Impaired somatic growth and delayed lung development in infants with congenital diaphragmatic hernia--evidence from a 10-year, single center prospective follow-up study

Approaches to nutrition and feeding in congenital diaphragmatic hernia

In patients with congenital diaphragmatic hernia1, nutrition can represent a challenge both in the short and long term. Its failure to resolve can have a significant impact on multiple aspects of the lives of patients with congenital diaphragmatic hernia (CDH), ranging from lung function to neurodevelopment. In this review, we will describe the causes of nutritional problems in patients with CDH, their consequences, and possible strategies to address them.

Impact of fetal treatments for congenital diaphragmatic hernia on lung development

The extent of lung hypoplasia impacts the survival and severity of morbidities associated with congenital diaphragmatic hernia (CDH). The alveoli of CDH infants and in experimental models of CDH have thickened septa with fewer type II pneumocytes and capillaries. Fetal treatments of CDH-risk preterm birth. Therefore, treatments must aim to balance the need for increased gas exchange surface area with the restoration of pulmonary epithelial type II cells and the long-term respiratory and neurodevelopmental consequences of prematurity. Achievement of sufficient lung development in utero for successful postnatal transition requires adequate intra-thoracic space for lung growth, maintenance of sufficient volume and appropriate composition of fetal lung fluid, regular fetal breathing movements, appropriate gas exchange area, and ample surfactant production. The review aims to examine the rationale for current and future therapeutic strategies to improve postnatal outcomes of infants with CDH.

The association between growth patterns and blood pressure in children and adolescents: A cross-sectional study of seven provinces in China

Aimed to investigate the associations between different growth patterns with high blood pressure, and further examine the mediation effect of BMI between growth patterns and high blood pressure among children and adolescents. A total of 31581 children and adolescents aged 7-18 years were selected based on the stratified cluster sampling method. Logistics regression models were used to calculate the odds rations (ORs) and 95% confidence interval (95%CI) of the association between different growth patterns and high blood pressure. Mediation effect analyses were applied to estimate the effect of BMI on the increase of blood pressure levels in different growth patterns. In different sex and ages, compared to reference group of normal growth, blood pressure levels and prevalence of high blood pressure of the catch-up growth were higher, but that of the catch-down growth were lower. The prevalence of high blood pressure was 11.69%, 16.06%, and 9.68% in normal growth, catch-up growth, and catch-down growth, respectively. In total, compared with the normal growth pattern, the ORs (95%CI) of high blood pressure, high systolic blood pressure and high diastolic blood pressure in the catch-up growth were 1.171(1.073,1.280), 1.110(1.001,1.230) and 1.141(1.025,1.270) (p < .05), respectively. Additionally, the mediation effect of current BMI existed in the association between blood pressure levels and different growth patterns, particularly in boys. Our findings suggested that different growth patterns after birth could modify blood pressure, and the potential risks of high blood pressure could be increased by catch-up growth at childhood and adolescence.

The NeoAPACHE Study Protocol I: Assessment of the Radiographic Pulmonary Area and Long-Term Respiratory Function in Newborns With Congenital Diaphragmatic Hernia

In newborns with congenital diaphragmatic hernia (CDH), the radiographic lung area is correlated with functional residual capacity (FRC) and represents an alternative method to estimate lung hypoplasia. In a cohort of newborn CDH survivors, we retrospectively evaluated the relationship between radiographic lung area measured on the 1st day of life and long-term respiratory function. As a secondary analysis, we compared radiographic lung areas and respiratory function between patients undergoing fetal endoscopic tracheal occlusion (FETO) and patients managed expectantly (non-FETO). Total, ipsilateral, and contralateral radiographic areas were obtained by tracing lung perimeter as delineated by the diaphragm and rib cage, excluding mediastinal structures and herniated organs. Tidal volume (V_T), respiratory rate (RR), and their Z-Scores when compared to the norm were collected from pulmonary function tests (PFTs) performed at 12 ± 6 months of age. Linear regression analyses using the absolute Z-Score values for each parameter were performed. In CDH survivors, an increase in total and ipsilateral lung area measured at birth was related to a reduction in the absolute Z-Score for V_T in PFTs (p = 0.046 and p = 0.023, respectively), indicating a trend toward an improvement in pulmonary volumes and V_T normalization. Radiographic lung areas were not significantly different between FETO and non-FETO patients, suggesting a volumetric lung increase due to prenatal intervention. However, the mean Z-Score value for RR was significantly higher in the FETO group (p < 0.001), probably due to impaired diaphragmatic motility in the most severe cases. Further analyses are necessary to better characterize the role of the radiographic pulmonary area in the prognostic evaluation of respiratory function in patients with CDH. Clinical Trial Registration: This trial was registered at ClinicalTrials.gov with the identifier NCT04396028.

Resting energy expenditure in infants with congenital diaphragmatic hernia without respiratory support at time of neonatal hospital discharge

BACKGROUND

Infants with congenital diaphragmatic hernia (CDH) are at risk for growth failure because of inadequate caloric intake and high catabolic stress. There is limited data on resting energy expenditure (REE) in infants with CDH.

AIMS

To assess REE via indirect calorimetry (IC) in term infants with CDH who are no longer on respiratory support and nearing hospital discharge with advancing post-conceptional age and to assess measured-to-predicted REE using predictive equations.

METHODS

A prospective cohort study of term infants with CDH who were no longer on respiratory support and nearing hospital discharge was conducted to assess REE via IC and caloric intake. Baseline characteristics and hospital course data were collected. Three day average caloric intake around time of IC testing was calculated. Change in REE with advancing post-conceptional age and advancing post-natal age was assessed. The average measured-to-predicted REE was calculated for the cohort using predictive equations [22].

RESULTS

Eighteen infants with CDH underwent IC. REE in infants with CDH increased with advancing postconceptional age (r2 = 0.3, p < 0.02). The mean REE for the entire group was 53.2 +/- 10.9 kcal/kg/day while the mean caloric intake was 101.2 +/- 17.4 kcal/kg/day. The mean measured-to-predicted ratio for the cohort was in the normal metabolic range (1.10 +/- 0.17) with 50% of infants considered hypermetabolic and 11% of infants considered hypo-metabolic.

CONCLUSIONS

Infant survivors of CDH repair who are without respiratory support at time of neonatal hospital discharge have REE, as measured by indirect calorimetry, that increases with advancing post-conceptional age and that is within the normal metabolic range when compared to predictive equations.

LEVEL OF EVIDENCE

III.

Defining outcomes following congenital diaphragmatic hernia using standardised clinical assessment and management plan (SCAMP) methodology within the CDH EURO consortium

Treatment modalities for neonates born with congenital diaphragmatic hernia (CDH) have greatly improved in recent times with a concomitant increase in survival. In 2008, CDH EURO consortium, a collaboration of a large volume of CDH centers in Western Europe, was established with a goal to standardize management and facilitate multicenter research. However, limited knowledge on long-term outcomes restricts the identification of optimal care pathways for CDH survivors in adolescence and adulthood. This review aimed to evaluate the current practice of long-term follow-up within the CDH EURO consortium centers, and to review the literature on long-term outcomes published from 2000 onward. Apart from having disease-specific morbidities, children with CDH are at risk for impaired neurodevelopmental problems and failure of educational attainments which may affect participation in society and the quality of life in later years. Thus, there is every reason to offer them long-term multidisciplinary follow-up programs. We discuss a proposed collaborative project using standardized clinical assessment and management plan (SCAMP) methodology to obtain uniform and standardized follow-up of CDH patients at an international level.

Long-term morbidity of congenital diaphragmatic hernia: A plea for standardization

Congenital diaphragmatic hernia (CDH) survivors present long-term morbidities in several systems, including the neurodevelopmental, gastrointestinal, pulmonary, and musculoskeletal ones, and CDH long-term sequelae are increasingly being recognized. Due to high co-morbidity, health related quality of life in a significant proportion of CDH patients might be compromised. As a consequence of consciousness on the long-term sequelae of CDH survivors, and their consequences for life, several follow-up programs were brought to life worldwide. In this review, we will summarize the long-term sequelae of CDH survivors, the impact of new treatments, and analyze the consistency of follow-up programs.

Long-term follow-up of congenital diaphragmatic hernia

Increased survival of patients with congenital diaphragmatic hernia has created a unique cohort of children, adolescent, and adult survivors with complex medical and surgical needs. Disease-specific morbidities offer the opportunity for multiple disciplines to unite together to provide long-term comprehensive follow-up, as well as an opportunity for research regarding late outcomes. These children can exhibit impaired pulmonary function, altered neurodevelopmental outcomes, nutritional insufficiency, musculoskeletal changes, and specialized surgical needs that benefit from regular monitoring and intervention, particularly in patients with increased disease severity. Below we aim to characterize the specific challenges that these survivors face as well as present an algorithm for a multidisciplinary long-term follow-up program.

Pulmonary function and nutritional morbidity in children and adolescents with congenital diaphragmatic hernia

BACKGROUND

Malnutrition is common among congenital diaphragmatic hernia (CDH) survivors and may result from elevated respiratory effort. We evaluated body mass index (BMI), measured resting energy expenditure (mREE) and pulmonary function test (PFT) results in children and adolescents with CDH to determine if there is a correlation.

METHODS

With ethics approval (REB# 1000035323), anthropometrics, indirect calorimetry (IC) results and PFTs were collected from patients 5-17years of age during CDH clinic visits between 2000 and 2016. Malnutrition was defined as BMI z-scores <-2.0; mREE (as percent predicted REE) was measured using IC; z-scores for forced expiratory volume in 1s (FEV1) and forced vital capacity (FVC) were normal if <-1.64.

STATISTICS

GraphPad Prism 6, San Diego, CA.

RESULTS & DISCUSSION

Of 118 patients who attended clinic, 33 had reproducible PFTs, anthropometrics and IC results. Mean BMI z-score was -0.89±1.47 and 24% of patients were malnourished; mean FVC z-score (-1.32±1.39) was within normal range, whereas mean z-scores for FEV₁ (-2.21±1.68) and FEV₁/FVC ratio (-1.78±0.73) were below normal. A correlation was noted between BMI and PFTs (FEV₁ r=0.70, P<0.0001; FVC r=0.74 P<0.0001). Mean mREE was 112%±12% of expected and 67% of patients were hypermetabolic (mREE<110% predicted). IC results did not correlate with z-scores for either FEV₁ (r=0.10, P=0.57); or FVC (r=0.28, P=0.12).

CONCLUSIONS

These preliminary results suggest that a correlation is present between BMI and lung function in CDH children and adolescents, whereas lung function does not seem to correlate with mREE.

LEVEL OF EVIDENCE

II.

Relationship between computerized wheeze detection and lung function parameters in young infants

OBJECTIVE

Computerized respiratory sound analysis (CORSA) has been validated in the assessment of wheeze in infants, but it is unknown whether automatically detected wheeze is associated with impaired lung function. This study investigated the relationship between wheeze detection and conventional lung function testing (LFT) parameters.

METHODS

CORSA was performed using the PulmoTrack® monitor in 110 infants, of median (interquartile range) postmenstrual age 50 (46-56) weeks and median body weight 4,810 (3,980-5,900) g, recovering from neonatal intensive care. In the same session, LFT was performed, including tidal breathing measurements, occlusion tests, body plethysmography, forced expiratory flow by rapid thoracoabdominal compression, sulfur hexafluoride (SF6 ) multiple breath washout (MBW), and capillary blood gas analysis. Infants were classified as wheezers or non-wheezers using predefined cut-off values for the duration of inspiratory and expiratory wheeze.

RESULTS

Wheezing was detected in 72 (65%) infants, with 43 (39%) having inspiratory and 53 (48%) having expiratory wheezing. Endotracheal mechanical ventilation in the neonatal period for > 24 hr was associated with inspiratory wheeze (P = 0.009). Airway resistance was increased in both inspiratory (P = 0.02) and expiratory (P = 0.004) wheezers and correlated with the duration of expiratory wheeze (r = 0.394, P < 0.001). Expiratory wheezers showed a significant increase in respiratory resistance (P = 0.001), time constant (0.012), and functional residual capacity using SF6 MBW (P = 0.019). There was no association between wheezing and forced expiratory flow or blood gases.

CONCLUSION

CORSA can help identify neonates and young infants with subclinical airway obstruction and may prove useful in the follow-up of high-risk infants.

Nutritional Intake, Energy Expenditure, and Growth of Infants Following Congenital Diaphragmatic Hernia Repair

BACKGROUND/OBJECTIVES

The pathophysiology of failure to thrive in congenital diaphragmatic hernia (CDH) has not been fully elucidated, and the nutritional care of these infants is hindered by paucity of data on the optimal calorie requirements for growth. The primary objective of this study was to investigate the energy intake required for infants with CDH to grow optimally at the time of first hospital discharge. The secondary objectives were to assess their measured resting energy expenditure in infancy, and their long-term growth outcomes.

METHODS

Nutritional intake, anthropometrics, indirect calorimetry results, and respiratory status of infants with CDH from 2011 to 2014 were collected retrospectively. Data on confounders (gastroesophageal reflux disease and feeding intolerance, respiratory rate and pulmonary hypertension) were also collected. Analyses were performed using Stata (College Station, TX).

RESULTS

Of the 72 infants diagnosed with CDH during that period of time, 43 met the inclusion criteria. A caloric intake of 125.0 ± 20 kcal · kg · day was required to meet discharge weight gain criteria (25-35 g · kg · day). In a subset of 17 patients, measured resting energy expenditure was higher than predicted resting energy expenditure (58.0 ± 18 vs 46.6 ± 3 kcal · kg · day, P < 0.05), and 59% of infants were hypermetabolic (measured resting energy expenditure >110% of predicted resting energy expenditure) in early infancy. Failure to thrive prevalence at discharge was 16.2% compared to 3.6% and 4.2% at 12- and 24-months of age, respectively (P = 0.03; P = 0.005, respectively).

CONCLUSIONS

Optimal weight gain can be achieved with higher than predicted calorie provision. Most infants with CDH are hypermetabolic. Despite this, failure to thrive prevalence can improve during the first year of life.

Lung function over the first 3 years of life in children with congenital diaphragmatic hernia

OBJECTIVES

Infants with congenital diaphragmatic hernia (CDH) have variable degrees of pulmonary hypoplasia at birth. Few reports of lung function over the first years of life exist in this group of children.

HYPOTHESIS

Pulmonary function abnormalities correlate with severity of neonatal disease and intensity of neonatal therapies needed. We also hypothesized that longitudinal measurements of lung function over the usual period of rapid lung growth would lend some insight into how the lung remodels in CDH infants.

METHODOLOGY

Ninety-eight infants with CDH between 11 days and 44 months of age underwent pulmonary function testing (PFT) on 1-5 occasions using the raised volume rapid thoracic compression technique. Demographic data were also collected.

MAIN RESULTS

Forced expiratory flows were below normal. Total lung capacity was normal, but residual volume and functional residual capacity were elevated. Children requiring patch closure, ECMO, or pulmonary vasodilators generally had lower lung functions at follow up. Additionally, longer duration of mechanical ventilation correlated with worse lung function.

CONCLUSIONS

Lung functions of survivors of CDH remain abnormal throughout the first 3 years of life. The degree of pulmonary function impairment correlated both with markers of the initial degree of pulmonary hypoplasia and the duration of mechanical ventilation. Understanding the relationship between the phenotypic presentation of CDH and the potential for subsequent lung growth could help refine both pre- and postnatal therapies to optimize lung growth in CDH infants.

An association between pulmonary hypertension and impaired lung function in infants with congenital diaphragmatic hernia

RATIONALE

Infants with congenital diaphragmatic hernia (CDH) can develop pulmonary hypertension (PH) from decreased number and abnormal muscularization of pulmonary arteries. Normally pulmonary vascular growth and remodeling parallel airspace growth and alveolarization, which exhibits a wide morphologic variation in CDH.

AIM

To assess whether infants with CDH and PH have greater abnormalities in infant pulmonary function testing (IPFT) compared to those without PH.

METHODS

We reviewed results of IPFTs and echocardiograms performed on infants with CDH from 2004 to June 2011. Lung volumes, forced flows and tidal mechanics were standardized according to available reference values. Comparisons between infants with and without PH were performed using linear regression, adjusting for potential confounders.

MAIN RESULTS

Sixty-six infants were included; 18 had PH and 48 did not. Z-score values for functional residual capacity (FRC), residual volume (RV), FRC/total lung capacity (TLC), and RV/TLC were significantly higher in infants with CDH and PH compared to those without PH. Z-score values for forced flows including forced expiratory volume in the first 0.5 sec (FEV0.5) and FEV0.5/forced vital capacity were significantly lower in infants with CDH and PH compared to those without PH. For 29 infants studied on ≥2 occasions, the slopes of FRC, RV, and TLC versus length were significantly higher in those with persistent PH compared to those without.

CONCLUSIONS

Infants with CDH and persistent PH demonstrate greater airspace overdistension with growth compared to those without. Therapies that modify disrupted pulmonary vascular and alveolar formation could potentially improve future care of these patients.

Long-term nutritional morbidity for congenital diaphragmatic hernia survivors: Failure to thrive extends well into childhood and adolescence

BACKGROUND

Failure to thrive (FTT) is well documented among congenital diaphragmatic hernia (CDH) survivors ≤3years of age, but its etiology, severity, and persistence beyond this age require further elucidation.

METHODS

We conducted a single-center, retrospective study assessing anthropometrics, measured energy expenditure, and feeding tube (FT) use of 5-17 year olds in our multidisciplinary CDH clinic since January 2001. We stratified clinic visits based on age A: 5.0-6.9, B: 7.0-9.9, C: 10.0-14.9, and D: 15-17.9years.

RESULTS

One hundred sixteen patients with 376 outpatient visits were reviewed. Anthropometric z-scores were below zero and did not vary across age cohorts. FTT and growth stunting each occurred in 14% of clinic visits. FTs inserted during infancy occurred in 25% of patients, and 60% remained by age 7years. In cohort A, those with FTs were lighter and shorter than those without (p<0.05) but had similar BMIs. FTT incidence was higher in the FT group (p=0.020), but FTs were present in only 30% of those with FTT. Indirect calorimetry revealed increased energy expenditure in 58% of patients.

CONCLUSIONS

Failure to thrive continues in long-term CDH survivors, FTs may not improve incidence of FTT. Increased energy expenditure may play a role.

Multidisciplinary long-term follow-up of congenital diaphragmatic hernia: a growing trend

This literature review discusses the growing trend toward multidisciplinary long term follow-up for congenital diaphragmatic hernia.

Contemporary outcomes in infants with congenital heart disease and bochdalek diaphragmatic hernia

BACKGROUND

Fifteen percent of infants with congenital diaphragmatic hernia (CDH) are born with a coexisting cardiac anomaly. The purpose of this study was to evaluate contemporary outcomes in this patient population and to identify potential risk factors for in-hospital mortality.

METHODS

Data from all CDH neonates with congenital heart disease managed at a single pediatric tertiary care referral center between 1997 and 2011 were retrospectively analyzed.

RESULTS

Forty (18%) of 216 CDH patients had a cardiac anomaly. This group was associated with a significant decrease in overall survival when compared with patients without cardiac anomaly (55% versus 81%; p = 0.001). There was no association between type of cardiac anomaly and mortality based on risk stratification according to the Risk Adjustment for Congenital Heart Surgery and The Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery scoring systems (p = 0.86 and p = 0.87, respectively). Birth weight was similarly no different between survivors and nonsurvivors (2.8 ± 0.6 kg versus 2.8 ± 0.9 kg, respectively; p = 0.98). There was a trend toward increased extracorporeal membrane oxygenation use among nonsurvivors (p = 0.13). Infants with hemodynamic stability enabling subsequent cardiac repair were associated with lower mortality (p = 0.04). Survivors had a wide spectrum of long-term morbidity, but most had some evidence of neurodevelopmental impairment.

CONCLUSIONS

This large single-institution series suggests that the overall prognosis of infants with concomitant CDH and congenital heart disease can be quite variable, regardless of the type of heart anomaly. Hemodynamic instability and need for extracorporeal membrane oxygenation correlate with higher mortality. Although some long-term survivors have excellent outcomes, most suffer from chronic, long-term morbidities.