective was to determine which interventions were most effective. This included evaluating the effects of theoretical approaches; additional booster sessions; programme deliverers; gender effects; and multifocal interventions versus those focused solely on smoking.

SEARCH METHODS:

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Tobacco Addiction Group's Specialised Register, MEDLINE, EMBASE, PsycINFO, ERIC, CINAHL, Health Star, and Dissertation Abstracts for terms relating to school-based smoking cessation programmes. In addition, we screened the bibliographies of articles and ran individual MEDLINE searches for 133 authors who had undertaken randomised controlled trials in this area. The most recent searches were conducted in October 2012.

SELECTION CRITERIA:

We selected randomised controlled trials (RCTs) where students, classes, schools, or school districts were randomised to intervention arm(s) versus a control group, and followed for at least six months. Participants had to be youth (aged 5 to 18). Interventions could be any curricula used in a school setting to deter tobacco use, and outcome measures could be never smoking, frequency of smoking, number of cigarettes smoked, or smoking indices.

DATA COLLECTION AND ANALYSIS:

Two reviewers independently assessed studies for inclusion, extracted data and assessed risk of bias. Based on the type of outcome, we placed studies into three groups for analysis: Pure Prevention cohorts (Group 1), Change in Smoking Behaviour over time (Group 2) and Point Prevalence of Smoking (Group 3).

MAIN RESULTS:

One hundred and thirty-four studies involving 428,293 participants met the inclusion criteria. Some studies provided data for more than one group.Pure Prevention cohorts (Group 1) included 49 studies (N = 142,447). Pooled results at follow-up at one year or less found no overall effect of intervention curricula versus control (odds ratio (OR) 0.94, 95% confidence interval (CI) 0.85 to 1.05). In a subgroup analysis, the combined social competence and social influences curricula (six RCTs) showed a statistically significant effect in preventing the onset of smoking (OR 0.49, 95% CI 0.28 to 0.87; seven arms); whereas significant effects were not detected in programmes involving information only (OR 0.12, 95% CI 0.00 to 14.87; one study), social influences only (OR 1.00, 95% CI 0.88 to 1.13; 25 studies), or multimodal interventions (OR 0.89, 95% CI 0.73 to 1.08; five studies). In contrast, pooled results at longest follow-up showed an overall significant effect favouring the intervention (OR 0.88, 95% CI 0.82 to 0.96). Subgroup analyses detected significant effects in programmes with social competence curricula (OR 0.52, 95% CI 0.30 to 0.88), and the combined social competence and social influences curricula (OR 0.50, 95% CI 0.28 to 0.87), but not in those programmes with information only, social influence only, and multimodal programmes.Change in Smoking Behaviour over time (Group 2) included 15 studies (N = 45,555). At one year or less there was a small but statistically significant effect favouring controls (standardised mean difference (SMD) 0.04, 95% CI 0.02 to 0.06). For follow-up longer than one year there was a statistically nonsignificant effect (SMD 0.02, 95% CI -0.00 to 0.02).Twenty-five studies reported data on the Point Prevalence of Smoking (Group 3), though heterogeneity in this group was too high for data to be pooled.We were unable to analyse data for 49 studies (N = 152,544).Subgroup analyses (Pure Prevention cohorts only) demonstrated that at longest follow-up for all curricula combined, there was a significant effect favouring adult presenters (OR 0.88, 95% CI 0.81 to 0.96). There were no differences between tobacco-only and multifocal interventions. For curricula with booster sessions there was a significant effect only for combined social competence and social influences interventions with follow-up of one year or less (OR 0.50, 95% CI 0.26 to 0.96) and at longest follow-up (OR 0.51, 95% CI 0.27 to 0.96). Limited data on gender differences suggested no overall effect, although one study found an effect of multimodal intervention at one year for male students. Sensitivity analyses for Pure Prevention cohorts and Change in Smoking Behaviour over time outcomes suggested that neither selection nor attrition bias affected the results.

AUTHORS' CONCLUSIONS:

Pure Prevention cohorts showed a significant effect at longest follow-up, with an average 12% reduction in starting smoking compared to the control groups. However, no overall effect was detected at one year or less. The combined social competence and social influences interventions showed a significant effect at one year and at longest follow-up. Studies that deployed a social influences programme showed no overall effect at any time point; multimodal interventions and those with an information-only approach were similarly ineffective.Studies reporting Change in Smoking Behaviour over time did not show an overall effect, but at an intervention level there were positive findings for social competence and combined social competence and social influences interventions.

Update of

·         Cochrane Database Syst Rev. 2006;(3):CD001293.

Screening women for intimate partner violence in healthcare settings

Taft A, O'Doherty L, Hegarty K, Ramsay J, Davidson L, Feder G. Screening women for intimate partner violence in healthcare settings. Cochrane Database of Systematic Reviews 2013, Issue 4. Art. No.: CD007007. DOI: 10.1002/14651858.CD007007.pub2.

Abstract

Background

Intimate partner violence (IPV) damages individuals, their children, communities, and the wider economic and social fabric of society. Some governments and professional organisations recommend screening all women for intimate partner violence rather than asking only women with symptoms (case-finding); however, what is the evidence that screening interventions will increase identification, and referral to support agencies, or improve women's subsequent wellbeing and not cause harm?

Objectives

To assess the effectiveness of screening for intimate partner violence conducted within healthcare settings for identification, referral to support agencies and health outcomes for women.

Search methods

We searched the following databases in July 2012: CENTRAL (2012, Issue 6), MEDLINE (1948 to September Week June Week 3 2012), EMBASE (1980 to Week 28 2012), MEDLINE In–Process (3 July 2012), DARE (2012, Issue 2), CINAHL (1937 to current), PsycINFO (1806 to June Week 4 2012), Sociological Abstracts (1952 to current) and ASSIA (1987 to October 2010). In addition we searched the following trials registers: metaRegister of Controlled Trials (mRCT) (to July 2012), and International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov, Australian New Zealand Clinical Trials Registry and the International Standard Randomised Controlled Trial Number Register to August 2010. We also searched the reference lists of articles and websites of relevant organisations.

Selection criteria

Randomised or quasi-randomised trials assessing the effectiveness of IPV screening where healthcare professionals screened women face-to-face or were informed of results of screening questionnaires, compared with usual care ( which included screening for other purposes).

Data collection and analysis

Two review authors independently assessed the risk of bias in the trials and undertook data extraction. For binary outcomes, we calculated a standardised estimation of the risk ratio (RR) and for continuous data, either a mean difference (MD) or standardised mean difference (SMD). All are presented with a 95% confidence interval (CI).

Main results

We included 11 trials that recruited 13,027 women overall. Six of 10 studies were assessed as being at high risk of bias.

When data from six comparable studies were combined (n = 3564), screening increased identification of victims/survivors (RR 2.33; 95% CI 1.40 to 3.89), particularly in antenatal settings (RR 4.26; 95% CI 1.76 to 10.31).

Only three studies measured referrals to support agencies (n = 1400). There is no evidence that screening increases such referrals, as although referral numbers increased in the screened group, actual numbers were very small and crossed the line of no effect (RR 2.67; 95% CI 0.99 to 7.20).

Only two studies measured women's experience of violence after screening (one at three months, the other at six, 12 and 18 months after screening) and found no significant reduction of abuse.

Only one study measured adverse effects and data from this study suggested that screening may not cause harm. This same study showed a trend towards mental health benefit, but the results did not reach statistical significance.

There was insufficient evidence on which to judge whether screening increases take up of specialist services, and no studies included economic evaluation.

Authors' conclusions

Screening is likely to increase identification rates but rates of referral to support agencies are low and as yet we know little about the proportions of false measurement (negatives or positives). Screening does not appear to cause harm, but only one study examined this outcome. As there is an absence of evidence of long-term benefit for women, there is insufficient evidence to justify universal screening in healthcare settings. Studies comparing screening versus case finding (with or without advocacy or therapeutic interventions) for women's long-term wellbeing would better inform future policies in healthcare settings.

 

Plain language su

mmary

Screening women for intimate partner violence in healthcare settings

Women who have experienced physical, psychological or sexual violence from an intimate partner (for example, husband, boyfriend, ex-husband or ex-boyfriend) can suffer poor physical and mental health, poor pregnancy outcomes and premature death. Their children and families can also suffer. The effects of violence often result in women attending healthcare settings. Some people have argued that healthcare professionals should routinely ask all women attending a healthcare setting whether they have experienced violence from their partner or ex-partner. They argue that this approach (known as universal screening) might encourage women who would not otherwise do so, to disclose abuse, or to recognise their experience as ‘abuse’. In turn, this would enable the healthcare professional to provide immediate support or refer them to specialist help, or both. Some governments and health organisations recommend universal screening for intimate partner violence (IPV). Others argue that such screening should be targeted to high risk groups, such as pregnant women attending antenatal clinics (targeted screening is known as ‘selective screening’).

We carried out this review to find out two things. First, whether there was any evidence that IPV screening increases the number of women identified and the number referred on to specialist services. Second, whether screening results in health benefits to women or causes any harm.

We found 11 studies that assessed the effectiveness of IPV screening where healthcare professionals screened women face-to-face or were informed of results of screening questionnaires, compared with usual care. No study compared the benefit of universal screening versus selective screening. All the studies were conducted in high income countries. The studies looked at screening in hospitals and in community settings. Screening methods included questionnaires (paper and computer based) completed by women themselves or face-to-face screening. No study took into account differences in how much abuse women were experiencing, or whether they were able or ready to take action – something that might affect the likelihood of disclosing abuse. Further, none looked at the sustainability of screening by healthcare professionals.

Screening doubled the likelihood that abused women were identified, but did not increase the numbers referred for specialist help. Both the numbers identified and referred for support were low. Screening did not reduce the level of violence experienced by women or improve women’s health and wellbeing at any time point from three to 18 months after the screening. One study reported no evidence of harm. The remaining ten studies did not address the issue of harmful consequences. We do not know if screening increases take up of specialist services. None of the studies measured how much it costs to deliver screening.

We conclude that there is insufficient evidence to justify universal screening for intimate partner violence in healthcare settings.

School-based programmes for preventing smoking

Thomas RE, McLellan J, Perera R. School-based programmes for preventing smoking. Cochrane Database of Systematic Reviews 2013, Issue 4. Art. No.: CD001293. DOI: 10.1002/14651858.CD001293.pub3.

Abstract

Background

Helping young people to avoid starting smoking is a widely endorsed public health goal, and schools provide a route to communicate with nearly all young people. School-based interventions have been delivered for close to 40 years.

Objectives

The primary aim of this review was to determine whether school smoking interventions prevent youth from starting smoking. Our secondary objective was to determine which interventions were most effective. This included evaluating the effects of theoretical approaches; additional booster sessions; programme deliverers; gender effects; and multifocal interventions versus those focused solely on smoking.

Search methods

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Tobacco Addiction Group's Specialised Register, MEDLINE, EMBASE, PsyclNFO, ERIC, CINAHL, Health Star, and Dissertation Abstracts for terms relating to school-based smoking cessation programmes. In addition, we screened the bibliographies of articles and ran individual MEDLINE searches for 133 authors who had undertaken randomised controlled trials in this area. The most recent searches were conducted in October 2012.

Selection criteria

We selected randomised controlled trials (RCTs) where students, classes, schools, or school districts were randomised to intervention arm(s) versus a control group, and followed for at least six months. Participants had to be youth (aged 5 to 18). Interventions could be any curricula used in a school setting to deter tobacco use, and outcome measures could be never smoking, frequency of smoking, number of cigarettes smoked, or smoking indices.

Data collection and analysis

Two reviewers independently assessed studies for inclusion, extracted data and assessed risk of bias. Based on the type of outcome, we placed studies into three groups for analysis: Pure Prevention cohorts (Group 1), Change in Smoking Behaviour over time (Group 2) and Point Prevalence of Smoking (Group 3).

Main results

One hundred and thirty-four studies involving 428,293 participants met the inclusion criteria. Some studies provided data for more than one group.

Pure Prevention cohorts (Group 1) included 49 studies (N = 142,447). Pooled results at follow-up at one year or less found no overall effect of intervention curricula versus control (odds ratio (OR) 0.94, 95% confidence interval (CI) 0.85 to 1.05). In a subgroup analysis, the combined social competence and social influences curricula (six RCTs) showed a statistically significant effect in preventing the onset of smoking (OR 0.49, 95% CI 0.28 to 0.87; seven arms); whereas significant effects were not detected in programmes involving information only (OR 0.12, 95% CI 0.00 to 14.87; one study), social influences only (OR 1.00, 95% CI 0.88 to 1.13; 25 studies), or multimodal interventions (OR 0.89, 95% CI 0.73 to 1.08; five studies). In contrast, pooled results at longest follow-up showed an overall significant effect favouring the intervention (OR 0.88, 95% CI 0.82 to 0.96). Subgroup analyses detected significant effects in programmes with social competence curricula (OR 0.52, 95% CI 0.30 to 0.88), and the combined social competence and social influences curricula (OR 0.50, 95% CI 0.28 to 0.87), but not in those programmes with information only, social influence only, and multimodal programmes.

Change in Smoking Behaviour over time (Group 2) included 15 studies (N = 45,555). At one year or less there was a small but statistically significant effect favouring controls (standardised mean difference (SMD) 0.04, 95% CI 0.02 to 0.06). For follow-up longer than one year there was a statistically nonsignificant effect (SMD 0.02, 95% CI -0.00 to 0.02).

Twenty-five studies reported data on the Point Prevalence of Smoking (Group 3), though heterogeneity in this group was too high for data to be pooled.

We were unable to analyse data for 49 studies (N = 152,544).

Subgroup analyses (Pure Prevention cohorts only) demonstrated that at longest follow-up for all curricula combined, there was a significant effect favouring adult presenters (OR 0.88, 95% CI 0.81 to 0.96). There were no differences between tobacco-only and multifocal interventions. For curricula with booster sessions there was a significant effect only for combined social competence and social influences interventions with follow-up of one year or less (OR 0.50, 95% CI 0.26 to 0.96) and at longest follow-up (OR 0.51, 95% CI 0.27 to 0.96). Limited data on gender differences suggested no overall effect, although one study found an effect of multimodal intervention at one year for male students. Sensitivity analyses for Pure Prevention cohorts and Change in Smoking Behaviour over time outcomes suggested that neither selection nor attrition bias affected the results.

Authors' conclusions

Pure Prevention cohorts showed a significant effect at longest follow-up, with an average 12% reduction in starting smoking compared to the control groups. However, no overall effect was detected at one year or less. The combined social competence and social influences interventions showed a significant effect at one year and at longest follow-up. Studies that deployed a social influences programme showed no overall effect at any time point; multimodal interventions and those with an information-only approach were similarly ineffective.

Studies reporting Change in Smoking Behaviour over time did not show an overall effect, but at an intervention level there were positive findings for social competence and combined social competence and social influences interventions.

School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6 to 18.

Dobbins M, Husson H, Decorby K, Larocca RL.
Cochrane Database Syst Rev. 2013 Feb 28;2:CD007651. doi: 10.1002/14651858.CD007651.pub2.

BACKGROUND: The World Health Organization (WHO) estimates that 1.9 million deaths
worldwide are attributable to physical inactivity and at least 2.6 million deaths
are a result of being overweight or obese. In addition, WHO estimates that
physical inactivity causes 10% to 16% of cases each of breast cancer, colon, and 
rectal cancers as well as type 2 diabetes, and 22% of coronary heart disease and 
the burden of these and other chronic diseases has rapidly increased in recent
decades.
OBJECTIVES: The purpose of this systematic review was to summarize the evidence
of the effectiveness of school-based interventions in promoting physical activity
and fitness in children and adolescents.
SEARCH METHODS: The search strategy included searching several databases to
October 2011. In addition, reference lists of included articles and background
papers were reviewed for potentially relevant studies, as well as references from
relevant Cochrane reviews. Primary authors of included studies were contacted as 
needed for additional information.
SELECTION CRITERIA: To be included, the intervention had to be relevant to public
health practice (focused on health promotion activities), not conducted by
physicians, implemented, facilitated, or promoted by staff in local public health
units, implemented in a school setting and aimed at increasing physical activity,
included all school-attending children, and be implemented for a minimum of 12
weeks. In addition, the review was limited to randomized controlled trials and
those that reported on outcomes for children and adolescents (aged 6 to 18
years). Primary outcomes included: rates of moderate to vigorous physical
activity during the school day, time engaged in moderate to vigorous physical
activity during the school day, and time spent watching television. Secondary
outcomes related to physical health status measures including: systolic and
diastolic blood pressure, blood cholesterol, body mass index (BMI), maximal
oxygen uptake (VOmax), and pulse rate.
DATA COLLECTION AND ANALYSIS: Standardized tools were used by two independent
reviewers to assess each study for relevance and for data extraction. In
addition, each study was assessed for risk of bias as specified in the Cochrane
Handbook for Systematic Reviews of Interventions. Where discrepancies existed,
discussion occurred until consensus was reached. The results were summarized
narratively due to wide variations in the populations, interventions evaluated,
and outcomes measured.
MAIN RESULTS: In the original review, 13,841 records were identified and
screened, 302 studies were assessed for eligibility, and 26 studies were included
in the review. There was some evidence that school-based physical activity
interventions had a positive impact on four of the nine outcome measures.
Specifically positive effects were observed for duration of physical activity,
television viewing, VO max, and blood cholesterol. Generally, school-based
interventions had little effect on physical activity rates, systolic and
diastolic blood pressure, BMI, and pulse rate. At a minimum, a combination of
printed educational materials and changes to the school curriculum that promote
physical activity resulted in positive effects.In this update, given the addition
of three new inclusion criteria (randomized design, all school-attending children
invited to participate, minimum 12-week intervention) 12 of the original 26
studies were excluded. In addition, studies published between July 2007 and
October 2011 evaluating the effectiveness of school-based physical interventions 
were identified and if relevant included. In total an additional 2378 titles were
screened of which 285 unique studies were deemed potentially relevant. Of those
30 met all relevance criteria and have been included in this update. This update 
includes 44 studies and represents complete data for 36,593 study participants.
Duration of interventions ranged from 12 weeks to six years.Generally, the
majority of studies included in this update, despite being randomized controlled 
trials, are, at a minimum, at moderate risk of bias. The results therefore must
be interpreted with caution. Few changes in outcomes were observed in this update
with the exception of blood cholesterol and physical activity rates. For example 
blood cholesterol was no longer positively impacted upon by school-based physical
activity interventions. However, there was some evidence to suggest that
school-based physical activity interventions led to an improvement in the
proportion of children who engaged in moderate to vigorous physical activity
during school hours (odds ratio (OR) 2.74, 95% confidence interval (CI), 2.01 to 
3.75). Improvements in physical activity rates were not observed in the original 
review. Children and adolescents exposed to the intervention also spent more time
engaged in moderate to vigorous physical activity (with results across studies
ranging from five to 45 min more), spent less time watching television (results
range from five to 60 min less per day), and had improved VOmax (results across
studies ranged from 1.6 to 3.7 mL/kg per min). However, the overall conclusions
of this update do not differ significantly from those reported in the original
review.
AUTHORS' CONCLUSIONS: The evidence suggests the ongoing implementation of
school-based physical activity interventions at this time, given the positive
effects on behavior and one physical health status measure. However, given these 
studies are at a minimum of moderate risk of bias, and the magnitude of effect is
generally small, these results should be interpreted cautiously. Additional
research on the long-term impact of these interventions is needed.

Cochrane Review: Screening programmes for developmental dysplasia of the hip in newborn infants

1. Shorter D, Hong T, Osborn DA.
2. Evid.-Based Child Health. 2013;8(1):11–54.

Article first published online: 9 JAN 2013. DOI: 10.1002/ebch.1891

Abstract

Background

Uncorrected developmental dysplasia of the hip (DDH) is associated with long term morbidity such as gait abnormalities, chronic pain and degenerative arthritis.

Objectives

To determine the effect of different screening programmes for DDH on the incidence of late presentation of congenital hip dislocation.

Search methods

Searches were performed in CENTRAL (The Cochrane Library), MEDLINE and EMBASE (January 2011) supplemented by searches of clinical trial registries, conference proceedings, cross references and contacting expert informants.

Selection criteria

Randomised, quasi-randomised or cluster trials comparing the effectiveness of screening programmes for DDH.

Data collection and analysis

Three independent review authors assessed study eligibility and quality, and extracted data.

Main results

No study examined the effect of screening (clinical and/or ultrasound) and early treatment versus not screening and later treatment.

One study reported universal ultrasound compared to clinical examination alone did not result in a significant reduction in late diagnosed DDH or surgery but was associated with a significant increase in treatment.

One study reported targeted ultrasound compared to clinical examination alone did not result in a significant reduction in late diagnosed DDH or surgery, with no significant difference in rate of treatment.

Meta-analysis of two studies found universal ultrasound compared to targeted ultrasound did not result in a significant reduction in late diagnosed DDH or surgery. There was heterogeneity between studies reporting the effect on treatment rate.

Meta-analysis of two studies found delayed ultrasound and targeted splinting compared to immediate splinting of infants with unstable (but not dislocated) hips resulted in no significant difference in the rate of late diagnosed DDH. Both studies reported a significant reduction in treatment with use of delayed ultrasound and targeted splinting.

One study reported delayed ultrasound and targeted splinting compared to immediate splinting of infants with mild hip dysplasia on ultrasound resulted in no significant difference in late diagnosed DDH but a significant reduction in treatment. No infants in either group received surgery.

Authors' conclusions

There is insufficient evidence to give clear recommendations for practice. There is inconsistent evidence that universal ultrasound results in a significant increase in treatment compared to the use of targeted ultrasound or clinical examination alone. Neither of the ultrasound strategies have been demonstrated to improve clinical outcomes including late diagnosed DDH and surgery. The studies are substantially underpowered to detect significant differences in the uncommon event of late detected DDH or surgery. For infants with unstable hips or mildly dysplastic hips, use of delayed ultrasound and targeted splinting reduces treatment without significantly increasing the rate of late diagnosed DDH or surgery.