1
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King S, Carr BDE, Mychaliska GB, Church JT. Surgical approaches to congenital diaphragmatic hernia. Semin Pediatr Surg 2024; 33:151441. [PMID: 38986242 DOI: 10.1016/j.sempedsurg.2024.151441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2024]
Abstract
Surgical repair of the diaphragm is essential for survival in congenital diaphragmatic hernia (CDH). There are many considerations surrounding the operation - why the operation matters, optimal timing of repair and its relation to extracorporeal life support (ECLS) use, minimally invasive versus open approaches, and strategies for reconstruction. Surgery is both affected by, and affects, the physiology of these infants and is an important factor in determining long-term outcomes. Here we discuss the evidence and provide insight surrounding this complex decision making, technical pearls, and outcomes in repair of CDH.
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Affiliation(s)
- Sarah King
- C.S. Mott Children's Hospital, Section of Pediatric Surgery, Department of Surgery, University of Michigan. Ann Arbor, MI, USA
| | - Benjamin D E Carr
- Doernbecher Children's Hospital, Division of Pediatric Surgery, Department of Surgery, Oregon Health and Science University. Portland, OR, USA
| | - George B Mychaliska
- C.S. Mott Children's Hospital, Section of Pediatric Surgery, Department of Surgery, University of Michigan. Ann Arbor, MI, USA
| | - Joseph T Church
- C.S. Mott Children's Hospital, Section of Pediatric Surgery, Department of Surgery, University of Michigan. Ann Arbor, MI, USA.
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2
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Pulvirenti R, IJsselstjin H, Mur S, Morini F. Approaches to nutrition and feeding in congenital diaphragmatic hernia. Semin Pediatr Surg 2024; 33:151442. [PMID: 39004036 DOI: 10.1016/j.sempedsurg.2024.151442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/16/2024]
Abstract
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.
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Affiliation(s)
- Rebecca Pulvirenti
- Department of Pediatric Surgery, Erasmus Medical Centre Sophia Children's Hospital, Rotterdam, the Netherlands; Pediatric Surgery Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Hanneke IJsselstjin
- Department of Pediatric Surgery, Erasmus Medical Centre Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Sebastien Mur
- Department of Neonatology, Lille University Hospital, French CDH reference center, Lille, France
| | - Francesco Morini
- Department of Maternal, Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy.
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3
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Sloan P, Johng S, Daniel JM, Rhee CJ, Mahmood B, Gravari E, Marshall S, Downey AG, Braski K, Gowda SH, Fernandes CJ, Dariya V, Haberman BE, Seabrook R, Makkar A, Gray BW, Cookson MW, Najaf T, Rintoul N, Hedrick HL, DiGeronimo R, Weems MF, Ades A, Chapman R, Grover TR, Keene S. A clinical consensus guideline for nutrition in infants with congenital diaphragmatic hernia from birth through discharge. J Perinatol 2024; 44:694-701. [PMID: 38627594 DOI: 10.1038/s41372-024-01965-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 03/28/2024] [Accepted: 04/08/2024] [Indexed: 05/15/2024]
Abstract
OBJECTIVE To develop a consensus guideline to meet nutritional challenges faced by infants with congenital diaphragmatic hernia (CDH). STUDY DESIGN The CDH Focus Group utilized a modified Delphi method to develop these clinical consensus guidelines (CCG). Topic leaders drafted recommendations after literature review and group discussion. Each recommendation was sent to focus group members via a REDCap survey tool, and members scored on a Likert scale of 0-100. A score of > 85 with no more than 25% outliers was designated a priori as demonstrating consensus among the group. RESULTS In the first survey 24/25 recommendations received a median score > 90 and after discussion and second round of surveys all 25 recommendations received a median score of 100. CONCLUSIONS We present a consensus evidence-based framework for managing parenteral and enteral nutrition, somatic growth, gastroesophageal reflux disease, chylothorax, and long-term follow-up of infants with CDH.
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Affiliation(s)
- Patrick Sloan
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8116, St. Louis, MO, 63110-1093, USA.
| | - Sandy Johng
- Department of Pediatrics, Division of Neonatology, University of Washington, Seattle Children's Hospital, Seattle, WA, USA
| | - John M Daniel
- Department of Pediatrics, Division of Neonatology, University of Missouri Kansas School of Medicine, Kansas City, MO, USA
| | - Christopher J Rhee
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Burhan Mahmood
- Department of Pediatrics, Division of Newborn Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Evangelia Gravari
- Department of Pediatrics, Division of Neonatology, University of Minnesota Medical School, Minneapolis, MN, USA
| | | | - Ann G Downey
- Department of Pediatrics, Division of Neonatology, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Katie Braski
- Department of Pediatrics, Division of Neonatology, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Sharada H Gowda
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Caraciolo J Fernandes
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Vedanta Dariya
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Beth E Haberman
- Department of Pediatrics, Division of Neonatology, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Ruth Seabrook
- Department of Pediatrics, Division of Neonatology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Abhishek Makkar
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Brian W Gray
- Department of Surgery, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN, USA
| | - Michael W Cookson
- Department of Pediatrics, Section of Neonatology, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
| | - Tasnim Najaf
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8116, St. Louis, MO, 63110-1093, USA
| | - Natalie Rintoul
- Department of Pediatrics, Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Holly L Hedrick
- Department of Pediatric General Thoracic and Fetal Surgery Children's Hospital of Philadelphia Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Robert DiGeronimo
- Department of Pediatrics, Division of Neonatology, University of Washington, Seattle Children's Hospital, Seattle, WA, USA
| | - Mark F Weems
- Division of Neonatology and Le Bonheur Children's Hospital, Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Anne Ades
- Department of Pediatrics, Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Rachel Chapman
- Department of Pediatrics, USC Keck School of Medicine, Fetal & Neonatal Institute, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Theresa R Grover
- Department of Pediatrics, Section of Neonatology, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
| | - Sarah Keene
- Division of Neonatal-Perinatal Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
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Bourezma M, Mur S, Storme L, Cailliau E, Vaast P, Sfeir R, Lauriot Dit Prevost A, Aubry E, Le Duc K, Sharma D. Surgical Risk Factors for Delayed Oral Feeding Autonomy in Patients with Left-Sided Congenital Diaphragmatic Hernia. J Clin Med 2023; 12:jcm12062415. [PMID: 36983415 PMCID: PMC10059888 DOI: 10.3390/jcm12062415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 03/09/2023] [Accepted: 03/14/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Congenital diaphragmatic hernia (CDH) is a rare disease associated with major nutritional and digestive morbidities. Oral feeding autonomy remains a major issue for the care and management of these patients. The aim of this study was to specify the perinatal risk factors of delayed oral feeding autonomy in patients treated for CDH. METHODS This monocentric cohort study included 138 patients with CDH. Eighty-four patients were analyzed after the exclusion of 54 patients (11 with delayed postnatal diagnosis, 5 with chromosomal anomaly, 9 with genetic syndrom, 13 with right-sided CDH, and 16 who died before discharge and before oral feeding autonomy was acquired). They were divided into two groups: oral feeding autonomy at initial hospital discharge (group 1, n = 51) and nutritional support at discharge (group 2, n = 33). Antenatal, postnatal, and perisurgical data were analyzed from birth until first hospital discharge. To remove biased or redundant factors related to CDH severity, statistical analysis was adjusted according to the need for a patch repair. RESULTS After analysis and adjustment, delayed oral feeding autonomy was not related to observed/expected lung-to-head ratio (LHR o/e), intrathoracic liver and/or stomach position, or operative duration. After adjustment, prophylactic gastrostomy (OR adjusted: 16.3, IC 95%: 3.6-74.4) and surgical reoperation (OR adjusted: 5.1, IC 95% 1.1-23.7) remained significantly associated with delayed oral feeding autonomy. CONCLUSIONS Delayed oral feeding autonomy occurred in more than one third of patients with CDH. Both prophylactic gastrostomy and surgical reoperation represent significant risk factors. Bowel obstruction might also impact oral feeding autonomy. Prophylactic gastrostomy seems to be a false "good idea" to prevent failure to thrive. This procedure should be indicated case per case. Bowel obstruction and all surgical reoperations represent decisive events that could impact oral feeding autonomy.
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Affiliation(s)
- Mélina Bourezma
- CHU Lille, Clinic of Pediatric Surgery, Jeanne de Flandre Hospital, FR-59000 Lille, France
| | - Sébastien Mur
- CHU Lille, Clinic of Neonatology, Jeanne de Flandre Hospital, FR-59000 Lille, France
- Center for Rare Disease Congenital Diaphragmatic Hernia, CHU Lille, Jeanne de Flandre Hospital, FR-59000 Lille, France
- ULR 2694-METRICS: Medical Practices and Health Technology Evaluation, CHU Lille, Université de Lille, FR-59000 Lille, France
| | - Laurent Storme
- CHU Lille, Clinic of Neonatology, Jeanne de Flandre Hospital, FR-59000 Lille, France
- Center for Rare Disease Congenital Diaphragmatic Hernia, CHU Lille, Jeanne de Flandre Hospital, FR-59000 Lille, France
- ULR 2694-METRICS: Medical Practices and Health Technology Evaluation, CHU Lille, Université de Lille, FR-59000 Lille, France
| | - Emeline Cailliau
- ULR 2694-METRICS: Medical Practices and Health Technology Evaluation, CHU Lille, Université de Lille, FR-59000 Lille, France
- Biostatistics Department, CHU Lille, FR-59000 Lille, France
| | - Pascal Vaast
- Center for Rare Disease Congenital Diaphragmatic Hernia, CHU Lille, Jeanne de Flandre Hospital, FR-59000 Lille, France
- CHU Lille, Clinic of Obstetrics and Gynaecology, Jeanne de Flandre Hospital, FR-59000 Lille, France
| | - Rony Sfeir
- CHU Lille, Clinic of Pediatric Surgery, Jeanne de Flandre Hospital, FR-59000 Lille, France
| | | | - Estelle Aubry
- CHU Lille, Clinic of Pediatric Surgery, Jeanne de Flandre Hospital, FR-59000 Lille, France
- Center for Rare Disease Congenital Diaphragmatic Hernia, CHU Lille, Jeanne de Flandre Hospital, FR-59000 Lille, France
| | - Kévin Le Duc
- CHU Lille, Clinic of Neonatology, Jeanne de Flandre Hospital, FR-59000 Lille, France
- Center for Rare Disease Congenital Diaphragmatic Hernia, CHU Lille, Jeanne de Flandre Hospital, FR-59000 Lille, France
- ULR 2694-METRICS: Medical Practices and Health Technology Evaluation, CHU Lille, Université de Lille, FR-59000 Lille, France
| | - Dyuti Sharma
- CHU Lille, Clinic of Pediatric Surgery, Jeanne de Flandre Hospital, FR-59000 Lille, France
- Center for Rare Disease Congenital Diaphragmatic Hernia, CHU Lille, Jeanne de Flandre Hospital, FR-59000 Lille, France
- ULR 2694-METRICS: Medical Practices and Health Technology Evaluation, CHU Lille, Université de Lille, FR-59000 Lille, France
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5
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Schwab ME, Lee H, Tsao K. In Utero Therapy for Congenital Diaphragmatic Hernia. Clin Perinatol 2022; 49:863-872. [PMID: 36328604 DOI: 10.1016/j.clp.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Congenital diaphragmatic hernia is an anomaly that is often prenatally diagnosed and spans a wide spectrum of disease, with high morbidity and mortality associated with fetuses with severe defects. Congenital diaphragmatic hernia is thus an ideal target for fetal intervention. We review the literature on prenatal diagnosis, describe the history of fetal intervention for congenital diaphragmatic hernia, and discuss fetal endoscopic tracheal occlusion and the Tracheal Occlusion To Accelerate Lung growth trial results. Finally, we present preclinical studies for potential future directions.
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Affiliation(s)
- Marisa E Schwab
- Division of Pediatric Surgery, University of California San Francisco, 550 16th Street, San Francisco, San Francisco, CA 94158, USA; Department of Surgery, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Hanmin Lee
- Division of Pediatric Surgery, University of California San Francisco, 550 16th Street, San Francisco, San Francisco, CA 94158, USA
| | - KuoJen Tsao
- Department of Pediatric Surgery and Obstetrics, Gynecology & Reproductive Sciences, McGovern Medical School at the University of Texas Health Science Center at Houston, 6410 Fannin Street, Suite 950, Houston, TX 77030, USA.
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6
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Zani A, Chung WK, Deprest J, Harting MT, Jancelewicz T, Kunisaki SM, Patel N, Antounians L, Puligandla PS, Keijzer R. Congenital diaphragmatic hernia. Nat Rev Dis Primers 2022; 8:37. [PMID: 35650272 DOI: 10.1038/s41572-022-00362-w] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2022] [Indexed: 11/09/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is a rare birth defect characterized by incomplete closure of the diaphragm and herniation of fetal abdominal organs into the chest that results in pulmonary hypoplasia, postnatal pulmonary hypertension owing to vascular remodelling and cardiac dysfunction. The high mortality and morbidity rates associated with CDH are directly related to the severity of cardiopulmonary pathophysiology. Although the aetiology remains unknown, CDH has a polygenic origin in approximately one-third of cases. CDH is typically diagnosed with antenatal ultrasonography, which also aids in risk stratification, alongside fetal MRI and echocardiography. At specialized centres, prenatal management includes fetal endoscopic tracheal occlusion, which is a surgical intervention aimed at promoting lung growth in utero. Postnatal management focuses on cardiopulmonary stabilization and, in severe cases, can involve extracorporeal life support. Clinical practice guidelines continue to evolve owing to the rapidly changing landscape of therapeutic options, which include pulmonary hypertension management, ventilation strategies and surgical approaches. Survivors often have long-term, multisystem morbidities, including pulmonary dysfunction, gastroesophageal reflux, musculoskeletal deformities and neurodevelopmental impairment. Emerging research focuses on small RNA species as biomarkers of severity and regenerative medicine approaches to improve fetal lung development.
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Affiliation(s)
- Augusto Zani
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada. .,Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Wendy K Chung
- Department of Paediatrics, Columbia University, New York, NY, USA
| | - Jan Deprest
- Department of Development and Regeneration, Cluster Woman and Child and Clinical Department of Obstetrics and Gynaecology, University Hospitals, KU Leuven, Leuven, Belgium.,Institute for Women's Health, UCL, London, UK
| | - Matthew T Harting
- Department of Paediatric Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, USA.,The Comprehensive Center for CDH Care, Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Tim Jancelewicz
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Shaun M Kunisaki
- Division of General Paediatric Surgery, Johns Hopkins Children's Center, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Neil Patel
- Department of Neonatology, Royal Hospital for Children, Glasgow, UK
| | - Lina Antounians
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Pramod S Puligandla
- Department of Paediatric Surgery, Harvey E. Beardmore Division of Paediatric Surgery, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Richard Keijzer
- Department of Surgery, Division of Paediatric Surgery, Paediatrics & Child Health, Physiology & Pathophysiology, University of Manitoba, Winnipeg, Manitoba, Canada.,Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
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7
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Chock VY, Danzer E, Chung S, Noh CY, Ebanks AH, Harting MT, Lally KP, Van Meurs KP. In-Hospital Morbidities for Neonates with Congenital Diaphragmatic Hernia: The Impact of Defect Size and Laterality. J Pediatr 2022; 240:94-101.e6. [PMID: 34506854 DOI: 10.1016/j.jpeds.2021.09.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 08/07/2021] [Accepted: 09/01/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To determine in-hospital morbidities for neonates with right-sided congenital diaphragmatic hernia (R-CDH) compared with those with left-sided defects (L-CDH) and to examine the differential effect of laterality and defect size on morbidities. STUDY DESIGN This retrospective, multicenter, cohort study from the international Congenital Diaphragmatic Hernia Study Group registry collected data from neonates with CDH surviving until hospital discharge from 90 neonatal intensive care units between January 1, 2007, and July 31, 2020. Major pulmonary, cardiac, neurologic, and gastrointestinal morbidities were compared between neonates with L-CDH and R-CDH, adjusted for prenatal and postnatal factors using logistic regression. RESULTS Of 4123 survivors with CDH, those with R-CDH (n = 598 [15%]) compared with those with L-CDH (n = 3525 [85%]) had an increased odds of pulmonary (1.7; 95% CI, 1.4-2.2, P < .0001), cardiac (1.4; 95% CI, 1.1-1.8; P = .01), gastrointestinal (1.3; 95% CI, 1.1-1.6; P = .01), and multiple (1.6; 95% CI, 1.2-2.0; P < .001) in-hospital morbidities, with a greater likelihood of morbidity with increasing defect size. There was no difference in neurologic morbidities between the groups. CONCLUSIONS Neonates with R-CDH and a larger defect size are at an increased risk for in-hospital morbidities. Counseling and clinical strategies should incorporate knowledge of these risks, and approach to neonatal R-CDH should be distinct from current practices targeted to L-CDH.
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Affiliation(s)
- Valerie Y Chock
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, CA
| | - Enrico Danzer
- Division of Pediatric Surgery, Kaiser Permanente Medical Center, Santa Clara, CA
| | - Sukyung Chung
- Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA
| | - Caroline Y Noh
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, CA
| | - Ashley H Ebanks
- Department of Pediatric Surgery, University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX
| | - Matthew T Harting
- Department of Pediatric Surgery, University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX
| | - Kevin P Lally
- Department of Pediatric Surgery, University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX
| | - Krisa P Van Meurs
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, CA
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8
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Valfré L, Conforti A, Morini F, Patel N, Bevilacqua F, Cianci MC, Bagolan P, Braguglia A. Unsolved problems in CDH follow-up. Front Pediatr 2022; 10:977354. [PMID: 36389367 PMCID: PMC9645578 DOI: 10.3389/fped.2022.977354] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 09/07/2022] [Indexed: 11/25/2022] Open
Abstract
In patients affected by CDH, survival beyond the neonatal period continues to increase thanks to technological and pharmacological improvements. Conversely, patients, families and caregivers are more and more frequently facing "new" complex late comorbidities, including chronic pulmonary and cardiac dysfunctions, neurodevelopmental challenges, and specific nutritional requirements, that often require ongoing long-term medical or surgical care. Therefore, late morbidity is now a key focus in clinical care of CDH. The aims of this paper are to stress some of the most important "unsolved problems" for CDH patients at long-term follow-up.
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Affiliation(s)
- Laura Valfré
- Neonatal Surgery Unit, Medical and Surgical Department of Fetus-Newborn-Infant, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Andrea Conforti
- Neonatal Surgery Unit, Medical and Surgical Department of Fetus-Newborn-Infant, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | | | - Neil Patel
- Department of Neonatology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Francesca Bevilacqua
- Unit of Clinical Psychology, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | | | - Pietro Bagolan
- Neonatal Surgery Unit, Medical and Surgical Department of Fetus-Newborn-Infant, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.,Department of Systems Medicine, University of Tor Vergata, Rome, Italy
| | - Annabella Braguglia
- Neonatal Intermediate Care Unit and Follow-Up, Medical and Surgical Department of Fetus-Newborn-Infant, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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9
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Fleming H, Dempsey AG, Palmer C, Dempsey J, Friedman S, Galan HL, Gien J. Primary contributors to gastrostomy tube placement in infants with Congenital Diaphragmatic Hernia. J Pediatr Surg 2021; 56:1949-1956. [PMID: 33773801 DOI: 10.1016/j.jpedsurg.2021.02.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 02/02/2021] [Accepted: 02/10/2021] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To identify factors associated with gastrostomy tube (GT) placement in infants with congenital diaphragmatic hernia (CDH). METHODS Retrospective cohort study of 114 surviving infants with CDH at a single tertiary care neonatal intensive care unit from 2010-2019. Prenatal, perinatal and postnatal characteristics were compared between patients who were discharged home with and without a GT. Prenatal imaging was available for 50.9% of the cohort. Logistic regression was used to assess the association between GT placement and pertinent clinical factors. ROC curves were generated, and Youden's J statistic was used to determine optimal predictive cutoffs for continuous variables. Elastic net regularized regression was used to identify variables associated with GT placement in multivariable analysis. RESULTS GT was placed in 43.9% of surviving infants with CDH. Prenatal variables predictive of GT placement were percent predicted lung volume (PPLV) <21%, total lung volume (TLV) <30 ml, lung-head ratio (LHR) <1.2 or observed to expected LHR (O/E LHR) <55%. Infants who required a GT were diagnosed earlier prenatally (23.6 ± 3.4 vs. 26.4 ± 5.6 weeks). Patients whose stomach was above the diaphragm on prenatal ultrasound (up) had a higher odds of GT placement compared to those with stomachs below the diaphragm (down) position by a factor of 2.9 (95% CI: 1.25, 7.1); p = 0.0154. Postnatally, infants with GT had lower Apgar scores at 1 and 5 min, longer lengths of stay and higher proportion of flap closures. Infants with a type C or D defect and extracorporeal membrane oxygenation (ECMO) were associated with increased odds of needing a GT. Postnatal association included being NPO for >12 days, need for transpyloric (TP) feeds for >10 days, >14 days to transition to a 30 min bolus feed, presence of gastro-esophageal reflux (GER), chronic lung disease and pulmonary hypertension. In multivariable analysis, duration of NPO, time to TP feeds, transition to 30 min bolus feeds remained significantly associated with GT placement after adjusting for severity of pulmonary hypertension (PH), GER diagnosis and sildenafil treatment. CONCLUSION Identification of risk factors associated with need for long-term feeding access may improve timing of GT placement and prevent prolonged hospitalization related to feeding issues. LEVEL OF EVIDENCE RATING Level II (Retrospective Study).
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Affiliation(s)
- Hannah Fleming
- Department of Audiology, Speech and Learning, Children's Hospital Colorado. (Aurora, CO), Boulder, CO 80309, USA.
| | - Allison G Dempsey
- University of Colorado, Department of Psychiatry. (Aurora, CO), Boulder, CO 80309, USA
| | - Claire Palmer
- University of Colorado, Section of Neonatology (Aurora, CO), Boulder, CO 80309, USA
| | - Jack Dempsey
- University of Colorado, Section of Developmental Pediatrics (Aurora, CO), Boulder, CO 80309, USA
| | - Sandra Friedman
- University of Colorado, Section of Developmental Pediatrics (Aurora, CO), Boulder, CO 80309, USA
| | - Henry L Galan
- University of Colorado, Department of Obstetrics and Gynecology. (Aurora, CO), Boulder, CO 80309, USA
| | - Jason Gien
- University of Colorado, Section of Neonatology (Aurora, CO), Boulder, CO 80309, USA
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10
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Factors and Growth Trends Associated With the Need for Gastrostomy Tube in Neonates With Congenital Diaphragmatic Hernia. J Pediatr Gastroenterol Nutr 2021; 73:555-559. [PMID: 34117194 DOI: 10.1097/mpg.0000000000003203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES A third of infants with congenital diaphragmatic hernia (CDH) require a gastrostomy tube (GT) for nutritional support. We compared CDH infants who are GT-dependent to those able to meet their nutritional needs orally, to identify factors associated with requiring a GT and evaluate their long-term growth. METHODS Patients with CDH repaired at a single institution between 2012 and 2020 were included. Charts were retrospectively reviewed for demographic, surgical, and post-operative details. Mann-Whitney test and Fischer exact test were performed to compare GT-dependent neonates (n = 38, experimental) with orally fed neonates (n = 63, control). Significance was set at <0.05. RESULTS Thirty-eight percent received a GT (median 67 days, interquartile range [IQR] 50-88). GT-dependent neonates were significantly more likely to have a lower lung-to-head ratio (median 1.2, IQR 0.9-1.4, vs 1.6, IQR 1.3-2.0, IQR P < 0.0001), undergone patch or flap repair (79% vs 33%, P < 0.0001), and been hospitalized longer (median 47, IQR 24-75 vs 28 days, P < 0.0001). Fourteen of 38 had their GT removed (median 26 months, IQR 14-36). GT-dependent neonates initiated oral feeds (calculated as time since extubation) later (median 21, IQR 8-26, vs 8 days, IQR 4-13, P = 0.006). Height-for-age z scores remained stable after GT removal, while weight-for-age z scores dropped initially and began improving a year later. CONCLUSIONS The need for a gastrostomy for nutritional support is associated with more severe CDH. Over a third of patients no longer needed a GT at a median of 26 months. Linear growth generally remains stable after removal. These results may help counsel parents regarding nutritional expectations.
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Cordier AG, Laup L, Letourneau A, Le Sache N, Fouquet V, Senat MV, Perrotin F, Rosenblatt J, Sananes N, Jouannic JM, Benoist G, Jani JC, Benachi A. Prenatal stomach position predicts gastrointestinal morbidity at 2 years in fetuses with left-sided congenital diaphragmatic hernia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:959-967. [PMID: 32462707 DOI: 10.1002/uog.22086] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 05/02/2020] [Accepted: 05/10/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE The long-term morbidity associated with isolated left-sided congenital diaphragmatic hernia (CDH) has been described previously. However, antenatal criteria impacting gastrointestinal morbidity (GIM) are not yet defined. The objective of this study was to evaluate the effect of fetal stomach position on the risk of GIM at 2 years of age in children with left-sided CDH. METHODS This was a retrospective, observational multicenter cohort study of data obtained from January 2010 to January 2014, that included patients whose fetus had isolated left-sided CDH, with or without fetal endoscopic tracheal occlusion (FETO). Prenatal maternal, fetal and pediatric data were collected. Fetal stomach position was evaluated a posteriori by two observers, using ultrasound images at the level of the four-chamber view of the heart that had been obtained to calculate the observed-to-expected lung-area-to-head-circumference ratio (O/E-LHR). Fetal stomach position was graded as follows: Grade 1, stomach not visualized; Grade 2, stomach visualized anteriorly, next to the apex of the heart, with no structure in between the stomach and the sternum; Grade 3, stomach visualized alongside the left ventricle of the heart, and abdominal structures anteriorly; or Grade 4, as Grade 3 but with stomach posterior to the level of the atrioventricular heart valves. The primary outcome was GIM at 2 years of age, assessed in a composite manner, including the occurrence of gastroesophageal reflux disease, need for gastrostomy, duration of parenteral and enteral nutrition and persistence of oral aversion. Regression analysis was performed in order to investigate the effect of O/E-LHR, stomach position and FETO on various GIM outcome variables. RESULTS Forty-seven patients with fetal left-sided CDH were included in the analysis. Thirteen (27.7%) infants did not meet the criterion of exclusive oral feeding at 2 years of age. Fetal stomach position grade was associated significantly and independently with the duration of parenteral nutrition (odds ratio (OR), 19.86; P = 0.031) and persistence of oral aversion at 2 years (OR, 3.40; P = 0.006). On multivariate analysis, O/E-LHR was predictive of the need for prosthetic patch repair, but not for GIM. FETO did not seem to affect the risk of GIM at 2 years. CONCLUSION In isolated left-sided CDH, fetal stomach position is the only factor that is predictive of GIM at 2 years of age. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- A G Cordier
- Department of Gynecology and Obstetrics, Antoine Béclère Hospital, Paris-Sud University, Clamart, France
- Reference Center for Rare Diseases: Congenital Diaphragmatic Hernia, Clamart, France
| | - L Laup
- Department of Gynecology and Obstetrics, Antoine Béclère Hospital, Paris-Sud University, Clamart, France
| | - A Letourneau
- Department of Gynecology and Obstetrics, Antoine Béclère Hospital, Paris-Sud University, Clamart, France
- Reference Center for Rare Diseases: Congenital Diaphragmatic Hernia, Clamart, France
| | - N Le Sache
- Reference Center for Rare Diseases: Congenital Diaphragmatic Hernia, Clamart, France
- Department of Neonatal Pediatrics, Bicêtre Hospital, Paris-Sud University, Le Kremlin-Bicêtre, France
| | - V Fouquet
- Reference Center for Rare Diseases: Congenital Diaphragmatic Hernia, Clamart, France
- Department of Pediatric Surgery, Bicêtre Hospital, Paris-Sud University, Le Kremlin-Bicêtre, France
| | - M V Senat
- Reference Center for Rare Diseases: Congenital Diaphragmatic Hernia, Clamart, France
- Department of Gynecology and Obstetrics, Bicêtre Hospital, Paris-Sud University, Le Kremlin-Bicêtre, France
| | - F Perrotin
- Department of Obstetrics, Gynecology and Fetal Medicine, Regional University Hospital, Francois Rabelais University, Tours, France
| | - J Rosenblatt
- Department of Obstetrics and Gynecology, Robert Debré Hospital, APHP, Paris, France
| | - N Sananes
- Department of Maternal-Fetal Medicine, Strasbourg University Hospital, Strasbourg, France
| | - J M Jouannic
- Department of Fetal Medicine, Trousseau Hospital, APHP Sorbonne, Sorbonne University, Paris, France
| | - G Benoist
- Department of Obstetrics and Gynecology, Caen University Hospital, Caen, France
| | - J C Jani
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - A Benachi
- Department of Gynecology and Obstetrics, Antoine Béclère Hospital, Paris-Sud University, Clamart, France
- Reference Center for Rare Diseases: Congenital Diaphragmatic Hernia, Clamart, France
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Abstract
Congenital diaphragmatic hernia (CDH) is a potentially severe anomaly that should be referred to a fetal care center with expertise in multidisciplinary evaluation and management. The pediatric radiologist plays an important role in the evaluation of CDH, both in terms of anatomical description of the anomaly and in providing detailed prognostic information for use in caring for the fetus and pregnant mother as well as planning for delivery and postnatal care. This article reviews the types of hernias, including distinguishing features and imaging clues. The most common methods of predicting severity are covered, and current fetal and postnatal therapies are explained. The author of this paper provides a handy reference for pediatric radiologists presented with a case of CDH as part of their daily practice.
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