Neurodevelopmental outcome at 3.5 years of age in children treated with extracorporeal life support: relationship to primary diagnosis

Health Disparities in Extracorporeal Membrane Oxygenation Utilization and Outcomes: A Scoping Review and Methodologic Critique of the Literature

OBJECTIVES

To map the scope, methodological rigor, quality, and direction of associations between social determinants of health (SDoH) and extracorporeal membrane oxygenation (ECMO) utilization or outcomes.

DATA SOURCES

PubMed, Web of Science, Embase, and Cochrane Library databases were systematically searched for citations from January 2000 to January 2023, examining socioeconomic status (SES), race, ethnicity, hospital and ECMO program characteristics, transport, and geographic location (context) with utilization and outcomes (concept) in ECMO patients (population).

STUDY SELECTION

Methodology followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses scoping review extension. Two reviewers independently evaluated abstracts and full text of identified publications. Exclusion criteria included non-English, unavailable, less than 40 patients, and periprocedural or mixed mechanical support.

DATA EXTRACTION

Content analysis used a standardized data extraction tool and inductive thematic analysis for author-proposed mediators of disparities. Risk of bias was assessed using the Quality in Prognosis Studies tool.

DATA SYNTHESIS

Of 8,214 citations screened, 219 studies were identified. Primary analysis focuses on 148 (68%) including race/ethnicity/SES/payer variables including investigation of ECMO outcomes 114 (77%) and utilization 43 (29%). SDoH were the primary predictor in 15 (10%). Overall quality and methodologic rigor was poor with advanced statistics in 7%. Direction of associations between ECMO outcomes or utilization according to race, ethnicity, SES, or payer varied. In 38% adverse outcomes or lower use was reported in underrepresented, under-resourced or diverse populations, while improved outcomes or greater use were observed in these populations in 7%, and 55% had no statistically significant result. Only 26 studies (18%) discussed mechanistic drivers of disparities, primarily focusing on individual- and hospital-level rather than systemic/structural factors.

CONCLUSIONS

Associations between ECMO utilization and outcomes with SDoH are inconsistent, complicated by population heterogeneity and analytic shortcomings with limited consideration of systemic contributors. Findings and research gaps have implications for measuring, analyzing, and interpreting SDoH in ECMO research and healthcare.

Neurodevelopmental outcomes in neonatal extracorporeal membrane oxygenation survivors: An institutional perspective

AIM

To describe the neurodevelopmental outcomes following extracorporeal membrane oxygenation (ECMO) in early infancy.

METHODS

Thirty-seven patients who had survived following ECMO support from 2008 to 2018 had their neurodevelopmental outcomes assessed and analysed using the Bayley Scales of Infant and Toddler Development. Developmental outcome was defined as impairment in any of the developmental domains of motor function, cognition and language with mild impairment being 1-2 standard deviations below the test mean, moderate being 2-3 standard deviations below and severe being greater than 3 standard deviations below.

RESULTS

Of these 37 patients, the median age at admission to Paediatric Intensive Care Unit was 0.4 months (interquartile range 2.8 months) with all of the study patients having an underlying diagnosis of congenital cardiac disease and 37/40 (92.5%) ECMO runs occurring in the immediate post-operative period. Of the 29 patients who had had follow-up at 12 months of age or older, 3 (10.3%) had severe impairment, 4 (13.8%) had moderate impairment, 12 (41.3%) had mild impairment and 10 (34.5%) had no impairment. Gross motor function was most significantly impacted in 18/29 (62.1%) patients, of which 7/18 (38.9%) had severe impairment. This was followed by impairment of receptive language in 8/29 (27.6%) patients and expressive language in 6/29 (20.1%) patients.

CONCLUSIONS

One in four infants undergoing ECMO treatment in early infancy has moderate to severe neurodevelopmental impairment. Gross motor and language are the most affected developmental domains.

Extracorporeal Life Support Organization (ELSO) Guidelines for Follow-up After Neonatal and Pediatric Extracorporeal Membrane Oxygenation

Neonates and children who have survived critical illness severe enough to require extracorporeal membrane oxygenation (ECMO) are at risk for neurologic insults, neurodevelopmental delays, worsening of underlying medical conditions, and development of new medical comorbidities. Structured neurodevelopmental follow-up is recommended for early identification and prompt interventions of any neurodevelopmental delays. Even children who initially survive this critical illness without new medical or neurologic deficits remain at risk of developing new morbidities/delays at least through adolescence, highlighting the importance of structured follow-up by personnel knowledgeable in the sequelae of critical illness and ECMO. Structured follow-up should be multifaceted, beginning predischarge and continuing as a coordinated effort after discharge through adolescence. Predischarge efforts should consist of medical and neurologic evaluations, family education, and co-ordination of long-term ECMO care. After discharge, programs should recommend a compilation of pediatric care, disease-specific care for underlying or acquired conditions, structured ECMO/neurodevelopmental care including school performance, parental education, and support. Institutionally, regionally, and internationally available resources will impact the design of individual center's follow-up program. Additionally, neurodevelopmental testing will need to be culturally and lingually appropriate for centers' populations. Thus, ECMO centers should adapt follow-up program to their specific populations and resources with the predischarge and postdischarge components described here.

Neurologic Outcomes in a Two-Center Cohort of Neonatal and Pediatric Patients Supported on Extracorporeal Membrane Oxygenation

Contemporary studies of long-term outcomes in children supported on extracorporeal membrane oxygenation (ECMO) in the United States are limited. We enrolled 99 ECMO patients between July 2010 and June 2015 in a two-center prospective observational study that included neurologic and neuropsychologic evaluation at 6 and 12 months, using standardized outcome measures. Pre-ECMO, 20 (20%) had a pre-existing neurologic diagnosis, 40 (40%) had cardiac arrest, and 10 of 47 (21%) children with neuroimaging had acute abnormal findings. Of 50 children eligible for follow-up at 6 or 12 months, 40 (80%) returned for at least one visit. At the follow-up visit of longest interval from ECMO, the median Vineland Adaptive Behavior Scales-II (VABS-II) score was 91 (interquartile range [IQR], 81-98), the median Pediatric Stroke Outcome Measure (PSOM) score was 1 (IQR, 0-2), and the median Mullen Scales of Early Learning composite score was 85 (IQR, 72-96). Presence of new neuroimaging abnormalities during ECMO or within 6 weeks post-ECMO was associated with VABS-II score <85 or death within 12 months after ECMO. The Pediatric Cerebral Performance Category at hospital discharge showed a strong relationship with unfavorable VABS-II and PSOM scores at 6 or 12 months after ECMO. In this study, we report a higher prevalence of pre-ECMO neurologic conditions than previously described. In survivors to hospital discharge, median scores for adaptive behavior and cognitive, neurologic, and quality of life assessments were all below the general population means, but most deficits would be considered minor within each of the domains tested.

Neurologic Outcomes After Extracorporeal Membrane Oxygenation: A Systematic Review

OBJECTIVES

The goal of this systematic review of the literature was to summarize neurologic outcomes following neonatal and pediatric extracorporeal membrane oxygenation.

DATA SOURCES

We conducted electronic searches of PubMed, Scopus, Web of Science, CINAHL, Cochrane, and EMBASE.

STUDY SELECTION

Inclusion criteria included publication dates 2000-2016, patient ages 0-18 years, and use of standardized measures to evaluate outcomes after extracorporeal membrane oxygenation.

DATA EXTRACTION

We identified 3,497 unique citations; 60 full-text articles were included in the final review.

DATA SYNTHESIS

Studies evaluated patients with congenital diaphragmatic hernia (7), cardiac disease (8), cardiac arrest (13), and mixed populations (32). Follow-up was conducted at hospital discharge in 10 studies (17%) and at a median of 26 months (interquartile range, 8-61 mo) after extracorporeal membrane oxygenation in 50 studies (83%). We found 55 outcome measures that assessed overall health and function (4), global cognitive ability (7), development (4), motor function (5), adaptive function (2), behavior/mood (6), hearing (2), quality of life (2), school achievement (5), speech and language (6), learning and memory (4), and attention and executive function (8). Overall, 10% to as many as 50% of children scored more than 2 SDS below the population mean on cognitive testing. Behavior problems were identified in 16-46% of children tested, and severe motor impairment was reported in 12% of children. Quality of life of former extracorporeal membrane oxygenation patients evaluated at school age or adolescence ranged from similar to healthy peers, to 31-53% having scores more than 1 SD below the population mean.

CONCLUSIONS

This systematic review of the literature suggests that children who have undergone extracorporeal membrane oxygenation suffer from a wide range of disabilities. A meta-analysis was not feasible due to heterogeneity in pathologies, outcome measures, and age at follow-up, underscoring the importance of developing and employing a core set of outcomes measures in future extracorporeal membrane oxygenation studies.

Is Extracorporeal Membrane Oxygenation for a Neonate Ever Ethically Obligatory?

Certain interventions in the neonatal intensive care unit are considered ethically obligatory, and should be provided over parental objections. After reviewing a case, comparative outcome data, and relevant ethical principles, we propose that extracorporeal membrane oxygenation for meconium aspiration syndrome may, in some cases, be an ethically obligatory treatment.

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.

Extracorporeal Life Support in Pediatric and Neonatal Critical Care: A Review

Extracorporeal life support (ECLS) is a modified form of cardiopulmonary bypass used to provide prolonged tissue oxygen delivery in patients with respiratory and/or cardiac failure. The first large-scale success of ECLS was achieved in the management of term newborns with respiratory failure. ECLS has become an accepted therapeutic modality for neonates, children, and adults who have failed conventional therapy and in whom cardiac and/or respiratory insufficiency is potentially reversible. The use of ECLS allows one to reduce other cardiopulmonary supports and apply a gentle ventilation strategy in a population of severely compromised critical care patients. ECLS has now been employed in more than 26,000 neonatal and pediatric patients with an overall survival rate of 68%. ECLS has evolved significantly over 25 years of clinical practice; patient selection for this complex and highly invasive therapy, as well as how ECLS is employed in different patient groups, is constantly changing. Generally, ECLS is used more liberally now than in the past. The number of patients requiring this support, however, is declining yearly, and those patients who receive ECLS compose a more severe subset of an intensive care population. This review provides an overview of the development of ECLS and the equipment and techniques employed. The use of ECLS for neonatal respiratory failure, pediatric respiratory failure, and cardiac support are outlined. Management of the ECLS patient is discussed in detail, and outcome of these patients is reviewed. Finally, current trends and future implications of ECLS in neonatal and pediatric critical care are addressed.

Perceived Motor Competence Differs From Actual Performance in 8-Year-Old Neonatal ECMO Survivors

OBJECTIVE

To assess perceived motor competence, social competence, self-worth, health-related quality of life, and actual motor performancein 8-year-old survivors of neonatal extracorporeal membrane oxygenation (ECMO).

METHODS

In a prospective nationwide study, 135 children completed the extended version of the "athletic competence" domain of the Self Perception Profile for Children (SPPC) called the m-CBSK (Motor supplement of the Competentie BelevingsSchaal voor Kinderen) to assess perceived motor competence, the SPPC, and the Pediatric Quality of Life Inventory (PedsQL), andwere tested with the Movement Assessment Battery for Children. SD scores (SDS) were used to compare with the norm.

RESULTS

The mean (SD) SDS for perceived motor competence, social competence, and self-worth were all significantly higher than the norm: 0.18 (0.94), P = .03; 0.35 (1.03), P < .001; and 0.32 (1.08), P < .001, respectively. The total PedsQL score was significantly below the norm: mean (SD) SDS: -1.26 (1.53), P < .001. Twenty-two percent of children had actual motor problems. The SDS m-CBSK and actual motor performance did not correlate (r = 0.12; P = .17). The SDS m-CBSK significantly correlated with the athletic competence domain of the SPPC (r = 0.63; P < .001).

CONCLUSIONS

Eight-year-old ECMO survivors feel satisfied with their motor- and social competence, despite impaired PedsQL scores and motor problems. Because motor problems in ECMO survivorsdeteriorate throughout childhood, clinicians should be aware that these patients may tend to "overrate" their actual motor performance. Education andstrict monitoring of actual motor performanceare important to enable timelyintervention.

Sensorineural hearing loss in congenital diaphragmatic hernia survivors is associated with postnatal management and not defect size

BACKGROUND/PURPOSE

We determined the incidence of sensorineural hearing loss (SNHL; >20dB at any frequency) in a contemporary cohort of congenital diaphragmatic hernia (CDH) survivors at a single tertiary care center and identified potential risk factors for SNHL.

METHODS

From 2000 through 2011, clinical and audiologic data were collected on 122 surgically-repaired Bochdalek CDH patients. CDH defect size, duration of ventilation, and cumulative aminoglycoside treatment were used for multivariate logistic regression.

RESULTS

Incidence of SNHL was 7.4% (9/122). We identified one significant independent predictor of SNHL: cumulative length of aminoglycoside treatment (P<.001; OR 1.44, 95% CI: 1.13-1.83).

CONCLUSIONS

Over the last decade, the incidence of SNHL in our CDH patients is low compared to previous reports in the literature (7.4%) and is not associated with CDH defect size or the need for extracorporeal membrane oxygenation. Prolonged duration of aminoglycoside treatment increases the risk of SNHL independent of defect size and duration of ventilation.

Long-term outcome of children treated with neonatal extracorporeal membrane oxygenation: increasing problems with increasing age

As more and more critically ill neonates survive, it becomes important to evaluate long-term morbidity. This review aims to provide an up-to-date overview of medical and neurodevelopmental outcomes in children who as neonates received treatment with extracorporeal membrane oxygenation (ECMO). Most patients-except those with congenital diaphragmatic hernia-have normal lung function and normal growth at older age. Maximal exercise capacity is below normal and seems to deteriorate over time in the CDH population. Gross motor function problems have been reported until school age. Although mental development is usually favorable within the first years and cognition is normal at school age, many children experience problems with working speed, spatial ability tasks, and memory. In conclusion, children who survived neonatal treatment with ECMO often encounter neurodevelopmental problems at school age. Long-term follow-up is needed to recognize problems early and to offer appropriate intervention.

Extended survival and re-hospitalisation among paediatric patients requiring extracorporeal membrane oxygenation for primary cardiac dysfunction

BACKGROUND

Although survival to hospital discharge among children requiring extracorporeal membrane oxygenation support for medical and surgical cardio-circulatory failure has been reported in international registries, extended survival and re-hospitalisation rates have not been well described in the literature.

MATERIAL AND METHODS

This is a single-institution, retrospective review of all paediatric patients receiving extracorporeal membrane oxygenation for primary cardiac dysfunction over a 5-year period.

RESULTS

A total of 74 extracorporeal membrane oxygenation runs in 68 patients were identified, with a median follow-up of 5.4 years from hospital discharge. Overall, 66% of patients were decannulated alive and 25 patients (37%) survived to discharge. There were three late deaths at 5 months, 20 months, and 6.8 years from discharge. Of the hospital survivors, 88% required re-hospitalisation, with 63% of re-admissions for cardiac indications. The median number of hospitalisations per patient per year was 0.62, with the first re-admission occurring at a mean time of 9 months after discharge from the index hospitalisation. In all, 38% of patients required further cardiac surgery.

CONCLUSIONS

Extended survival rates for paediatric hospital survivors of cardiac extracorporeal membrane oxygenation support for medical and post-surgical indications are encouraging. However, re-hospitalisation within the first year following hospital discharge is common, and many patients require further cardiac surgery. Although re-admission hospital mortality is low, longer-term follow-up of quality-of-life indicators is required

Follow-up of the survivors of congenital diaphragmatic hernia

INTRODUCTION

Survivors of congenital diaphragmatic hernia have increased with the introduction of new treatment modalities and have been reported to experience ongoing medical morbidity until adulthood.

AIM

To describe the long-term functional impact of congenital diaphragmatic repair on the survivors of a single institution cohort of newborns over a 14-year period.

METHODS

The follow up medical charts of 39 congenital diaphragmatic hernia survivors treated at a tertiary neonatal intensive care unit, from January 1997 to December 2010, were analyzed.

RESULTS

The median age at follow up was 70 (4-162) months. Gastrointestinal sequelae were the most common with 12 (30.7%) patients affected by failure to thrive. Chronic lung disease occurred in 5 (12.8%) patients, neurodevelopmental delay in 5 (12.8%), musculoskeletal sequelae in 6 (15.3%), recurrence of hernia in 4 (10.2%) and 2 (7.6%) were deceased.

CONCLUSION

Congenital diaphragmatic hernia survivors are a group of patients that requires long term periodic follow up in a multidisciplinary setting to provide adequate support and improve their quality of life.

Neurodevelopmental and neurofunctional outcomes in children with congenital diaphragmatic hernia

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.

Hospital readmissions and survival after nonneonatal pediatric ECMO

PURPOSE

The late effects of treatment with extracorporeal membrane oxygenation (ECMO) in nonneonatal pediatric patients remain unclear. The aims of our study were to better characterize the long-term survival and hospital readmission rates for pediatric patients after ECMO treatment.

PATIENTS AND METHODS

From 1999 to 2006, data on children aged 1 month to 18 years who underwent ECMO were extracted from the California Patient Discharge Database. Data from patients with diagnoses of congenital cardiac disease were excluded. We analyzed patient data on initial hospital course, subsequent readmissions, development of long-term morbidities, and long-term survival.

RESULTS

The study cohort consisted of 188 children from 13 California hospitals. The median age was 3 years, and 46% of the patients survived to hospital discharge. ECMO indications included acquired heart disease in 81 patients, pneumonia in 56, other respiratory failure in 22, sepsis in 8, trauma in 8, and other indications in 12. Of the 87 survivors, 56 were tracked for a median period of 3.7 years. The readmission rate was 62%, and the mean time to first readmission was 1.2 years. Readmissions for respiratory infections were observed in 34% of the patients and for reactive airway disease in 7%. Neurologically debilitating conditions (epilepsy [7%] and developmental delay [9%]) occurred in 16%. Late deaths occurred in 5% of the children. Readmitted survivors had a cumulative length of readmission hospitalization of 8 days and hospital charge of $43 000. Cox proportional hazard regression demonstrated a positive relationship between treatment-center case volume and long-term survival outcomes (hazard ratio: 0.98 per case; P < .01).

CONCLUSIONS

Pediatric ECMO survivors suffered from significant long-term morbidities after initial hospital discharge. More than 60% of these children required subsequent readmissions, and late deaths were observed in 5%. Furthermore, hospitals with high case volumes were associated with improved long-term survival.

Can we improve outcome of congenital diaphragmatic hernia?

This review gives an overview of the disease spectrum of congenital diaphragmatic hernia (CDH). Etiological factors, prenatal predictors of survival, new treatment strategies and long-term morbidity are described. Early recognition of problems and improvement of treatment strategies in CDH patients may increase survival and prevent secondary morbidity. Multidisciplinary healthcare is necessary to improve healthcare for CDH patients. Absence of international therapy guidelines, lack of evidence of many therapeutic modalities and the relative low number of CDH patients calls for cooperation between centers with an expertise in the treatment of CDH patients. The international CDH Euro-Consortium is an example of such a collaborative network, which enhances exchange of knowledge, future research and development of treatment protocols.

Neurodevelopmental outcome of infants with meconium aspiration syndrome: report of a study and literature review

There is a paucity of information on long-term outcome of infants who have suffered from meconium aspiration syndrome (MAS) in the neonatal period. We analyzed long-term developmental outcome data of 35 infants who were admitted to the neonatal intensive care unit (NICU) at the University of Illinois Hospital at Chicago (UICMC) with a diagnosis of MAS, and we reviewed the literature pertinent to the subject. The objective of the study was to assess the neurodevelopment status of MAS infants and compare the possible effects of different variables that are known to affect the later developmental outcome. The variables included mode of delivery, APGAR score, cord pH, mode of treatment, and neurological findings during the course of NICU. The infants were enrolled in the developmental follow-up program (DFUP) after discharge from the nursery for assessment of long-term developmental status and neurodevelopmental outcome. In order to assess the impact of the treatment on long-term outcome and compare our findings with previously published reports, we also reviewed the previously published literature on neurodevelopment outcome of infants treated for MAS (with different modalities) during the last three decades. Total of 35 infants with a diagnosis of MAS admitted to the NICU at UICMC were followed in the DFUP clinic for 3 years during January 1999 to September 2001. The medical records of these infants were reviewed for the mode of delivery, APGAR score, birth weight (BW), gestational age, mode of treatment during the neonatal period, and neurodevelopment status. 19/35 (54%) infants were delivered vaginally, 16/35 (46%) by cesarean section (C-section). All were treated in the delivery room using the standard resuscitation protocol. Following initial resuscitation, all except three required intubation and ventilation for varying duration. One infant required inhaled nitric oxide therapy, and two required extracorporeal membrane oxygenation treatment. Subsequent to discharge, the infants were evaluated in the clinic at 2 months of age, and then every 4 months up to 3 years. The developmental assessment of mental development index (MDI), psychomotor development index (PDI), and behavior rating scale (BRS) were obtained using the Bayley II infant motor scale, and neurodevelopment evaluation was performed using the Amiel-Tison technique. Speech evaluation was performed in infants >18 months using the Rossetti Infant-Toddler language scale. Infants were considered normal when MDI and PDI scores were >85 to 110; mildly delayed when scores were >70 to 84; and severely delayed if the scores were <69. In addition, neurological evaluation also confirmed the disability. The report is based on the final analysis of 29 infants. Data of six infants were not included in the final analysis because of incomplete information. The mean BW of the infants was 3269+/-671 g; mean gestational age was 39.5+/-3.1 weeks. The median APGAR score at 1' was 4, and at 5' was 6. Out of 29, 11 (38%) infants were normal. Out of 29, 2 infants (7%) had cerebral palsy (CP) and 4 (14%) had severe delay at 12 months of age. Out of 29, 2 who were neurologically disabled had PDI <69. Out of 29, 12 (41%) had mild delay in speech. No statistical difference in neurodevelopment was found in infants born vaginally or by C-section. Our findings show poor outcome (CP and global delay) in 21% of infants who suffered MAS, even though the majority of the infants (26/29) responded to conventional ventilator support alone. No difference was found in the outcome of infants between NSVD vs C-section delivery. These findings suggest that infants with the diagnosis of MAS manifest later neurodevelopmental delays, even if they respond well to conventional treatment. This abstract was presented at the Society for Pediatric Research Annual Meeting, 2000.

Neurodevelopmental outcomes of congenital diaphragmatic hernia survivors followed in a multidisciplinary clinic at ages 1 and 3

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.

Long-term follow up of infants with congenital diaphragmatic hernia

With improving treatment strategies for congenital diaphragmatic hernia (CDH) infants, an increase in survival of more severely affected patients can be expected. Consequently, more attention is now focused on long-term follow up of these patients. Many reports have emphasized associated morbidity, including pulmonary sequelae, neurodevelopmental deficits, gastrointestinal disorders, and other abnormalities. Therefore, survivors of CDH remain a complex patient population to care for throughout infancy and childhood, thus requiring long-term follow up. Much information has been provided from many centers regarding individual institutional improvements in overall survival. Few of these, however, have reported long-term follow up. The aim of this review is to describe the long-term outcome of survivors with CDH and to suggest a possible follow-up protocol for these patients.

Persistent pulmonary hypertension of the newborn: pathogenesis, etiology, and management

Persistent pulmonary hypertension of the newborn (PPHN) is characterized by severe hypoxemia shortly after birth, absence of cyanotic congenital heart disease, marked pulmonary hypertension, and vasoreactivity with extrapulmonary right-to-left shunting of blood across the ductus arteriosus and/or foramen ovale. In utero, a number of factors determine the normally high vascular resistance in the fetal pulmonary circulation, which results in a higher pulmonary compared with systemic vascular pressure. However, abnormal conditions may arise antenatally, during, or soon after birth resulting in the failure of the pulmonary vascular resistance to normally decrease as the circulation evolves from a fetal to a postnatal state. This results in cyanosis due to right-to-left shunting of blood across normally existing cardiovascular channels (foramen ovale or ductus arteriosus) secondary to high pulmonary versus systemic pressure. The diagnosis is made by characteristic lability in oxygenation of the infant, echocardiographic evidence of increased pulmonary pressure, with demonstrable shunts across the ductus arteriosus or foramen ovale, and the absence of cyanotic heart disease lesions. Management of the disease includes treatment of underlying causes, sedation and analgesia, maintenance of adequate systemic blood pressure, and ventilator and pharmacologic measures to increase pulmonary vasodilatation, decrease pulmonary vascular resistance, increase blood and tissue oxygenation, and normalize blood pH. Inhaled nitric oxide has been one of the latest measures to successfully treat PPHN and significantly reduce the need for extracorporeal membrane oxygenation.

Cost-utility analysis of salvage cardiac extracorporeal membrane oxygenation in children

BACKGROUND

Indications for extracorporeal membrane oxygenation therapy have expanded to include cardiopulmonary arrest and support after congenital heart surgery. Data from a national registry have reported that cardiac patients have the poorest survival of all extracorporeal membrane oxygenation recipients. Concerns have been raised about the appropriateness of such an aggressive strategy, especially in light of the high costs and potential for long-term neurologic disability. We reviewed our experience with salvage cardiac extracorporeal membrane oxygenation to determine the cost-utility, which accounts for both costs and quality of life.

METHODS

Medical records of patients with congenital heart disease receiving salvage cardiac extracorporeal membrane oxygenation between January 2000 and May 2004 were reviewed. Charges for all medical care after the institution of extracorporeal membrane oxygenation were determined and converted to costs by published standards. The quality-of-life status of survivors was determined with the Health Utilities Index Mark II.

RESULTS

Salvage cardiac extracorporeal membrane oxygenation was instituted in 32 patients (18 for cardiopulmonary arrest and 14 for cardiac failure after heart surgery) at a median age of 2.0 months (range, 4 days to 5.1 years). Congenital heart disease was present in 27 (84%). The mean duration of extracorporeal membrane oxygenation support was 5.1 +/- 4.1 days. Survival to hospital discharge was 50%, including 1 patient bridged to heart transplantation. Survival to 1 year was 47%. The mean score of the Health Utilities Index for the survivors was 0.75 +/- 0.19 (range, 0.41-1.0). The median cost for hospital stay after the institution of extracorporeal membrane oxygenation was USD 156,324 per patient. The calculated cost-utility for salvage extracorporeal membrane oxygenation in this population was USD 24,386 per quality-adjusted life-year saved, which would be considered within the range of accepted cost-efficacy (< USD 50,000 per quality-adjusted life-year saved).

CONCLUSIONS

Salvage cardiac extracorporeal membrane oxygenation results in reasonable survival and is justified on a cost-utility basis.

The role of extracorporeal membrane oxygenation in congenital diaphragmatic hernia

The aim of this paper is to review the role of extracorporeal membrane oxygenation (ECMO) in neonates with severe acute hypoxemic respiratory failure secondary to congenital diaphragmatic hernia (CDH). The difficulties in identifying patients with fatal lung hypoplasia are highlighted and the role of adjunctive therapies on ECMO (surfactant, inhaled nitric oxide, high-frequency ventilation and liquid lung distension) as well as the timing of surgical repair is discussed. Survivors of severe CDH who have been supported on ECMO have significant late mortality and morbidity. There remains a need for a randomized controlled trial of the role of ECMO in neonates with severe CDH.

ECMO for neonatal respiratory failure

Extracorporeal membrane oxygenation (ECMO) has been offered as a life-saving technology to newborns with respiratory and cardiac failure refractory to maximal medical therapy. ECMO has been used in treatment of neonates with a variety of cardio-respiratory problems, including meconium aspiration syndrome (MAS), persistent pulmonary hypertension of the neonate (PPHN), congenital diaphragmatic hernia (CDH), sepsis/pneumonia, respiratory distress syndrome (RDS), air leak syndrome, and cardiac anomalies. For this group of high-risk neonates with an anticipated mortality rate of 80% to 85%, ECMO has an overall survival rate of 84%, with recent data showing nearly 100% survival in many diagnostic groups. This article reviews the current selection criteria for ECMO and the clinical management of neonates on ECMO, and discusses the long-term outcome of neonates treated with ECMO.

Twenty Years of Progress in Congenital Diaphragmatic Hernia at the University of Florida

Over the past 20 years the clinical paradigms underlying the care of children with congenital diaphragmatic hernia (CDH) have undergone profound changes. The purpose of this work is to provide an historic review of research and clinical studies related to CDH at the University of Florida (UF) and Shands Children's Hospital during the chairmanship of Edward M. Copeland, III, M.D. and to present our current clinical results. During Dr Copeland's tenure survival for newborns symptomatic with CDH treated at UF/Shands Children's Hospital has improved from less than 20 per cent to 85 per cent. Clinical observations have suggested and research studies at UF using a fetal lamb model have confirmed that fetal distress can occur late in gestation, which may predispose infants with CDH to pulmonary hypertension. However, our patient experience has confirmed that the most significant cause of mortality in human infants is not pulmonary hypertension but iatrogenic injury to their hypoplastic lungs. Strict avoidance of barotrauma in these babies has been the most important clinical advance during these two decades. Significant clinical and research problems remain including defining optimal prenatal care, management of complications during the first few weeks of life, and development of strategies to accelerate lung growth. Dramatic improvements in survival have resulted in children who manifest a number of clinical problems that were not evident when most of these patients died early in infancy. Our experience at Shand's Children's Hospital/UF indicates that feeding problems, respiratory infections, and management of subtle or overt neurologic complications may become major issues for some of these survivors and their families.

Use of plasma lactate to predict early mortality and adverse outcome after neonatal extracorporeal membrane oxygenation: a prospective cohort in early childhood

OBJECTIVE

To examine the use of plasma lactate levels to predict mortality and neurodevelopmental outcome of neonates treated with extracorporeal membrane oxygenation.

DESIGN

Prospective cohort study.

SETTING

Two level III neonatal intensive care units in Canada and the United States.

PATIENTS

Seventy-four neonates requiring extracorporeal membrane oxygenation in two neonatal intensive care units from 1994 to 1996.

INTERVENTIONS

Differences in clinical and biochemical measurements, including serial lactate levels between three outcome groups (early deaths, adverse survivors, and normal survivors) were compared using analysis of variance. We also examined the predictive relationship between plasma lactate levels and the outcome at neonatal intensive care unit discharge and at 18-24 months postnatal age by backward, stepwise regression and Fisher's exact test.

MEASUREMENTS AND MAIN RESULTS

Fifteen (20%) neonates died before neonatal intensive care unit discharge (early deaths), with seven additional deaths before follow-up, which are included in the adverse survivors group. Among 49 early childhood survivors (22 +/- 7 months), 27 were disabled or delayed with Mental and Performance Developmental Indices of 70 +/- 21 and 72 +/- 22, respectively. Early deaths had higher plasma lactate levels and were more acidemic than adverse and normal survivors, who were not different from each other (p <.05). Plasma lactate and the lowest arterial pH independently predicted 42% of the variance of the outcome ( p<.001). A peak lactate level of >or=25 mM predicted early mortality (sensitivity, 47%; specificity, 100%; positive and negative predictive values, 100% and 88%, respectively; p<.001), whereas a level of >or=15 mM predicted adverse outcome (sensitivity, 35%; specificity, 91%; positive and negative predictive values, 89% and 38%, respectively; p<.05). The predictability of plasma lactate was significantly improved in 45 neonates without congenital diaphragmatic hernia or lethal anomalies (sensitivity of 100% for early mortality, negative predictive value of 63% for adverse outcome). CONCLUSIONS In addition to assessing tissue oxygenation, plasma lactate may facilitate the decision-making process by providing early predictive information about the outcome of neonates treated with extracorporeal membrane oxygenation.

Outcome of infants with bronchopulmonary dysplasia who receive extracorporeal membrane oxygenation therapy

BACKGROUND/PURPOSE

Extracorporeal membrane oxygenation (ECMO) is an accepted therapy for acute respiratory failure but more recently has been used in infants with bronchopulmonary dysplasia (BPD) and superimposed acute pulmonary insults. The purpose of this study was to review the outcomes of such infants.

METHODS

Charts of infants at The Children's Hospital of Philadelphia (CHOP) who had a diagnosis of BPD before ECMO were reviewed. In addition, to obtain survival data in a larger population, the Extracorporeal Life Support Organization (ELSO) Registry was searched for infants with BPD before ECMO.

RESULTS

Of 204 patients who received noncardiac ECMO at CHOP, 9 had BPD before ECMO. Of 7 survivors, 4 were still ventilator dependent at 9 to 39 months of corrected age. Developmentally, 4 had significant global delays, whereas 3 had significant language and motor delays with average to mildly delayed cognitive abilities. The ELSO Registry search showed 76 patients with BPD before ECMO, with a 78% survival.

CONCLUSIONS

The survival rate of infants with BPD who receive ECMO is comparable to, or better than, the survival rates in most other ECMO populations. However, there appears to be a high risk of severe pulmonary and neurodevelopmental sequelae.