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Cimbak N, Zalieckas JM, Staffa SJ, Lemire L, Janeczek J, Sheils C, Visner G, Mullen M, Studley M, Becker R, Dickie BH, Demehri FR, Buchmiller TL. Disparities in Healthcare Utilization: An Analysis of Disease Specific and Patient Level Factors in a Congenital Diaphragmatic Hernia Clinic. J Pediatr Surg 2024:S0022-3468(24)00300-2. [PMID: 38806317 DOI: 10.1016/j.jpedsurg.2024.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 04/03/2024] [Accepted: 04/29/2024] [Indexed: 05/30/2024]
Abstract
OBJECTIVES Our study examines if the disease severity profile of our Congenital Diaphragmatic Hernia (CDH) patient cohort adherent to long-term follow-up differs from patients lost to follow-up after discharge and examines factors associated with health care utilization. METHODS Retrospective review identified CDH survivors born 2005-2019 with index repair at our institution. Primary outcome was long-term follow-up status: "active" or "inactive" according to clinic guidelines. Markers of CDH disease severity including CDH defect classification, oxygen use, tube feeds at discharge, and sociodemographic factors were examined as exposures. RESULTS Of the 222 included patients, median age [IQR] was 10.2 years [6.7-14.3], 61% male, and 57 (26%) were insured by Medicaid. Sixty-three percent (139/222) of patients were adherent to follow-up. Seventy-six percent of patients discharged on tube feeds had active follow-up compared to 55% of patients who were not, with similar findings for oxygen at discharge (76% vs. 55%). Kaplan-Meier analysis showed patients with smaller defect size had earlier attrition compared to patients with larger defect size. Other race (Hispanic, Asian, Middle Eastern) patients had 2.87 higher odds of attrition compared to white patients (95% CI 1.18-7.0). Medicaid patients had 2.64 higher odds of attrition compared to private insurance (95% CI 1.23-5.66). CONCLUSION Loss to follow-up was associated with race and insurance type. Disease severity was similar between the active and inactive clinic cohorts. Long-term CDH clinic publications should examine attrition to ensure reported outcomes reflect the discharged population. This study identified important factors to inform targeted interventions for follow-up adherence. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Nicole Cimbak
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Fegan 3, 300 Longwood Ave, Boston, MA 02115, USA.
| | - Jill M Zalieckas
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Fegan 3, 300 Longwood Ave, Boston, MA 02115, USA
| | - Steven J Staffa
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Fegan 3, 300 Longwood Ave, Boston, MA 02115, USA
| | - Lindsay Lemire
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Fegan 3, 300 Longwood Ave, Boston, MA 02115, USA
| | - Joslyn Janeczek
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Fegan 3, 300 Longwood Ave, Boston, MA 02115, USA
| | - Catherine Sheils
- Division of Pulmonary Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Gary Visner
- Division of Pulmonary Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mary Mullen
- Department of Cardiology and Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mollie Studley
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Ronald Becker
- Division of Developmental Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Belinda Hsi Dickie
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Fegan 3, 300 Longwood Ave, Boston, MA 02115, USA
| | - Farokh R Demehri
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Fegan 3, 300 Longwood Ave, Boston, MA 02115, USA
| | - Terry L Buchmiller
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Fegan 3, 300 Longwood Ave, Boston, MA 02115, USA
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Cimbak N, Buchmiller TL. Long-term follow-up of patients with congenital diaphragmatic hernia. WORLD JOURNAL OF PEDIATRIC SURGERY 2024; 7:e000758. [PMID: 38618013 PMCID: PMC11015326 DOI: 10.1136/wjps-2023-000758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 02/28/2024] [Indexed: 04/16/2024] Open
Abstract
Neonates with congenital diaphragmatic hernia encounter a number of surgical and medical morbidities that persist into adulthood. As mortality improves for this population, these survivors warrant specialized follow-up for their unique disease-specific morbidities. Multidisciplinary congenital diaphragmatic hernia clinics are best positioned to address these complex long-term morbidities, provide long-term research outcomes, and help inform standardization of best practices in this cohort of patients. This review outlines long-term morbidities experienced by congenital diaphragmatic hernia survivors that can be addressed in a comprehensive follow-up clinic.
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Affiliation(s)
- Nicole Cimbak
- Department of Pediatric Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Terry L Buchmiller
- Department of Pediatric Surgery, Boston Children's Hospital, Boston, MA, USA
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Walden AR, Nembhard WN, Akmyradov C, Goudie A, ElHassan NO. School age educational outcomes of infants born with congenital diaphragmatic hernia. Birth Defects Res 2023; 115:96-109. [PMID: 36260492 DOI: 10.1002/bdr2.2104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/31/2022] [Accepted: 09/22/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND To compare academic proficiency among children with congenital diaphragmatic hernia (CDH) versus controls and identify predictors of academic performance among children with CDH. METHODS Infants born with CDH in Arkansas, 2000-2005, were identified from the Arkansas Reproductive Health Monitoring System. For each case, two controls were selected from birth certificate data and matched for hospital and month of birth, sex, and race/ethnicity. Data on re-hospitalization within the first 5 years and payer data were collected from the Arkansas Hospital Inpatient Discharge database. Surviving cases and controls were linked to the Arkansas Department of Education database. Primary outcomes were odds of proficiency on fourth grade literacy and mathematics achievement tests. Multivariable logistic regression models evaluated the association between study characteristics and academic proficiency. RESULTS The final study cohort included 25 surviving CDH cases and 31 controls who were linked to their education data. After adjusting for differences in characteristics (5-min Apgar score and associated congenital anomalies) between cases and controls, there were no statistically significant differences in literacy (72% vs. 84%, p = .93) or mathematics (64% vs. 81%, p = .98) test proficiency between the two groups. In multivariable analyses, among CDH cases, oxygen at discharge and Medicaid payer/longer hospital stay were associated with worse fourth grade literacy and mathematics proficiency, respectively. CONCLUSIONS Oxygen at discharge, Medicaid payer, and longer hospital stay were associated with lower academic performance among CDH cases.
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Affiliation(s)
- Alyssa R Walden
- Department of Pediatrics (Neonatal-Perinatal Medicine), Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Wendy N Nembhard
- Department of Pediatrics (Neonatal-Perinatal Medicine), Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
- Department of Epidemiology, Fay W. Boozman College of Public Heath, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
- Arkansas Center for Birth Defects Research and Prevention, Little Rock, Arkansas, USA
| | - Chary Akmyradov
- Arkansas Research Institute, Arkansas Children's Hospital, Little Rock, Arkansas, USA
| | - Anthony Goudie
- Department of Health Policy and Management, Fay W. Boozman College of Public Heath, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Nahed O ElHassan
- Department of Pediatrics (Neonatal-Perinatal Medicine), Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
- Arkansas Center for Birth Defects Research and Prevention, Little Rock, Arkansas, USA
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Ito M, Terui K, Nagata K, Yamoto M, Shiraishi M, Okuyama H, Yoshida H, Urushihara N, Toyoshima K, Hayakawa M, Taguchi T, Usui N. Clinical guidelines for the treatment of congenital diaphragmatic hernia. Pediatr Int 2021; 63:371-390. [PMID: 33848045 DOI: 10.1111/ped.14473] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 08/31/2020] [Accepted: 09/07/2020] [Indexed: 11/28/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is a birth defect of the diaphragm in which abdominal organs herniate through the defect into the thoracic cavity. The main pathophysiology is respiratory distress and persistent pulmonary hypertension because of pulmonary hypoplasia caused by compression of the elevated organs. Recent progress in prenatal diagnosis and postnatal care has led to an increase in the survival rate of patients with CDH. However, some survivors experience mid- and long-term disabilities and complications requiring treatment and follow-up. In recent years, the establishment of clinical practice guidelines has been promoted in various medical fields to offer optimal medical care, with the goal of improvement of the disease' outcomes, thereby reducing medical costs, etc. Thus, to provide adequate medical care through standardization of treatment and elimination of disparities in clinical management, and to improve the survival rate and mid- and long-term prognosis of patients with CDH, we present here the clinical practice guidelines for postnatal management of CDH. These are based on the principles of evidence-based medicine using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. The recommendations are based on evidence and were determined after considering the balance among benefits and harm, patient and society preferences, and medical resources available for postnatal CDH treatment.
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Affiliation(s)
- Miharu Ito
- Departments of, Department of, Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Keita Terui
- Department of, Pediatric Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Kouji Nagata
- Department of, Pediatric Surgery, Reproductive and Developmental Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masaya Yamoto
- Department of, Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
| | | | - Hiroomi Okuyama
- Department of, Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Hideo Yoshida
- Department of, Pediatric Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Naoto Urushihara
- Department of, Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Katsuaki Toyoshima
- Department of, Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Masahiro Hayakawa
- Division of Neonatology, Center for Maternal-Neonatal Care, Nagoya University Hospital, Nagoya, Japan
| | - Tomoaki Taguchi
- Department of, Pediatric Surgery, Reproductive and Developmental Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Noriaki Usui
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, Izumi, Japan
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Abstract
Congenital diaphragmatic hernia (CDH) is a rare developmental defect of the diaphragm, characterized by herniation of abdominal contents into the chest that results in varying degrees of pulmonary hypoplasia and pulmonary hypertension (PH). Significant advances in the prenatal diagnosis and identification of prognostic factors have resulted in the continued refinement of the approach to fetal therapies for CDH. Postnatally, protocolized approaches to lung-protective ventilation, nutrition, prevention of infection, and early aggressive management of PH have led to improved outcomes in infants with CDH. Advances in our understanding of the associated left ventricular (LV) hypoplasia and myocardial dysfunction in infants with severe CDH have allowed for the optimization of hemodynamics and management of PH. This article provides a comprehensive review of CDH for the anesthesiologist, focusing on the complex pathophysiology, advances in prenatal diagnosis, fetal interventions, and optimal postnatal management of CDH.
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Affiliation(s)
| | | | - Jason Gien
- Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
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Montalva L, Raffler G, Riccio A, Lauriti G, Zani A. Neurodevelopmental impairment in children with congenital diaphragmatic hernia: Not an uncommon complication for survivors. J Pediatr Surg 2020; 55:625-634. [PMID: 31227219 DOI: 10.1016/j.jpedsurg.2019.05.021] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 04/04/2019] [Accepted: 05/26/2019] [Indexed: 12/22/2022]
Abstract
PURPOSE To evaluate neurodevelopmental impairment (NDI) in children born with congenital diaphragmatic hernia (CDH). METHODS Using a defined search strategy, a systematic review was conducted to define the incidence and types of NDI, to report abnormal neuroimaging findings and to evaluate possible NDI predictors. A meta-analysis was performed on comparative studies reporting risk factors for NDI, using RevMan 5.3. RESULTS Of 3541 CDH children (33 studies), 829 (23%) had NDI, with a higher incidence in CDH survivors who received ECMO treatment (49%) vs. those who had no ECMO (22%; p<0.00001). NDI included neuromuscular hypotonia (42%), hearing (13%) and visual (8%) impairment, neurobehavioral issues (20%), and learning difficulties (31%). Of 288 survivors that had postnatal neuroimaging, 49% had abnormal findings. The main risk factors for NDI were severe pulmonary hypoplasia, large defect size, ECMO use. CONCLUSIONS NDI is a relevant problem for CDH survivors, affecting 1 in 4. The spectrum of NDI covers all developmental domains and ranges from motor and sensory (hearing, visual) deficits to cognitive, language, and behavioral impairment. Further studies should be designed to better understand the pathophysiology of NDI in CDH children and to longitudinally monitor infants born with CDH to correct risk factors that can be modifiable. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Louise Montalva
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Gabriele Raffler
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Angela Riccio
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Canada; Department of Pediatric Surgery, "Spirito Santo" Hospital, Pescara, and "G. d'Annunzio" University, Chieti-Pescara, Italy
| | - Giuseppe Lauriti
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Canada; Department of Pediatric Surgery, "Spirito Santo" Hospital, Pescara, and "G. d'Annunzio" University, Chieti-Pescara, Italy
| | - Augusto Zani
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Canada.
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Gunn-Charlton JK, Burnett AC, Malarbi S, Moran MM, Hutchinson EA, Greaves S, Hunt RW. Neonatal neuroimaging after repair of congenital diaphragmatic hernia and long-term neurodevelopmental outcome. WORLD JOURNAL OF PEDIATRIC SURGERY 2019; 2:e000037. [PMID: 38813572 PMCID: PMC11131113 DOI: 10.1136/wjps-2019-000037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 08/07/2019] [Accepted: 08/08/2019] [Indexed: 11/04/2022] Open
Abstract
Objective Previous outcome reports of congenital diaphragmatic hernia (CDH) have described neuroimaging anomalies and neurodevelopmental impairment. However, the link between imaging and outcome has not been described. We aimed to determine whether routine postoperative neonatal neuroimaging in infants with CDH detects later neurodevelopmental impairment. Methods In a prospective cohort study within a clinical service in The Royal Children's Hospital Newborn Intensive Care. Cerebral ultrasound was performed in 81 children and MRI in 57 children who subsequently underwent neurodevelopmental follow-up after surgery for CDH. MRI scans were analyzed using a scoring system designed to identify injury, maturation and volume loss. Neurodevelopmental assessment occurred at 2 years (48) and neurocognitive assessment at 5 years (26) and/or 8 years (27). Brain imaging scores corrected for gestational age at scan time were correlated with outcome measures, adjusting for known clinical confounders. Results Clinically significant findings were identified on MRI of 16 (28%) infants. Mean scores were in the normal range for all domains assessed at each age. Language impairment was seen in 23% at 2 years and verbal intellectual impairment in 25% at 8 years. Mean cognitive scores were lower in 2-year-old children with white matter injury on MRI (p=0.03). Mean motor scores were lower in 2-year-old children with brain immaturity (p=0.01). Associations between MRI and 5-year and 8-year assessments were no longer significant when adjusting for known clinical confounders. Conclusions Neuroimaging abnormalities were associated with worse neurodevelopment at 2 years, but not with later neurocognitive outcomes, after accounting for clinical risk factors.
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Affiliation(s)
- Julia Kate Gunn-Charlton
- Newborn Intensive Care, The Royal Children’s Hospital, Melbourne, Victoria, Australia
- Neonatal Research Group, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Alice C Burnett
- Newborn Intensive Care, The Royal Children’s Hospital, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
- Victorian Infant Brain Studies (VIBeS) Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Stephanie Malarbi
- Newborn Intensive Care, The Royal Children’s Hospital, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Margaret M Moran
- Newborn Intensive Care, The Royal Children’s Hospital, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Esther A Hutchinson
- Newborn Intensive Care, The Royal Children’s Hospital, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Susan Greaves
- Department of Occupational Therapy, The Royal Children’s Hospital, Melbourne, Victoria, Australia
| | - Rod W Hunt
- Newborn Intensive Care, The Royal Children’s Hospital, Melbourne, Victoria, Australia
- Neonatal Research Group, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
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Danzer E, Hoffman C, D’Agostino JA, Miller JS, Waqar LN, Gerdes M, Bernbaum JC, Rosenthal H, Rintoul NE, Herkert LM, Peranteau WH, Flake AW, Adzick NS, Hedrick HL. Rate and Risk Factors Associated with Autism Spectrum Disorder in Congenital Diaphragmatic Hernia. J Autism Dev Disord 2018; 48:2112-2121. [DOI: 10.1007/s10803-018-3472-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Antiel RM, Lin N, Licht DJ, Hoffman C, Waqar L, Xiao R, Monos S, D'Agostino JA, Bernbaum J, Herkert LM, Rintoul NE, Peranteau WH, Flake AW, Adzick NS, Hedrick HL. Growth trajectory and neurodevelopmental outcome in infants with congenital diaphragmatic hernia. J Pediatr Surg 2017; 52:1944-1948. [PMID: 29079316 DOI: 10.1016/j.jpedsurg.2017.08.063] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 08/28/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the impact of impaired growth on short-term neurodevelopmental (ND) outcomes in CDH survivors. METHODS Between 9/2005-12/2014, 84 of 215 (39%) CDH survivors underwent ND assessment at 12months of age using the BSID-III. RESULTS Mean cognitive, language, and motor scores were 92.6±13.5, 87.1±11.6, and 87.0±14.4, respectively (normal 100±15). 51% of patients scored 1 SD below the population mean in at least one domain, and 13% scored 2 SD below the population mean. Group-based trajectory analysis identified two trajectory groups ('high' and 'low') for weight, length, and head circumference (HC) z-scores. (Fig. 1) 74% of the subjects were assigned to the 'high' trajectory group for weight, 77% to the 'high' height group, and 87% to the 'high' HC group, respectively. In multivariate analysis, longer NICU stay (p<0.01) was associated with lower cognitive scores. Motor scores were 11 points higher in the 'high' HC group compared to the 'low' HC group (p=0.05). Motor scores were lower in patients with longer NICU length of stay (p<0.001). CONCLUSIONS At 1 year, half of CDH survivors had a mild delay in at least one developmental domain. Low HC trajectory was associated with worse neurodevelopmental outcomes. TYPE OF STUDY Prognosis Study/Retrospective Study. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Ryan M Antiel
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nan Lin
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Daniel J Licht
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Casey Hoffman
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lindsay Waqar
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Rui Xiao
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Stylianos Monos
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jo Ann D'Agostino
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Judy Bernbaum
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lisa M Herkert
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Natalie E Rintoul
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - William H Peranteau
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alan W Flake
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - N Scott Adzick
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Holly L Hedrick
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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Danzer E, Hoffman C, D'Agostino JA, Gerdes M, Bernbaum J, Antiel RM, Rintoul NE, Herkert LM, Flake AW, Adzick NS, Hedrick HL. Neurodevelopmental outcomes at 5years of age in congenital diaphragmatic hernia. J Pediatr Surg 2017; 52:437-443. [PMID: 27622588 DOI: 10.1016/j.jpedsurg.2016.08.008] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 08/04/2016] [Accepted: 08/22/2016] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate neurodevelopmental sequelae in congenital diaphragmatic hernia (CDH) children at 5years of age. MATERIALS AND METHODS The study cohort of 35 CDH patients was enrolled in our follow-up program between 06/2004 and 09/2014. The neurodevelopmental outcomes assessed at a median of 5years (range, 4-6) included cognition (Wechsler Preschool and Primary Scale of Intelligence [WPPSI], n=35), Visual-Motor-Integration (n=35), academic achievement (Woodcock-Johnson Tests of Achievement, n=25), and behavior problems (Child Behavior Check List [CBCL], n=26). Scores were grouped as average, borderline, or extremely low by SD intervals. RESULTS Although mean Full (93.9±19.4), Verbal (93.4±18.4), and Performance (95.2±20.9) IQ were within the expected range, significantly more CDH children had borderline (17%) and extremely low (17%) scores in at least one domain compared to normative cohorts (P<0.02). The Visual-Motor-Integration score was below population average (P<0.001). Academic achievement scores were similar to expected means for those children who were able to complete testing. CBCL scores for the emotionally reactive (23%) and pervasive developmental problems scales (27%) were more likely to be abnormal compared to normal population scores (P=0.02 and P=0.0003, respectively). Autism was diagnosed in 11%, which is significantly higher than the general population (P<0.01). Univariate analysis suggests that prolonged NICU stay, prolonged intubation, tracheostomy placement, pulmonary hypertension, autism, hearing impairment, and developmental delays identified during infancy are associated with worse cognitive outcomes (P<0.05). CONCLUSION The majority of CDH children have neurodevelopmental outcomes within the average range at 5years of age. However, rates of borderline and extremely low IQ scores are significantly higher than in the general population. CDH survivors are also at increased risk for developing symptoms of emotionally reactive and pervasive developmental problems. Risk of autism is significantly elevated. Disease severity and early neurological dysfunction appear to be predictive of longer-term impairments.
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Affiliation(s)
- Enrico Danzer
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Casey Hoffman
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jo Ann D'Agostino
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Marsha Gerdes
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Judy Bernbaum
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ryan M Antiel
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Natalie E Rintoul
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lisa M Herkert
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alan W Flake
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - N Scott Adzick
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Holly L Hedrick
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Danzer E, Gerdes M, D'Agostino JA, Bernbaum J, Hoffman C, Herkert LM, Rintoul NE, Peranteau WH, Flake AW, Adzick NS, Hedrick HL. Younger gestational age is associated with increased risk of adverse neurodevelopmental outcome during infancy in congenital diaphragmatic hernia. J Pediatr Surg 2016; 51:1084-90. [PMID: 26831532 DOI: 10.1016/j.jpedsurg.2015.12.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 12/21/2015] [Accepted: 12/24/2015] [Indexed: 12/25/2022]
Abstract
BACKGROUND The purpose of the study was to investigate the impact of gestational age (GA) on short-term neurodevelopmental (ND) outcomes in congenital diaphragmatic hernia survivors. MATERIALS Between 6/2004 and 2/2013, 135 consecutive CDH patients underwent ND assessment using the Bayley Scales of Infant Development-III at a median follow-up age of 13months (range, 5-36). ND delay was defined by a score of ≤85 in any of the composite scales. Severe impairment was defined as a score of ≤69 in at least one domain. The effect of GA was evaluated as continuous and categorical variables. GA at delivery was grouped into full term (39-41weeks), near term (37-38), late preterm (34-36), and preterm (24-33). RESULTS Median GA at delivery was 38weeks (range, 24-41). Fifty (37%) patients were delivered full term, 59 (44%) near term, 16 (12%) late preterm, and 10 (7%) preterm. CDH children born before 39weeks' gestation were more likely to score below average (P=0.005) with corrected age for at least one composite score compared to full term peers. Cognitive (P=0.06) and language (P=0.08) scores tended to be lower in the near-term and late-preterm group compared to full-term CDH infants. Patients born near term and late preterm had significantly lower motor composite and fine motor scores compared to full-term children (P=0.009 and P<0.01, respectively). Preterm children scored the lowest in all composite scales (P<0.05). CONCLUSIONS Compared to term infants, not only preterm but also late preterm and near-term CDH children carry an increased risk of ND delays. Motor performance appears most susceptible to earlier delivery.
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Affiliation(s)
- Enrico Danzer
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; The University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
| | - Marsha Gerdes
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; The University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Jo Ann D'Agostino
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; The University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Judy Bernbaum
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; The University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Casey Hoffman
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; The University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Lisa M Herkert
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; The University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Natalie E Rintoul
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; The University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - William H Peranteau
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; The University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Alan W Flake
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; The University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - N Scott Adzick
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; The University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Holly L Hedrick
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; The University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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Stolwijk LJ, Lemmers PM, Harmsen M, Groenendaal F, de Vries LS, van der Zee DC, Benders MJN, van Herwaarden-Lindeboom MYA. Neurodevelopmental Outcomes After Neonatal Surgery for Major Noncardiac Anomalies. Pediatrics 2016; 137:e20151728. [PMID: 26759411 DOI: 10.1542/peds.2015-1728] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/16/2015] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Increasing concerns have been raised about the incidence of neurodevelopmental delay in children with noncardiac congenital anomalies (NCCA) requiring neonatal surgery. OBJECTIVE This study aimed to determine the incidence and potential risk factors for developmental delay after neonatal surgery for major NCCA. DATA SOURCES A systematic search in PubMed, Embase and the Cochrane Library was performed through March 2015. STUDY SELECTION Original research articles on standardized cognitive or motor skills tests. DATA EXTRACTION Data on neurodevelopmental outcome, the Bayley Scales of Infant Development, and risk factors for delay were extracted. RESULTS In total, 23 eligible studies were included, reporting on 895 children. Meta-analysis was performed with data of 511 children, assessed by the Bayley Scales of Infant Development at 12 and 24 months of age. Delay in cognitive development was reported in a median of 23% (3%-56%). Meta-analysis showed a cognitive score of 0.5 SD below the population average (Mental Development Index 92 ± 13, mean ± SD; P < .001). Motor development was delayed in 25% (0%-77%). Meta-analysis showed a motor score of 0.6 SD below average (Psychomotor Development Index 91 ± 14; P < .001). Several of these studies report risk factors for psychomotor delay, including low birth weight, a higher number of congenital anomalies, duration of hospital admission, and repeated surgery. LIMITATIONS All data were retrieved from studies with small sample sizes and various congenital anomalies using different neurodevelopmental assessment tools. CONCLUSIONS Cognitive and motor developmental delay was found in 23% of patients with NCCA. Meta-analysis showed that the mean neurodevelopmental outcome scores were 0.5 SD below the normative score of the healthy population.
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Affiliation(s)
- Lisanne J Stolwijk
- Paediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Netherlands Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Netherlands Brain Center Rudolf Magnus, University Medical Center, Utrecht
| | - Petra Ma Lemmers
- Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Netherlands
| | - Marissa Harmsen
- Paediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Netherlands
| | - Floris Groenendaal
- Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Netherlands
| | - Linda S de Vries
- Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Netherlands Brain Center Rudolf Magnus, University Medical Center, Utrecht
| | - David C van der Zee
- Paediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Netherlands
| | - Manon J N Benders
- Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Netherlands Brain Center Rudolf Magnus, University Medical Center, Utrecht
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Tracy S, Chen C. Multidisciplinary long-term follow-up of congenital diaphragmatic hernia: a growing trend. Semin Fetal Neonatal Med 2014; 19:385-91. [PMID: 25306470 DOI: 10.1016/j.siny.2014.09.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
This literature review discusses the growing trend toward multidisciplinary long term follow-up for congenital diaphragmatic hernia.
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Affiliation(s)
- Sarah Tracy
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Catherine Chen
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA.
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Abstract
Congenital diaphragmatic hernia is an uncommon congenital anomaly of the diaphragm with pulmonary hypoplasia and persistent pulmonary hypertension as serious consequences. Despite recent advances in therapy, congenital diaphragmatic hernia remains a challenging condition. Best treatment strategies are still largely unknown, and practice strategies vary widely among different centres. Additionally, as congenital diaphragmatic hernia is a relatively uncommon condition, it is difficult to recruit sufficient numbers of patients for clinical trials. In recent years, survival rates of congenital diaphragmatic hernia patients appear to have increased. With the progressively improved survival rates, the long-term prognosis and quality of life of patients have become an increasingly important issue. Survivors have been shown to be at risk for many long-term morbidities, which highlights the importance of long-term follow-up of these children. The aim of this review is to give an overview of the current knowledge regarding congenital diaphragmatic hernia.
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Affiliation(s)
- Lisette Leeuwen
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, New South Wales, Australia; Medical School, University of Groningen, Groningen, The Netherlands
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15
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Danzer E, Kim SS. Neurodevelopmental outcome in congenital diaphragmatic hernia: Evaluation, predictors and outcome. World J Clin Pediatr 2014; 3:30-36. [PMID: 25254182 PMCID: PMC4162442 DOI: 10.5409/wjcp.v3.i3.30] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Revised: 05/16/2014] [Accepted: 07/29/2014] [Indexed: 02/06/2023] Open
Abstract
To review the reported neurodevelopmental outcome of congenital diaphragmatic hernia (CDH) survivors, identify important predictors of developmental disabilities, and describe the pathophysiological mechanisms contributing to adverse outcome. A Medline search was performed for English-language articles cross-referencing CDH with pertinent search terms. Retrospective, prospective, and longitudinal follow-up studies were examined. The reference lists of identified articles were also searched. Neurodevelopmental dysfunction has been recognized as one of most common and potentially most disabling outcome of CDH. Intelligence appears to be in the low normal to mildly delayed range. Neuromotor dysfunction is common during early childhood. Behavioral problems, hearing impairment, and quality of life related issues are frequently encountered in older children and adolescence. Disease severity correlates with the degree of neurological dysfunction. Neurodevelopmental follow-up in CDH children should become standard of care to identify those who would benefit from early intervention services and improve neurological outcomes.
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16
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Leeuwen L, Walker K, Halliday R, Fitzgerald DA. Neurodevelopmental outcome in Congenital Diaphragmatic Hernia survivors during the first three years. Early Hum Dev 2014; 90:413-5. [PMID: 24951078 DOI: 10.1016/j.earlhumdev.2014.04.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Revised: 04/04/2014] [Accepted: 04/20/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To determine neurodevelopmental outcome in Congenital Diaphragmatic Hernia (CDH) survivors during the first three years of life. METHODS Admitted CDH patients were assessed at the age of 12 (n=18) and 36 months (n=15) using the Bayley Scales of Infant and Toddler Development Third Edition. Neurodevelopmental results of CDH patients were compared with published norms and with a healthy matched control group. RESULTS At 12 months, receptive language was mildly delayed in 6% of patients and 6% of patients demonstrated mildly delay in expressive language and gross motor skills. Eighteen percent of CDH patients had severely delayed scores for gross motor skills. At 36 months, expressive language scores were mildly delayed in 21% of patients. When compared to the control group, CDH patients had similar neurodevelopmental scores at 12 and 36 months of age. CONCLUSION CDH is not necessarily associated with impaired neurodevelopmental outcomes during the first three years of life. SUMMARY The aim of this study was to describe neurodevelopmental outcomes in Congenital Diaphragmatic Hernia (CDH) survivors. At 12 months, three (18%) patients had severely delayed scores for gross motor skills. At 36 months, expressive language scores were mildly delayed in three (21%) patients. Neurodevelopmental outcomes of CDH patients were no different to healthy matched controls at 12 and 36 months.
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Affiliation(s)
- Lisette Leeuwen
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, Australia; Medical School, University of Groningen, Groningen, The Netherlands.
| | - Karen Walker
- Discipline of Paediatrics and Child Health, Sydney Medical School, University of Sydney, Sydney, Australia; Grace Centre for Newborn Care, The Children's Hospital at Westmead, Sydney, Australia
| | - Robert Halliday
- Discipline of Paediatrics and Child Health, Sydney Medical School, University of Sydney, Sydney, Australia; Grace Centre for Newborn Care, The Children's Hospital at Westmead, Sydney, Australia
| | - Dominic A Fitzgerald
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, Australia; Discipline of Paediatrics and Child Health, Sydney Medical School, University of Sydney, Sydney, Australia
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17
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Danzer E, Gerdes M, D'Agostino JA, Hoffman C, Bernbaum J, Bebbington MW, Siegle J, Sulkowski J, Rintoul NE, Flake AW, Scott Adzick N, Hedrick HL. Longitudinal neurodevelopmental and neuromotor outcome in congenital diaphragmatic hernia patients in the first 3 years of life. J Perinatol 2013; 33:893-8. [PMID: 23660581 DOI: 10.1038/jp.2013.47] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Revised: 03/25/2013] [Accepted: 03/25/2013] [Indexed: 01/18/2023]
Abstract
OBJECTIVE The objective of this study was to longitudinally evaluate the neurodevelopmental (ND) outcome in congenital diaphragmatic hernia (CDH) survivors during the first 3 years of life. STUDY DESIGN The study cohort consists of 47 CDH survivors that were enrolled in our prospective, follow-up program between July 2004 and September 2010, and underwent serial ND evaluations during the first 3 years of life. ND outcomes were evaluated using the Bayley Scales of Infant Development (BSID)-II or BSID-III. Persistent ND impairment was defined as a score that remained 79 for the cognitive, language and psychomotor domains at the most recent follow-up visit compared with the first assessment. RESULT The median age at first and last evaluation was 8 (range, 5 to 15) and 29 (range, 23 to 36) months, respectively. During the follow-up, ND scores improved to average in 17%, remained average in 60%, remained delayed in 10%, improved from severely delayed to mildly delayed in 2% and deteriorated from average to delayed in 15%. Motor scores improved to average in 26%, remained average in 55%, remained delayed in 8% and improved from severely delayed to mildly delayed in 11%. Intrathoracic liver position (P=0.004), preterm delivery (P=0.03), supplemental O2 requirement at day of life 30 (P=0.007), age at discharge (P=0.03), periventricular leukomalacia (PVL; P=0.004) and initial neuromuscular hypotonicity (P=0.01) were associated with persistent motor delays. No relationship was found between patient's characteristics and the risk of persistent cognitive and language delays. CONCLUSION (1) The majority of children with CDH are functioning in the average range by early preschool age, (2) most children who had early delays showed improvement in their ND outcome, (3) children showing delays in all the three domains were the least likely to show improvement and (4) CDH severity appears to be predictive of persistent psychomotor delays.
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Affiliation(s)
- E Danzer
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia and The University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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18
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Wynn J, Aspelund G, Zygmunt A, Stolar CJH, Mychaliska G, Butcher J, Lim FY, Gratton T, Potoka D, Brennan K, Azarow K, Jackson B, Needelman H, Crombleholme T, Zhang Y, Duong J, Arkovitz MS, Chung WK, Farkouh C. Developmental outcomes of children with congenital diaphragmatic hernia: a multicenter prospective study. J Pediatr Surg 2013; 48:1995-2004. [PMID: 24094947 PMCID: PMC3884579 DOI: 10.1016/j.jpedsurg.2013.02.041] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 01/08/2013] [Accepted: 02/03/2013] [Indexed: 12/16/2022]
Abstract
PURPOSE To determine developmental outcomes and associated factors in patients with congenital diaphragmatic hernia (CDH) at 2 years of age. METHODS This is a multicenter prospective study of a CDH birth cohort. Clinical and socioeconomic data were collected. Bayley Scales of Infant Development (BSID-III) and Vineland Adaptive Behavior Scales (VABS-II) were performed at 2 years of age. RESULTS BSID-III and VABS-II assessments were completed on 48 and 49 children, respectively. The BSID-III mean cognitive, language, and motor scores were significantly below the norm mean with average scores of 93 ± 15, 95 ± 16, and 95 ± 11. Ten percent (5/47) scored more than 2 standard deviations below the norm on one or more domains. VABS-II scores were similar to BSID-III scores with mean communication, daily living skills, social, motor, adaptive behavior scores of 97 ± 14, 94 ± 16, 93 ± 13, 97 ± 10, and 94 ± 14. For the BSID-III, supplemental oxygen at 28 days, a prenatal diagnosis, need for extracorporeal membrane oxygenation (ECMO) and exclusive tube feeds at time of discharge were associated with lower scores. At 2 years of age, history of hospital readmission and need for tube feeds were associated with lower scores. Lower socioeconomic status correlated with lower developmental scores when adjusted for significant health factors. CONCLUSION CDH patients on average have lower developmental scores at 2 years of age compared to the norm. A need for ECMO, oxygen at 28 days of life, ongoing health issues and lower socioeconomic status are factors associated with developmental delays.
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Affiliation(s)
- Julia Wynn
- Department of Pediatrics, Columbia University, NY, NY
| | - Gudrun Aspelund
- Division of Pediatric Surgery, Department of Surgery, Columbia University, NY, NY
| | | | - Charles JH. Stolar
- Division of Pediatric Surgery, Department of Surgery, Columbia University, NY, NY
| | - George Mychaliska
- Division of Pediatric Surgery, Department of Surgery, University of Michigan School of Medicine, Ann Arbor, MI
| | - Jennifer Butcher
- Division of Child Behavioral Health, Department of Pediatrics and Communicable Diseases, University of Michigan School of Medicine, Ann Arbor, MI
| | - Foong-Yen Lim
- Division of Pediatric General, Thoracic, and Fetal Surgery, Center for Molecular Fetal Therapy, Cincinnati Children’s Hospital Medical Center, and Cincinnati, OH
| | - Teresa Gratton
- University of Cincinnati, Department of Pediatrics, Cincinnati, OH; Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, Division of Neonatology and Pulmonary Biology, Cincinnati, OH
| | - Douglas Potoka
- Division of Pediatric Surgery, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Kate Brennan
- Department of Instruction and Learning - Early Intervention Program, University of Pittsburgh, Pittsburgh, PA
| | - Ken Azarow
- Division of Pediatric Surgery, Department of Surgery, University of Nebraska College of Medicine/Children’s Hospital and Medical Center, Omaha, NE
| | - Barbara Jackson
- Department of Education, Munroe-Meyer Institute, University of Nebraska Medical Center Omaha, NE
| | - Howard Needelman
- Section of Developmental/Behavioral Pediatrics, Munroe-Meyer Institute, University of Nebraska Medical Center Omaha, NE
| | - Timothy Crombleholme
- Colorado Fetal Care Center, Division of Pediatric General, Thoracic, and Fetal Surgery, Children’s Hospital Colorado and the University of Colorado School of Medicine
| | - Yuan Zhang
- Department of Biostatistics, Mailman School of Public Health, Columbia University, NY, NY
| | - Jimmy Duong
- Department of Biostatistics, Mailman School of Public Health, Columbia University, NY, NY
| | - Marc S. Arkovitz
- Department of Pediatric Surgery, Tel Hashomer medical center, Tel Aviv, Israel
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Preschool neurological assessment in congenital diaphragmatic hernia survivors: outcome and perinatal factors associated with neurodevelopmental impairment. Early Hum Dev 2013; 89:393-400. [PMID: 23333410 DOI: 10.1016/j.earlhumdev.2012.12.009] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2012] [Revised: 12/12/2012] [Accepted: 12/13/2012] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To evaluate the preschool neurodevelopmental outcome in CDH survivors between 2 and 5 years of age and to identify perinatal and postnatal factors that may be predictive of persistent neurological deficits. METHODS The study cohort consists of 60 CDH survivors that were enrolled in our prospective, follow-up program between January 2006 and September 2012. Developmental assessment of study participants between 2 and 3 years of age was performed using the Bayley Scales of Infant Development, 3rd Edition (BSID-III). Cognitive outcomes of CDH children older than 3 years of age were evaluated using The Wechsler Preschool and Primary Scale of Intelligence, 3rd Edition (WPPSI-III). Neurodevelopmental delay was defined by a score of ≤ 85 in any of the evaluated composite scores. Severe impairments were defined as a score of ≤ 69 in at least one domain tested. RESULTS Mean follow-up for children assessed by BSID-III (n=42) and WPPSI-III (n=18) was 28 ± 4.5 months and 58 ± 4.0 months, respectively. As a group, mean composite and subdomain BSID-III and WPPSI-III scores were within the expected normal range. For the BSID-III group, 9 (22%) had mild deficits in at least one domain, and 6 (14%) had severe deficits in at least one. Only 3 (7%) patients demonstrated severe neurological delays for all BSID-III composite scales. For the WPPSI-III group, 4 (22%) patients scored within the borderline-delayed range for at least one subscale and only one (6%) child had a WPPSI-III VIQ score in the severe delay range. Abnormal muscle tonicity was found in 35% (hypotonicity 33%, hypertonicity 2%). Need for ECMO, prolonged ventilation, hypotonicity, and other surrogate markers of disease severity (P<0.05) were associated with borderline or delayed neurological outcome. CONCLUSION The majority of CDH children are functioning in the average range at early preschool and preschool age. Neuromuscular hypotonicity is common in CDH survivors. CDH severity appears to be predictive of adverse neurodevelopmental outcome.
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Abstract
Congenital diaphragmatic hernia (CDH) is a congenital anomaly that presents with a broad spectrum of severity that is dependent upon components of pulmonary hypoplasia and pulmonary hypertension. While advances in neonatal care have improved the overall survival of CDH in experienced centers, mortality and morbidity remain high in a subset of CDH infants with severe CDH. Prenatal predictors have been refined for the past two decades and are the subject of another review in this issue. So far, all randomized trials comparing prenatal intervention to standard postnatal therapy have shown no benefit to prenatal intervention. Although recent non-randomized reports of success with fetoscopic endoluminal tracheal occlusion (FETO) and release are promising, prenatal therapy should not be widely adopted until a well-designed prospective randomized trial demonstrating efficacy is performed. The increased survival and subsequent morbidity of CDH survivors has resulted in the need to provide resources for the long-term follow up and support of the CDH population.
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Affiliation(s)
- Holly L Hedrick
- Perelman School of Medicine at the University of Pennsylvania, The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
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21
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Multi-institutional follow-up of patients with congenital diaphragmatic hernia reveals severe disability and variations in practice. J Pediatr Surg 2012; 47:836-41. [PMID: 22595557 DOI: 10.1016/j.jpedsurg.2012.01.032] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2011] [Accepted: 01/26/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND/PURPOSE Survivors of congenital diaphragmatic hernia (CDH) have a high incidence of morbidity. Variability in follow-up practices between institutions may affect perception of disability and prevent population-based outcome analysis. METHODS A survey of follow-up practices at 16 centers within a population-based CDH network was performed. A descriptive analysis of outcomes (minimum 24 months postdischarge) of CDH survivors from the 2 largest centers was performed. RESULTS The nature of follow-up of CDH survivors was highly variable in 12 of 16 responding centers, ranging from ad hoc, community-based, and pediatrician-sponsored follow-up to a single perinatal center-based multispecialty CDH clinic. Outcomes at 24 to 36 months were reported from the 2 largest centers (n = 44). Among survivors, neurodevelopmental disability was most common (12/44; 27%) followed by gastrointestinal (9; 20.5%), pulmonary (5; 11.4%), musculoskeletal (5; 11.4%), and cardiac (2; 4.5%). Additional surgery was required in 17 patients (38.6%), including recurrent CDH repair in 7 (15.9%). Five patients (11.4%) had hearing loss. Among 41 children with available 24-month data, 32 (78%), 17 (41.5%), and 14 (34.1%) patients had weights below the 50th, 25th, and 3rd percentiles, respectively. CONCLUSION Congenital diaphragmatic hernia survivorship is associated with significant disability. Standardization of follow-up practices is essential to enable population-based outcomes analysis.
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Danzer E, Zarnow D, Gerdes M, D'Agostino JA, Siegle J, Bebbington MW, Flake AW, Adzick NS, Hedrick HL. Abnormal brain development and maturation on magnetic resonance imaging in survivors of severe congenital diaphragmatic hernia. J Pediatr Surg 2012; 47:453-61. [PMID: 22424337 DOI: 10.1016/j.jpedsurg.2011.10.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Revised: 10/02/2011] [Accepted: 10/03/2011] [Indexed: 01/18/2023]
Abstract
PURPOSE The aim of the study was to evaluate the incidence of abnormal brain maturation in survivors of severe congenital diaphragmatic hernia (CDH). MATERIAL AND METHODS Between July 2004 and December 2009, 50 CDH survivors underwent detailed brain magnetic resonance (MR) imaging before discharge. Magnetic resonance images were analyzed to evaluate the presence of structural brain abnormalities and to calculate overall brain maturation using the total maturation score (TMS). RESULTS Thirty-two children (64%) underwent MR imaging between 39 and 43 weeks of gestation, allowing for evaluation of the TMS. Eighteen (36%) underwent MR imaging between 44 and 69 weeks of gestation, allowing for structural analysis of brain maturity only. The mean TMS was 14.1 ± 1.2 and significantly lower than reported age-matched normative data in infants without CDH (15.3 ± 1.0, P = .02). The TMS in 4 patients (12.5%) corresponded to a delay of 1 month in structural brain development. Eight infants (25%) demonstrated a 2-week delay. Periventricular leukomalacia was detected in 9 (18%), incomplete development of the opercula in 7 (14%), various degrees of intracranial hemorrhage in 24 (48%), and prominent extraaxial fluid spaces in 20 (40%) cases. CONCLUSIONS Brain maturation in infants with severe CDH appears to be delayed. Long-term neurodevelopmental follow-up is needed to determine the significance of a lower-than-expected TMS and the presence of structural brain abnormalities on functional outcomes in this population.
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Affiliation(s)
- Enrico Danzer
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia and The University of Pennsylvania School of Medicine, Philadelphia, PA 19104-4318, USA.
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Danzer E, Hedrick HL. Neurodevelopmental and neurofunctional outcomes in children with congenital diaphragmatic hernia. Early Hum Dev 2011; 87:625-32. [PMID: 21640525 DOI: 10.1016/j.earlhumdev.2011.05.005] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2011] [Accepted: 05/12/2011] [Indexed: 10/18/2022]
Abstract
The objective of this review was to provide a critical overview of our current understanding on the neurocognitive, neuromotor, and neurobehavioral development in congenital diaphragmatic hernia (CDH) patients, focusing on three interrelated clinical issues: (1) comprehensive outcome studies, (2) characterization of important predictors of adverse outcome, and (3) the pathophysiological mechanism contributing to neurodevelopmental disabilities in infants with CDH. Improved survival for CDH has led to an increasing focus on longer-term outcomes. Neurodevelopmental dysfunction has been recognized as the most common and potentially most disabling outcome of CDH and its treatment. While increased neuromotor dysfunction is a common problem during infancy, behavioral problems, hearing impairment and quality of life related issues are frequently found in older children and adolescence. Intelligence appears to be in the low normal range. Patient and disease specific predictors of adverse neurodevelopmental outcome have been defined. Imaging studies have revealed a high incidence of structural brain abnormalities. An improved understanding of the pathophysiological pathways and the neurodevelopmental consequences will allow earlier and possibly more targeted therapeutic interventions. Continuous assessment and follow-up as provided by an interdisciplinary team of medical, surgical and developmental specialists should become standard of care for all CDH children to identify and treat morbidities before additional disabilities evolve and to reduce adverse outcomes.
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Affiliation(s)
- Enrico Danzer
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, PA 1910, USA.
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Abstract
This case report describes occupational therapy (OT) intervention in an outpatient setting and outcomes for a child diagnosed with congenital diaphragmatic hernia (CDH) from 4 to 28 months of age. There is little information on therapy intervention and outcomes of children who have survived. The patient is a white male, born at 35 weeks gestation with a diagnosis of left CDH that required a patch repair. He also had a Nissen fundoplication, gastrostomy tube and spent the first 100 days of his life in the hospital. He received outpatient OT for 2 years. The process of service provision is described using the "Occupational therapy practice framework: Domain and process, 2nd edition" (American Occupational Therapy Association, 2008 , American Journal of Occupational Therapy, 62(6), 625-683). The focus of intervention, description of the intervention process, and timeline for achievement of skills is provided. Outcomes and assessment tools used included the Canadian Occupational Performance Measure and Peabody Developmental Motor Scales-Second Edition.
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Affiliation(s)
- Angela C Bates
- Occupational Therapy, Cincinnati Children's Hospital, Cincinnati, Ohio 45229, USA.
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25
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Danzer E, Gerdes M, Bernbaum J, D'Agostino J, Bebbington MW, Siegle J, Hoffman C, Rintoul NE, Flake AW, Adzick NS, Hedrick HL. Neurodevelopmental outcome of infants with congenital diaphragmatic hernia prospectively enrolled in an interdisciplinary follow-up program. J Pediatr Surg 2010; 45:1759-66. [PMID: 20850617 DOI: 10.1016/j.jpedsurg.2010.03.011] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2009] [Revised: 03/04/2010] [Accepted: 03/05/2010] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of the study was to evaluate the neurodevelopmental outcome in infants with congenital diaphragmatic hernia (CDH). METHODS Between June 2004 and September 2007, 41 CDH survivors were prospectively enrolled in an interdisciplinary follow-up program. Neurodevelopmental status was evaluated using the Bayley Scales of Infant Development II (prior 2006, n = 9), the Bayley Scales of Infant Development III (after 2006, n = 27), or the Wechsler Preschool and Primary Scale of Intelligence III (children older than 4 years, n = 5). Scores were grouped as average, mildly delayed, and severely delayed by standard deviation intervals (115-85, 71-84, <70), and mixed if average and mildly delayed in either cognitive or language. RESULTS Median age at last assessment was 24 months (range, 6-62). Average, mixed, mildly delayed, and severely delayed scores for neurocognitive and language skills were found in 49%, 19%, 17%, and 15%, respectively. Psychomotor scores were normal, mildly delayed, and severely delayed in 46%, 23%, and 31%, respectively. Autism was present in 7%. Abnormal muscle tonicity was found in 51% (49% hypotonic, 2% hypertonic). Multivariate risk factors for borderline or delayed neurodevelopmental, neurocognitive, and/or psychomotor outcome were intrathoracic liver position (P = .02), presence of a right-sided CDH (P = .02), extracorporeal membrane oxygenation need (P < .001), Gore-Tex patch repair (P = .02), O(2) requirement at 30 days of life (P < .01), and hypotonicity (P < .01). CONCLUSIONS The prospective evaluation in an interdisciplinary follow-up program uncovered striking morbidities in neurodevelopmental status in approximately half of the CDH infants. The most common neurologic sequelae are neuromuscular hypotonicity and psychomotor dysfunction. Patient-specific factors are important determinants of adverse neurologic outcome.
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Affiliation(s)
- Enrico Danzer
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA 19104-4318, USA
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Tracy S, Estroff J, Valim C, Friedman S, Chen C. Abnormal neuroimaging and neurodevelopmental findings in a cohort of antenatally diagnosed congenital diaphragmatic hernia survivors. J Pediatr Surg 2010; 45:958-65. [PMID: 20438935 DOI: 10.1016/j.jpedsurg.2010.02.015] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2010] [Accepted: 02/03/2010] [Indexed: 12/17/2022]
Abstract
PURPOSE Prior studies have shown that survivors of congenital diaphragmatic hernia (CDH) repair may have long-term cardiac, pulmonary, and nutritional issues, as well as neurodevelopmental sequelae within the first 3 years of life. In this study, we examined the relationship between neuroimaging abnormalities and neurodevelopmental outcomes in a cohort of antenatally diagnosed CDH survivors. METHODS Retrospective chart reviews were performed for CDH survivors born from January 2000 to December 2007 who were evaluated antenatally in the Advanced Fetal Care Center at Children's Hospital Boston (Mass). Prenatal and postnatal neuroimaging findings, clinical data, and neurodevelopmental findings were collected for a cohort of 45 patients who were evaluated by a developmental pediatrician at ages 1 and/or 3. RESULTS Prenatal neuroimaging studies detected brain anomalies in this cohort with a false-negative rate of 7%. Of the 45 study participants, 87% had left-sided CDH, 22% had cardiac anomalies, and 18% had congenital malformations or genetic syndromes. Nearly all required ventilator management (98%) with a median ventilator time of 17 days (range, 3-56 days). Moreover, 24% required extracorporeal membrane oxygenation. While 84% of patients had medical issues at discharge, 68% and 77% had medical issues at ages 1 and 3, respectively. Pulmonary problems were noted in 32% and 47% of the ages 1 and 3 cohorts, respectively. Motor problems were detected in 46% and 71% of the ages 1 and 3 cohorts, respectively. More patients with motor problems at age 1 had abnormal rather than normal postnatal neuroimaging studies (P = .01). Children with motor problems at age 1 were more apt to have an abnormal postnatal neuroimaging finding (odds ratio [OR], 6.3; 95% confidence interval [CI], 1.5-26.8; P = .01), pulmonary problems at age 1 (OR, 4.0; 95% CI, 0.99-16.6; P = .04), and a history of ventilatory management with a linear ventilator time (OR, 1.1; 95% CI, 1.01-1.12; P = .03). CONCLUSIONS Prenatal neuroimaging can accurately image the brain of fetuses with CDH. Abnormal postnatal neuroimaging findings, the presence of pulmonary problems at age 1, and the length of ventilator time were predictors of motor problems at age 1. Ongoing follow-up of CDH survivors should include neurodevelopmental evaluations.
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Affiliation(s)
- Sarah Tracy
- Department of Surgery, Children's Hospital, Boston, MA 02115, USA
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Hedrick HL. Management of prenatally diagnosed congenital diaphragmatic hernia. Semin Fetal Neonatal Med 2010; 15:21-7. [PMID: 19884051 DOI: 10.1016/j.siny.2009.07.012] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is a congenital anomaly that presents with a broad spectrum of severity dependent upon components of pulmonary hypoplasia and pulmonary hypertension. While advances in neonatal care have improved the overall survival of CDH in experienced centers, mortality and morbidity remain high in a subset of CDH infants with severe CDH. The most important prenatal predictor of outcome in left-sided CDH is liver position. More precise and reproducible prenatal predictive parameters need to be developed to allow standardization of results between centers and appropriate design of clinical trials in CDH. Thus far, all randomized trials comparing prenatal intervention to standard postnatal therapy have shown no benefit to prenatal intervention. Although recent non-randomized reports of success with balloon tracheal occlusion (and release) are promising, prenatal therapy should not be widely adopted until a well-designed prospective randomized trial demonstrating efficacy is performed. The increased survival and subsequent morbidity of CDH survivors has resulted in the need to provide resources for the long-term follow-up and support of the CDH population.
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Affiliation(s)
- Holly L Hedrick
- University of Pennsylvania, Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, USA.
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Chiu PP, Langer JC. Surgical Conditions of the Diaphragm: Posterior Diaphragmatic Hernias in Infants. Thorac Surg Clin 2009; 19:451-61. [DOI: 10.1016/j.thorsurg.2009.08.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Peetsold MG, Heij HA, Kneepkens CMF, Nagelkerke AF, Huisman J, Gemke RJBJ. The long-term follow-up of patients with a congenital diaphragmatic hernia: a broad spectrum of morbidity. Pediatr Surg Int 2009; 25:1-17. [PMID: 18841373 DOI: 10.1007/s00383-008-2257-y] [Citation(s) in RCA: 129] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/17/2008] [Indexed: 01/18/2023]
Abstract
Congenital diaphragmatic hernia (CDH) is a life-threatening anomaly with a mortality rate of approximately 40-50%, depending on case selection. It has been suggested that new therapeutic modalities such as nitric oxide (NO), high frequency oxygenation (HFO) and extracorporal membrane oxygenation (ECMO) might decrease mortality associated with pulmonary hypertension and the sequelae of artificial ventilation. When these new therapies indeed prove to be beneficial, a larger number of children with severe forms of CDH might survive, resulting in an increase of CDH-associated complications and/or consequences. In follow-up studies of infants born with CDH, many complications including pulmonary damage, cardiovascular disease, gastro-intestinal disease, failure to thrive, neurocognitive defects and musculoskeletal abnormalities have been described. Long-term pulmonary morbidity in CDH consists of obstructive and restrictive lung function impairments due to altered lung structure and prolonged ventilatory support. CDH has also been associated with persistent pulmonary vascular abnormalities, resulting in pulmonary hypertension in the neonatal period. Long-term consequences of pulmonary hypertension are unknown. Gastro-esophageal reflux disease (GERD) is also an important contributor to overall morbidity, although the underlying mechanism has not been fully understood yet. In adult CDH survivors incidence of esophagitis is high and even Barrett's esophagus may ensue. Yet, in many CDH patients a clinical history compatible with GERD seems to be lacking, which may result in missing patients with pathologic reflux disease. Prolonged unrecognized GERD may eventually result in failure to thrive. This has been found in many young CDH patients, which may also be caused by insufficient intake due to oral aversion and increased caloric requirements due to pulmonary morbidity. Neurological outcome is determined by an increased risk of perinatal and neonatal hypoxemia in the first days of life of CDH patients. In patients treated with ECMO, the incidence of neurological deficits is even higher, probably reflecting more severe hypoxemia and the risk of ECMO associated complications. Many studies have addressed the substantial impact of the health problems described above, on the overall well-being of CDH patients, but most of them concentrate on the first years after repair and only a few studies focus on the health-related quality of life in CDH patients. Considering the scattered data indicating substantial morbidity in long-term survivors of CDH, follow-up studies that systematically assess long-term sequelae are mandatory. Based on such studies a more focused approach for routine follow-up programs may be established.
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Affiliation(s)
- M G Peetsold
- Department of Pediatrics, VU University Medical Center, Amsterdam, The Netherlands.
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Chiu P, Hedrick HL. Postnatal management and long-term outcome for survivors with congenital diaphragmatic hernia. Prenat Diagn 2008; 28:592-603. [PMID: 18551724 DOI: 10.1002/pd.2007] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Significant advances in the postnatal management of patients with congenital diaphragmatic hernia (CDH) have resulted in a remarkable improvement in survival rates over the past two decades. The success of current postnatal management of CDH patients has rendered fetal intervention to be limited to the most severe cases, and the role for prenatal treatment of CDH patients remains unclear. The adoption of lung-preserving strategies including high-frequency oscillatory ventilation (HFOV) and extracorporeal membrane oxygenation (ECMO) have improved CDH outcomes especially in those patients with significant ventilatory or circulatory compromise. Survival rates of up to 90% are being reported in some high-volume centers. However, the increased survival in CDH patients has been accompanied by an increase in neurological, nutritional and musculoskeletal morbidity among the long-term survivors. This has resulted in the need to provide resources for the long-term follow-up and support of this patient population. In this article, the postnatal management strategies and primary and secondary outcomes of high-volume international pediatric surgical centers will be reviewed. Finally, the role of a multidisciplinary management team for the follow-up of long-term CDH survivors will be discussed.
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Affiliation(s)
- Priscilla Chiu
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
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Abstract
PURPOSE OF REVIEW To evaluate the impact of recent research on the management of congenital diaphragmatic hernia in the light of new theories on embryological development, earlier antenatal diagnosis, fetal and postnatal interventions together with advances in perinatal intensive care. RECENT FINDINGS The year 2007 provided in excess of 200 publications that address various aspects of congenital diaphragmatic hernia. The genetic basis and the causes of pulmonary hypoplasia at the molecular level are slowly being unravelled. Fetal MRI of lung volume, lung-head ratio, liver position and size of diaphragmatic defect have all been evaluated as early predictors of outcome and with a view to prenatal counselling. The impact of fetal interventions such as fetal endoluminal tracheal occlusion, the mode of delivery, the surgical techniques and agents for treating pulmonary hypertension were evaluated. The influence of associated anomalies and therapeutic interventions on the outcome and quality of life of survivors continue to be appraised. SUMMARY Deferred surgery after stabilization with gentle ventilation and reversal of pulmonary hypertension remain the cornerstones of management. Optimal presurgery and postsurgery ventilatory settings remain unproven. Continued improvement in neonatal intensive care raises the bar against which any intervention such as fetal endoluminal tracheal occlusion and extracorporeal membrane oxygenation will be judged.
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Friedman S, Chen C, Chapman JS, Jeruss S, Terrin N, Tighiouart H, Parsons SK, Wilson JM. Neurodevelopmental outcomes of congenital diaphragmatic hernia survivors followed in a multidisciplinary clinic at ages 1 and 3. J Pediatr Surg 2008; 43:1035-43. [PMID: 18558179 DOI: 10.1016/j.jpedsurg.2008.02.029] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2008] [Accepted: 02/09/2008] [Indexed: 02/08/2023]
Abstract
PURPOSE Infants who survive congenital diaphragmatic hernia (CDH) repair may have ongoing medical and neurodevelopmental morbidity after hospital discharge. We evaluated the relationship between medical and neurodevelopmental outcomes of CDH survivors seen in a multidisciplinary clinic at ages 1 and/or 3. METHODS From January 1997 to December 2004, 69 (61%) of 112 CDH survivors were followed in our CDH clinic at ages 1 and/or 3. Medical issues (cardiac, pulmonary, gastrointestinal) were tabulated at hospital discharge and at follow-up. Neurodevelopmental data were obtained from clinic assessments by a neurodevelopmental pediatrician. Descriptive results were summarized for each cohort. Multivariate analyses were performed to identify predictors of motor problems at age 1. RESULTS Of the 69 study participants, 64% were male, 75% had left-sided CDH, 17% had cardiac anomalies, and 25% had other congenital malformations. Nearly all required ventilator management (99%) with a median ventilator time of 14 days (range, 1-54 days); 30% required extracorporeal membrane oxygenation. While 87% of patients had medical issues at hospital discharge, 61% and 67% had medical issues at ages 1 and 3, respectively. Pulmonary problems were noted in 34% and 33% of the ages 1 and 3 cohorts, respectively. Motor and language problems were detected in 60% and 18% of the age 1 cohort and 73% and 60% of the age 3 cohort, respectively. Multivariate analysis found ventilator time as the only independent predictor of motor problems at age 1 (odds ratio, 1.12 per day; 95% confidence interval, 1.05-1.20; P < .01). CONCLUSIONS Young CDH survivors continue to have ongoing medical problems and a high incidence of motor and language problems. Duration of neonatal ventilatory support was a significant predictor of motor problems at age 1. Prospective studies are needed to confirm these findings.
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Affiliation(s)
- Sandra Friedman
- Department of Medicine, Children's Hospital, Boston, MA 02115, USA
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