Survival in early- and late-term infants with congenital diaphragmatic hernia treated with extracorporeal membrane oxygenation

Case Report: Fetoscopic Laparoschisis (FETO-LAP)-A New Therapeutic Route to Explore for Fetuses with Severe Diaphragmatic Hernias

BACKGROUND

The purpose of this report is to describe the seminal case of a near-term human fetus with a life-threatening left diaphragmatic hernia that underwent fetoscopic tracheal occlusion (FETO) combined with fetoscopic partial removal of herniated bowel from the fetal chest by fetoscopic laparoschisis (FETO-LAP).

CASE SUMMARY

A life-threatening left diaphragmatic hernia (liver-up; o/e LHR of ≤25%; MRI lung volume ≤ 20%) was observed in a human fetus at 34 weeks of gestation. After counselling the mother about the high risks of postnatal demise if left untreated, the expected limitations of fetoscopic tracheal occlusion (FETO), and the previously untested option of combining FETO with fetoscopic laparoschisis, i.e., partial removal of the herniated bowel from the fetal chest (FETO-LAP), she consented to the latter novel treatment approach. FETO-LAP was performed at 36 + 5 weeks of gestation under general maternofetal anesthesia. Mother and fetus tolerated the procedure well. The neonate was delivered and the balloon removed on placental support at 37 + 2 weeks of gestation. On ECMO, a rapid increase in tidal volume was seen over the next eight days. Unfortunately, after this period, blood clots obstructed the ECMO circuit and the neonate passed away.

DISCUSSION

This seminal case shows that in a fetus with severe left diaphragmatic hernia, partial removal of the herniated organs from the fetal chest is not only possible by minimally invasive fetoscopic techniques but also well tolerated. As the effect of FETO alone is limited in saving severely affected fetuses, combining FETO with fetoscopic laparoschisis (FETO-LAP) offers a new therapeutic route with multiple, potentially life-saving implications.

Expanding neonatal ECMO criteria: When is the premature neonate too premature

Extracorporeal membrane oxygenation (ECMO) is a universally accepted and life-saving therapy for neonates with respiratory or cardiac failure that is refractory to maximal medical management. Early studies found unacceptable risks of mortality and morbidities such as intracranial hemorrhage among premature and low birthweight neonates, leading to widely accepted ECMO inclusion criteria of gestational age ≥34 weeks and birthweight >2 kg. Although contemporary data is lacking, the most recent literature demonstrates increased survival and decreased rates of intracranial hemorrhage in premature neonates who are supported with ECMO. As such, it seems like the right time to push the boundaries of ECMO on a case-by-case basis beginning with neonates 32-34 weeks GA in large volume centers with careful neurodevelopmental follow-up to better inform practices changes on this select population.

Extracorporeal Membrane Oxygenation (ECMO) and its complications in newborns with congenital diaphragmatic hernia

BACKGROUND

Extracorporeal Membrane Oxygenation (ECMO) is offered to patients with congenital diaphragmatic hernia (CDH) who are in severe respiratory and cardiac failure. We aim to describe the types of complications among these patients and their impact on survival.

METHODS

A single-center, retrospective review of CDH patients cannulated onto ECMO between January 2005 and November 2020 was conducted. ECMO complications, as categorized by the Extracorporeal Life Support Organization (ELSO), were correlated with survival status. Descriptive statistics were used to compare observed complications between survivors and non-survivors.

RESULTS

In our cohort of CDH neonates, 21% (54/258) were supported with ECMO, of whom, 61% (33/54) survived. Survivors and non-survivors were similar in baseline characteristics except for birthweight z-score (p = 0.043). Seventy percent of CDH neonates experienced complications during their ECMO run, with the most common categories being metabolic (48.1%) and mechanical (38.9%), followed by hemorrhage (22.2%), neurological (18.5%), renal (11.1%), pulmonary (7.4%), and cardiovascular (7.4%). The median number of complications per patient was higher in the non-survivor group  (2 (IQR: 1-4) vs 1 (IQR: 0-2), p = 0.043). In addition, mechanical (57.1% vs 27.3%, p = 0.045) and renal (28.6% vs 0%, p = 0.002) complications were more common among non-survivors compared to survivors.

CONCLUSION

Complications occur frequently among ECMO-treated newborns with CDH, some of which have serious long-term consequences. Survivors had higher birth weight z-scores, shorter ECMO runs, and fewer complications per patient. Mechanical and renal complications were independently associated with mortality, emphasizing the utility of more focused strategies to target fluid balance and renal protection and to prevent circuit and cannula complications.

Premature and Extracorporeal Life Support: Is it Time? A Systematic Review

Early preterm birth < 34 gestational weeks (GA) and birth weight (BW) <2 kg are relative contraindications for extracorporeal membrane oxygenation (ECMO). However, with improved technology, ECMO is presently managed more safely and with decreasing complications. Thus, these relative contraindications may no longer apply. We performed a systematic review to evaluate the existing literature on ECMO in early and late (34-37 GA) prematurity focusing on survival to hospital discharge and the complication intracranial hemorrhage (ICH). Data sources: MEDLINE, PubMed, Web of Science, Embase, and the Cochrane Database. Only publications in the English language were evaluated. Of the 36 included studies, 23 were related to ECMO support for respiratory failure, 10 for cardiac causes, and four for congenital diaphragmatic hernia (CDH). Over the past decades, the frequency of ICH has declined (89-21%); survival has increased in both early prematurity (25-76%), and in CDH (33-75%), with outcome similar to late prematurity (48%). The study was limited by an inherent risk of bias from overlapping single-center and registry data. Both the risk of ICH and death have decreased in prematurely born treated with ECMO. We challenge the 34 week GA time limit for ECMO and propose an international task force to revise current guidelines. At present, gestational age < 34 weeks might no longer be considered a contraindication for ECMO in premature neonates.

Influence of Gestational Age and Mode of Delivery on Neonatal Outcomes in Prenatally Diagnosed Isolated Congenital Diaphragmatic Hernia

AIM

The optimal gestational age (GA) at delivery and mode of delivery (MoD) for pregnancies with fetal congenital diaphragmatic hernia (CDH) is undetermined. The impact of early term (37-38 weeks 6 days) versus full term (39-40 weeks 6 days) and MoD on immediate neonatal outcomes in prenatally diagnosed isolated CDH cases was evaluated.

MATERIAL AND METHODS

A retrospective chart review of pregnancies evaluated and delivered with the prenatal diagnosis of CDH between July 1, 2008, and December 31, 2018. The primary outcome was survival to hospital discharge. Secondary outcomes included neonatal intensive care unit (NICU) length of stay (LOS), extracorporeal membrane oxygenation (ECMO) requirement and need for supplemental oxygen at day 30 of life.

RESULTS

A total of 296 patients were prenatally evaluated for CDH and delivered in a single center during the study period. After applying exclusion criteria, data were available on 113 women who delivered early term and 72 women who delivered full term. Survival to hospital discharge was comparable between the 2 groups - 83.2% in the early term versus 93.1% in the full term (p = 0.07; 95% CI of 0.13-1.04). No difference was observed in any other secondary outcomes. MoD was stratified into spontaneous vaginal, induced vaginal, unplanned cesarean and scheduled cesarean delivery with associated neonatal survival rates of 74.2, 90.6, 89.7 and 88.2%, respectively, p = 0.13. The 5-min Apgar score was higher in the elective cesarean group (7.94) followed by the induced vaginal delivery group (7.8) compared to 7.17 and 7.18 in the spontaneous vaginal and unplanned cesarean groups, respectively (p = 0.03). The GA and MoD did not influence survival to hospital discharge nor NICU LOS in multivariate analysis.

CONCLUSIONS

Though there were no significant differences in neonatal outcomes for early term compared to full term deliveries of CDH neonates, a trend toward improved survival rates and lower ECMO requirements in the full term group may suggest an underlying importance GA at delivery. Further studies are warranted to validate these findings.

What should we tell parents? Congenital diaphragmatic hernia

Congenital diaphragmatic hernia (CDH) is characterized by a defect in the muscle dividing the thoracic and abdominal cavities. This leads to herniation of the abdominal organs into the thorax and a disturbance of lung development. Two-thirds of cases are identified by prenatal ultrasound in the second trimester, which should prompt referral to a tertiary center for prognosis assessment and counseling by a multidisciplinary team familiar with this condition. In this review, we summarize evidence on prenatal diagnosis and postnatal management of CDH. There is a focus on information that should be provided to expecting parents during prenatal counseling.

The development of multiorgan dysfunction in CDH-ECMO neonates is associated with the level of pre-ECMO support

PURPOSE

Congenital diaphragmatic hernia (CDH) is the most common indication for neonatal extracorporeal membrane oxygenation (ECMO), but mortality remains at 50%. Multiorgan failure can occur in 25% and has been linked to worse outcomes. We sought to examine the factors that would increase the risk of multiorgan dysfunction (MOD).

METHODS

The Extracorporeal Life Support Organization (ELSO) database was used to identify infants with CDH (2000-2015). The primary outcome was MOD, which was defined as the presence of organ failure in ≥2 organ systems. We used a multivariable logistic regression to examine the effect of demographics, pre-ECMO respiratory status, comorbidities, and therapies on MOD.

RESULTS

There were a total of 4374 CDH infants who were treated with ECMO. Overall mortality was 52.4%. The risk models demonstrated that pre-ECMO cardiac arrest (OR 1.458, CI: 1.146-1.861, p = 0.002) and hand-bagging (OR 1.461, CI: 1.094-1.963, p = 0.032) had the strongest association with MOD. In addition, other pre-ECMO indicators of disease severity (pH, HFOV, MAP, 5-min APGAR) and pre-ECMO therapies (bicarb, neuromuscular [NM] blockers) were also associated with MOD.

CONCLUSIONS

The level of pre-ECMO support has a significant association with the development of MOD, and initiation of ECMO prior to arrest seems to be critical to avoid complications.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

Level III.

Controversies in extracorporeal membrane oxygenation (ECMO) utilization and congenital diaphragmatic hernia (CDH) repair using a Delphi approach: from the American Pediatric Surgical Association Critical Care Committee (APSA-CCC)

PURPOSE

Review current practices and expert opinions on contraindications to extracorporeal membrane oxygenation (ECMO) in congenital diaphragmatic hernia (CDH) and contraindications to repair of CDH following initiation of ECMO.

METHODS

Modified Delphi method was employed to achieve consensus among members of the American Pediatric Surgical Association Critical Care Committee (APSA-CCC).

RESULTS

Overall response rate was 81% including current and former members of the APSA-CCC. An average of 5-15 CDH repairs were reported annually per institution; 26-50% of patients required ECMO. 100% of respondents would not offer ECMO to a patient with a complex or unrepairable cardiac defects or lethal chromosomal abnormality; 94.1% would not in the setting of severe intracranial hemorrhage (ICH). 76.5% and 72.2% of respondents would not offer CDH repair to patients on ECMO with grade III-IV ICH or new diagnosis of lethal genetic or metabolic abnormalities, respectively. There was significant variability in whether or not to repair CDH if unable to wean from ECMO at 4-5 weeks.

CONCLUSIONS

Significant variability in practice pattern and opinions exist regarding contraindications to ECMO and when to offer repair of CDH for patients on ECMO. Ongoing work to evaluate outcomes is needed to standardize management and minimize potentially futile interventions.

LEVEL OF EVIDENCE

V (expert opinion).

Improving outcome in congenital diaphragmatic hernia - experience of a tertiary center without ECMO

BACKGROUND

Congenital diaphragmatic hernia (CDH) has a high mortality rate, representing a therapeutic challenge. Prenatal diagnosis (PND) is essential in defining optimal perinatal strategy, particularly delivery planning. Hospital Pediátrico de Coimbra is the referral centre for all neonatal surgery, particularly CDH, for the central region of Portugal. The aim was to evaluate clinical management and outcome of newborns with CDH.

METHODS

An exploratory retrospective study made up of newborns admitted to PICU with CDH was undertaken between January 1995 and December 2014. Two groups were formed based on their year of admission: group A (1995- 2004) and group B (2005- 2014) and were compared.

RESULTS

The mean birth weight of the 69 newborns admitted was 2.762 ± 696 g; the median of the gestational age was 38 weeks. Associated malformations were observed in 28 (40.5%) and 15 (21.7%) had a right-sided diaphragm defect. The global mortality was 13.0%; in group A was significantly higher than in group B (22.2 vs 3.0%; p = 0.029). A reduction in mortality throughout the years was confirmed after adjusting for POS score (OR = 0.77; 95% CI: 0.62- 0.96, p = 0.021). PND was made in 30.6% of cases in the group A and 66.7% in the group B (p = 0.03). Tertiary perinatal hospital birth was achieved in 60% of newborns in the group A versus 84.8% in group B (p = 0.022). Maximum fraction of inspired oxygen showed a statistically significant difference between the two study groups (60% vs 40%; p = 0.009).

CONCLUSIONS

A significant decrease in mortality was observed throughout the study. The authors highlight the increase in prenatal diagnosis and an improvement in perinatal care with planning delivery as important contributors to these results.

Cannulating the contraindicated: effect of low birth weight on mortality in neonates with congenital diaphragmatic hernia on extracorporeal membrane oxygenation

BACKGROUND/PURPOSE

Restrictions for ECMO in neonates include birth weight less than 2kg (BW <2kg) and/or gestational age less than 34weeks (GA <34weeks). We sought to describe their relationship on mortality.

METHODS

Neonates with a primary diagnosis code of CDH were identified in the Extracorporeal Life Support Organization (ELSO) registry, and logistic regression models were used to examine the effect of BW <2kg and GA <34weeks on mortality.

RESULTS

We identified 7564 neonates with CDH. The overall mortality was 50%. There was a significantly higher risk of death with unadjusted odds ratio (OR) 2.39 (95% confidence interval [CI]: 1.53-3.74; P<0.01) for BW <2kg neonates. The adjusted OR of death for BW <2kg neonates remained significantly high with over two-fold increase in the odds of mortality when adjusted for potential confounding variables (OR 2.11, 95% CI: 1.30-3.43; P<0.01). However, no difference in mortality was observed in neonates with GA <34weeks.

CONCLUSIONS

While mortality among CDH neonates with a BW <2kg was substantially increased, GA <34weeks was not significantly associated with mortality. Effort should be made to identify the best candidates for ECMO in this high-risk group and develop treatment strategies to optimize their survival.

TYPE OF STUDY

Case-Control Study, Retrospective Comparative Study.

LEVEL OF EVIDENCE

Level III.

Shifting Risks and Conflicting Outcomes-ECMO for Neonates with Congenital Diaphragmatic Hernia in the Modern Era

OBJECTIVES

To update previously described trends for neonates with congenital diaphragmatic hernia (CDH) receiving ECMO with changes in recommendations for care, and to determine how recent advancements in respiratory care have affected this patient population.

STUDY DESIGN

This study is a retrospective review of more than 2500 neonates with CDH who received ECMO listed in the Extracorporeal Life Support Organization (ELSO) registry. Cochran-Armitage and multivariate regression analyses were used to analyze changes in the patient population over time and in mortality-related risk factors.

RESULTS

Almost one-half (48.1%) of the term neonates survived to discharge, representing a 13.8% decline in survival over the past 25 years (P < .0001). Over the past 10 years, the prevalence of respiratory acidosis more than doubled (P < .0001) and the prevalence of major complications increased (P < .001). During the same period, the number of ECMO courses longer than 1 week increased (P < .001), whereas the prevalence of multiple complications (>4) decreased (P < .0001). Surgeries performed on ECMO were associated with worse outcomes than those performed off ECMO. ECMO duration no longer represents a mortality-related risk factor.

CONCLUSIONS

Survival rates for neonates with CDH receiving ECMO have continued to drop in the modern era. Although the safety of ECMO has improved over the last decade, the number of patients experiencing significant respiratory acidosis has more than doubled-increasing the risk of intracranial hemorrhage and overall mortality. The evidence for permissive hypercapnia remains mixed; nonetheless, we believe that the risks outweigh the rewards in this patient population.

Pushing the boundaries of ECLS: Outcomes in <34 week EGA neonates

PURPOSE

Extracorporeal life support (ECLS) is usually reserved for infants ≥34weeks estimated gestational age (EGA) owing to concerns about increased mortality and incidence of intracranial hemorrhage (ICH). We sought to characterize survival, rates of ICH, and complications in <34week EGA neonates placed on ECLS.

METHODS

752 neonates of EGA 29-34weeks were identified in the Extracorporeal Life Support Organization (ELSO) Registry (1976-2008). Data analyzed included birthweight, survival, pre-ECLS conditions, ventilatory parameters and complications (including ICH and other neurological outcomes). Data were compared using t-test, Chi-square and logistic regression analyses.

RESULTS

When compared to survival rates of 34week EGA neonates (58%), survival was statistically different for 29-33week EGA (48%, p=0.05). No significant difference in ICH incidence was seen between the 29-33week and 34week groups (21% vs. 17%, respectively), but a significant difference was seen in the incidence of cerebral infarct between groups (22% for 29-33weeks vs. 16% for 34weeks; p=0.03). ICH and survival did not correlate with EGA during logistic regression analysis.

CONCLUSIONS

Though rates of survival and cerebral infarction were worse at 29-33weeks EGA compared with 34weeks, these differences were modest and may be clinically acceptable. This suggests that EGA<34weeks may not be an absolute contraindication to use of ECLS.

LEVEL OF EVIDENCE

III.

Development and Validation of the Neonatal Risk Estimate Score for Children Using Extracorporeal Respiratory Support

OBJECTIVE

To develop and validate the Neonatal Risk Estimate Score for Children Using Extracorporeal Respiratory Support, which estimates the risk of in-hospital death for neonates prior to receiving respiratory extracorporeal membrane oxygenation (ECMO) support.

STUDY DESIGN

We used an international ECMO registry (2008-2013); neonates receiving ECMO for respiratory support were included. We divided the registry into a derivation sample and internal validation sample, by calendar date. We chose candidate variables a priori based on published evidence of association with mortality; variables independently associated with mortality in logistic regression were included in this parsimonious model of risk adjustment. We evaluated model discrimination with the area under the receiver operating characteristic curve (AUC), and we evaluated calibration with the Hosmer-Lemeshow goodness-of-fit test.

RESULTS

During 2008-2013, 4592 neonates received ECMO respiratory support with mortality of 31%. The development dataset contained 3139 patients treated in 2008-2011. The Neo-RESCUERS measure had an AUC of 0.78 (95% CI 0.76-0.79). The validation cohort had an AUC = 0.77 (0.75-0.80). Patients in the lowest risk decile had an observed mortality of 7.0% and a predicted mortality of 4.4%, and those in the highest risk decile had an observed mortality of 65.6% and a predicted mortality of 67.5%.

CONCLUSIONS

Neonatal Risk Estimate Score for Children Using Extracorporeal Respiratory Support offers severity-of-illness adjustment for neonatal patients with respiratory failure receiving ECMO. This score may be used to adjust patient survival to assess hospital-level performance in ECMO-based care.

Current Concepts in the Management of Congenital Diaphragmatic Hernia in Infants

The therapeutic approach to congenital diaphragmatic hernia (CDH) has shifted from one of immediate repair to management of pulmonary hypertension, physiologic stabilization, and delayed surgical repair. Lung hypoplasia, remodeled pulmonary vasculature, and ventricular dysfunction all contribute to the high morbidity and mortality associated with CDH. In addition, genetic syndromes associated with CDH can increase the incidence of serious anomalies and hence impact survival. Prenatal and postnatal management of infants with CDH is challenging in the best of circumstances and need multidisciplinary teams for optimal outcomes. However, advances using ultrasound and fetal MRI can predict prognosis and survival and plan for postnatal management. Survival rates for patients with CDH have increased for the past decade with better management at resuscitation; implementation of gentle ventilation strategies; and medical management of pulmonary hypertension, physiologic stabilization, and extracorporeal membrane oxygenation. However, follow-up of these infants for long-term morbidities is essential for optimal outcomes after discharge.

Congenital diaphragmatic hernia

Congenital diaphragmatic hernia is an uncommon congenital anomaly of the diaphragm with pulmonary hypoplasia and persistent pulmonary hypertension as serious consequences. Despite recent advances in therapy, congenital diaphragmatic hernia remains a challenging condition. Best treatment strategies are still largely unknown, and practice strategies vary widely among different centres. Additionally, as congenital diaphragmatic hernia is a relatively uncommon condition, it is difficult to recruit sufficient numbers of patients for clinical trials. In recent years, survival rates of congenital diaphragmatic hernia patients appear to have increased. With the progressively improved survival rates, the long-term prognosis and quality of life of patients have become an increasingly important issue. Survivors have been shown to be at risk for many long-term morbidities, which highlights the importance of long-term follow-up of these children. The aim of this review is to give an overview of the current knowledge regarding congenital diaphragmatic hernia.

Extracorporeal membrane oxygenation for neonatal and pediatric respiratory failure: an evidence-based review of the past decade (2002-2012)

OBJECTIVE

To provide a comprehensive evidence-based review of extracorporeal membrane oxygenation for neonatal and pediatric respiratory failure.

DATA SOURCE

A thorough computerized bibliographic search of the clinical literature regarding the use of extracorporeal membrane oxygenation in the neonatal and pediatric populations.

STUDY SELECTION

Clinical trials published between January 1, 2002, and October 1, 2012, including "extracorporeal membrane oxygenation" or "ECMO" and limited to studies involving humans aged 0-18 years. Trials focused on extracorporeal membrane oxygenation for cardiac indications were excluded from this study, unless the study was evaluating ancillary therapies in conjunction with extracorporeal membrane oxygenation.

DATA EXTRACTION

Studies were evaluated for inclusion based on reporting of patient outcomes and/or strategic considerations, such as cannulation strategies, timing of extracorporeal membrane oxygenation utilization, and ancillary therapies.

DATA SYNTHESIS

Pertinent data are summarized, and the available data are objectively classified based on the value of the study design from which the data are obtained.

CONCLUSIONS

Despite a large number of published extracorporeal membrane oxygenation studies, there remains a paucity of high-quality clinical trials. The available data support continued use of extracorporeal membrane oxygenation for respiratory failure refractory to conventional therapy for neonatal and pediatric patients without significant comorbidities. Further research is needed to better quantify the benefit of extracorporeal membrane oxygenation and the utility of many therapies commonly applied to extracorporeal membrane oxygenation patients.

Periodic MRI lung volume assessment in fetuses with congenital diaphragmatic hernia: prediction of survival, need for ECMO, and development of chronic lung disease

OBJECTIVE

The purpose of the study was to investigate the ability to predict survival, need for extracorporeal membrane oxygenation (ECMO), and incidence of chronic lung disease in patients with congenital diaphragmatic hernia in the context of a classification into three different times of gestation (< 28, 28-32, and > 32 weeks) by assessing the ratio between observed and expected MRI fetal lung volume.

MATERIALS AND METHODS

The data analysis included 226 fetuses with congenital diaphragmatic hernia. MRI was performed at different times of gestation with a T2-weighted HASTE sequence. Receiver operating characteristic curve analysis was performed to investigate the prognostic value of assessment of the ratio between observed and expected MRI fetal lung volumes at different stages of fetal growth.

RESULTS

For all reviewed times of gestation, the ratio between observed and expected MRI fetal lung volumes had almost equivalent statistically significant differences for neonatal survival (p ≤ 0.0029), need for ECMO therapy (p ≤ 0.0195), and development of chronic lung disease (p ≤ 0.0064). Results with high prognostic accuracy for early and for medium and late times in gestation also were obtained. Receiver operating characteristic analysis showed the highest area under the curve (≥ 0.819) for neonatal survival.

CONCLUSION

In patients with congenital diaphragmatic hernia, the relation between observed and expected MRI fetal lung volume is a valuable prognostic parameter for predicting neonatal mortality, morbidity represented by the development of chronic lung disease, and the need for ECMO therapy in early gestation (< 28 weeks) as well as later gestation with no statistically significant differences.

[Does the regional health care organization impact the outcome of infants born with congenital diaphragmatic hernia?]

INTRODUCTION

Congenital diaphragmatic hernia (CDH) is a serious pathology that requires optimal management in very specialized health centers. French medical care organization is regionally based. Hence, evaluating local practices may help deliver clear information to parents before delivery. The aim of this study was to analyze the neonatal characteristics and the postnatal outcome of infants affected with CDH, treated within two different French perinatal health care networks.

PATIENTS AND METHODS

Retrospective cohort study of infants with CDH, cared for in the Lorraine perinatal health care network (Réseau Périnatal Lorrain [RPL]) or at Édouard-Herriot Hospital (HEH) in Lyon, between 1997 and 2007.

RESULTS

One hundred and twenty-seven newborns were included, 44 in the RPL and 83 in Lyon. Prenatal diagnosis of CDH was similar in RPL and at HEH; 47.7% of infants with CDH died in RPL vs 36.1% in HEH (P=0.2). Surgery delayed for more than 24h was more frequent in RPL (68.6% vs 31.7%; P<0.001), with a postoperative mortality rate of 31.4% vs 15.9%; P=0.08. In RPL, specialized medical follow-up was rare (33.3% vs 100%; P<0.001), while psychomotor retardation was more frequent (33.3% vs 5.7%; P=0.002).

CONCLUSION

This study brings to light the diversity of care and outcome for infants affected with CDH in two French perinatal health care networks. These results may help improve both centers' practices. In Lorraine for instance, the follow-up of these vulnerable children can be improved.

Costs of congenital diaphragmatic hernia repair in the United States-extracorporeal membrane oxygenation foots the bill

BACKGROUND

Congenital diaphragmatic hernia (CDH) is the costliest noncardiac congenital defect. Extracorporeal membrane oxygenation (ECMO) is a treatment strategy offered to those babies with CDH who would not otherwise survive on conventional therapy. The primary objective of our study was to identify the leading source of expenditures in CDH care.

METHODS

All patients surviving CDH repair were identified in the Kids' Inpatient Database (KID) from 1997 to 2006, with costs converted to 2006 US dollars. Patients were categorized into groups based on severity of disease for comparison including CDH repair only, prolonged ventilator dependence, and ECMO use. Factors associated with greater expenditures in CDH management were analyzed using a regression model.

RESULTS

Eight hundred thirty-nine patients from 213 hospitals were studied. Extracorporeal membrane oxygenation use decreased from 18.2% in 1997 to 11.4% in 2006 (P = .002). Congenital diaphragmatic hernia survivors managed with ECMO cost more than 2.4 times as much as CDH survivors requiring only prolonged ventilation postrepair and 3.5 times as much as those with CDH repair only (both P < .001). Age, multiplicity of diagnoses, patient transfer, inhaled nitric oxide use, prolonged ventilation, and ECMO use were all associated with higher costs. Extracorporeal membrane oxygenation use was the single most important factor associated with higher costs, increasing expenditures 2.4-fold (95% confidence interval, 2.1-2.8). Though the CDH repair with ECMO group constituted 12.2% of patients, this group has the highest median costs ($156,499.90/patient) and constitutes 28.5% of national costs based on CDH survivors in the KID. Annual national cost for CDH survivors is $158 million based on the KID, and projected burden for all CDH patients exceeds $250 million/year.

CONCLUSIONS

Extracorporeal membrane oxygenation use is the largest contributing factor to the economic burden in CDH. With limited health care resources, judicious resource utilization in CDH care merits further study.

Re-evaluation of stomach position as a simple prognostic factor in fetal left congenital diaphragmatic hernia: a multicenter survey in Japan

OBJECTIVES

To document outcome and to explore prognostic factors in fetal left congenital diaphragmatic hernia (CDH).

METHODS

This was a multicenter retrospective study of 109 patients with prenatally diagnosed isolated left CDH born between 2002 and 2007. The primary outcome was intact discharge, defined as discharge from hospital without major morbidities, such as a need for respiratory support including oxygen supplementation, tube feeding, parenteral nutrition or vasodilators. All patients were managed at perinatal centers with immediate resuscitation, gentle ventilation (mostly with high-frequency oscillatory ventilation) and surgery after stabilization. Prenatal data collected included liver and stomach position, lung-to-head ratio, gestational age at diagnosis and presence or absence of polyhydramnios. Stomach position was classified into four grades: Grade 0, abdominal; Grade 1, left thoracic; Grade 2, less than half of the stomach herniated into the right chest; and Grade 3, more than half of the stomach herniated into the right chest.

RESULTS

Overall intact discharge and 90-day survival rates were 65.1% and 79.8%, respectively. Stomach herniation was classified as Grade 0 in 19.3% of cases, Grade 1 in 45.9%, Grade 2 in 13.8% and Grade 3 in 21.1%. Multivariate analysis revealed that liver position was the strongest prognostic variable for intact discharge, followed by stomach position. Based on our results, we divided patients into three groups according to liver (up vs. down) and stomach (Grade 0-2 vs. Grade 3) position. Intact discharge rates declined significantly from liver-down (Group I), to liver-up with stomach Grade 0-2 (Group II), to liver-up with stomach Grade 3 (Group III) (87.0%, 47.4% and 9.5% of cases, respectively).

CONCLUSION

Current status and outcomes of prenatally diagnosed left CDH in Japan were surveyed. Stomach herniation into the right chest was not uncommon and its grade correlated with outcome. The combination of liver and stomach positions was useful to stratify patients into three groups (Group I-III) with different prognoses.

Impact of hospital volume on in-hospital mortality of infants undergoing repair of congenital diaphragmatic hernia

OBJECTIVES

Congenital diaphragmatic hernia (CDH) remains a significant cause of neonatal morbidity and mortality.

SUMMARY OF BACKGROUND DATA

Previous studies have suggested that hospital volume is an independent predictor of in-hospital mortality. We sought to validate this effect using a large national database incorporating 37 free-standing children's hospitals in the United States.

METHODS

Infants who underwent repair of CDH from 2000 to 2008 at Pediatric Health Information Systems-member hospitals were evaluated. Hospitals were categorized by tertiles into low-volume (≤6 cases/yr), medium-volume (6-10 cases/yr), and high-volume (>10 cases/yr). Using generalized linear mixed models with random effects, we computed the risk-adjusted odds ratio of mortality by yearly hospital volume of CDH repair, after adjustment for salient patient and hospital characteristics.

RESULTS

There were 2203 infants who underwent repair with an overall survival of 82%. Average yearly hospital volume of CDH repair varied from 1.4 to 17.5 cases per year. Smaller birthweight (adjusted odds ratio [aOR]: 0.56 per kg, P < 0.001), year of birth (P < 0.001), chromosomal abnormalities (aOR: 3.83, P < 0.01), longer time to repair (aOR: 1.12 per week, P < 0.05), the thoracic approach for repair (P < 0.02), and requirement for extracorporeal membrane oxygenation (aOR: 10.31, P < 0.0001), or inhaled nitric oxide (aOR: 5.25, P < 0.0001) were each independently associated with mortality. Compared with low-volume hospitals, medium-volume (aOR: 0.56, P < 0.05) and high-volume (aOR: 0.44, P < 0.01) hospitals had a significantly lower mortality. The rate of extracorporeal membrane oxygenation use at each facility was not independently associated with mortality.

CONCLUSIONS

This large study suggests that hospitals which perform high volumes of CDH repair achieve lower in-hospital mortality. These data support the paradigm of regionalized centers of excellence for the management of infants with this morbid condition.

Successful thoracoscopic staged repair of bilateral congenital diaphragmatic hernia

Congenital diaphragmatic hernia (CDH) occurs in 1 of every 2000 to 3000 live births and accounts for 8% of all major congenital anomalies. Bilateral hernias account for no more than 1% of all types of CDH; furthermore, they are usually fatal prenatally. Those that survive are identified through a limited number of case reports. We are presenting an unusual case of bilateral CDH hernia in a neonate that was repaired successfully using a staged thoracoscopic approach. To our knowledge, this represents the first case in the world literature of bilateral CDH that was repaired thoracoscopically. In carefully selected patients, appropriate use of disruptive new technologies such as thoracoscopy can be achieved.

Congenital diaphragmatic hernia: review of the literature in reflection of unresolved dilemmas

BACKGROUND

Congenital diaphragmatic hernia (CDH) is a rare but clinically and scientifically challenging condition. The introduction of ultrasound has enabled early prenatal detection and consequently, hope of early therapeutic intervention.

AIM

We undertook the task to review the recent developments in understanding the pathology of CDH as well as the history and current management strategies to aid perinatologists in consultations with parents of CDH-affected foetuses.

STUDY DESIGN

A Medline search was undertaken of all reports and reviews published between 1980 and 2008 using MeSH search terms 'diaphragmatic hernia', 'congenital' and 'newborn'.

RESULTS

The true incidence of CDH is still difficult to estimate because of the high incidence of hidden mortality of CDH. Complete case ascertainment also poses difficulties in assessment of the impact of new therapeutic modalities on overall survival. Recent improvements in prenatal detection are a milestone in affording time for re-assessments and parental counselling. The true benefit of antenatal therapy is circumscribed and should be offered only in selected cases of isolated severe CDH as defined by existing guidelines. Postnatal intensive respiratory supportive therapy and innovative surgical techniques within specialized tertiary centres has had a major impact on survival of babies with CDH.

CONCLUSION

The high survival of 'selected cases' that are live births and benefit from optimal care will be difficult to improve by antenatal interventions. The multidisciplinary approach to basic research and randomized clinical trials will further define the best approach to the foetus and neonate with CDH.

Outcome analysis of neonates with congenital diaphragmatic hernia treated with venovenous vs venoarterial extracorporeal membrane oxygenation

PURPOSE

Venoarterial extracorporeal membrane oxygenation (ECMO) (VA) is used more commonly in neonates with congenital diaphragmatic hernia (CDH) than venovenous ECMO (VV). We hypothesized that VV may result in comparable outcomes in infants with CDH requiring ECMO.

METHODS

We retrospectively analyzed the Extracorporeal Life Support Organization (ELSO) database (1991-2006). Multivariate logistic regression analyses were used to compare VV- and VA-associated mortality.

RESULTS

Four thousand one hundred fifteen neonates required ECMO, with an overall mortality rate of 49.6%. Venoarterial ECMO was used in 82% and VV in 18% of neonates. Pre-ECMO inotrope use and complications were equivalent between VA and VV. The mortality rate for VA and VV was 50% and 46%, respectively. After adjusting for birth weight, gestational age, prenatal diagnosis, ethnicity, Apgar scores, pH less than 7.20, Paco(2) greater than 50, requiring high-frequency ventilation, and year of ECMO, there was no difference in mortality between VV vs VA. Renal complications and on-ECMO inotrope use were more common with VV, whereas neurologic complications were more common with VA. The conversion rate from VV to VA was 18%; conversion was associated with a 56% mortality rate.

CONCLUSION

The short-term outcomes of VV and VA are comparable. Patients with CDH who fail VV may be predisposed to a worse outcome. Nevertheless, VV offers equal benefit to patients with CDH requiring ECMO while preserving the native carotid.

Timing of delivery and survival rates for infants with prenatal diagnoses of congenital diaphragmatic hernia

OBJECTIVES

The goal of the study was to test the hypothesis that infants with known congenital diaphragmatic hernias born at early term gestation (37-38 weeks) rather than later (39-41 weeks) had greater survival rates and less extracorporeal membrane oxygenation use. Primary outcomes were survival to hospital discharge or transfer and extracorporeal membrane oxygenation use. METHODS; A retrospective cohort study of term infants with prenatal diagnoses of congenital diaphragmatic hernia was performed with the Congenital Diaphragmatic Hernia Study Group Registry of patients with congenital diaphragmatic hernias who were treated between January 1995 and December 2006.

RESULTS

Among 628 term infants at 37 to 41 weeks of gestation who had prenatal diagnoses of congenital diaphragmatic hernia and were free of major associated anomalies, early term birth (37 vs 39-41 weeks) and greater birth weight were associated independently with survival, whereas black race was related inversely to survival. Infants born at early term with birth weights at or above the group mean (3.1 kg) had the greatest survival rate (80%). Among infants born through elective cesarean delivery, infants born at 37 to 38 weeks of gestation, compared with 39 to 41 weeks, had less use of extracorporeal membrane oxygenation (22.0% vs 35.5%) and a trend toward a greater survival rate (75.0% vs 65.8%).

CONCLUSIONS

The timing of delivery is an independent, potentially important factor in the consideration of elective delivery for infants diagnosed prenatally as having congenital diaphragmatic hernias. Among fetuses with prenatally diagnosed congenital diaphragmatic hernias and without major associated anomalies, early term delivery may confer advantage.

Identifying neonates at a very high risk for mortality among children with congenital diaphragmatic hernia managed with extracorporeal membrane oxygenation

PURPOSE

The purpose of this study was to identify mortality risk factors in children with congenital diaphragmatic hernia (CDH) treated with extracorporeal membrane oxygenation (ECMO) and generate a prediction score for those at a very high risk for mortality.

METHODS

Data on first ECMO runs of all neonates with CDH, between January 1997 and June 2007, were obtained from the Extracorporeal Life Support Organization registry (N = 2678). The data were split into "training data (TD)" (n = 2006) and "validation data" (n = 672). The primary outcome analyzed was in-hospital mortality. Modified Poisson regression was used for analyses.

RESULTS

Overall in-hospital mortality among 2678 neonates (males, 57%; median age at ECMO, 1 day) was 52%. The univariate and multivariable analyses were performed using TD. An empirically weighted mortality prediction score was generated with possible scores ranging from 0 to 35 points. Of 69 who scored 14 or higher in the TD, 62 died (positive predictive value [PPV], 90%), of 37 with 15 or higher, 35 died (PPV, 95%), of 23 with 16 or higher, 22 died (PPV, 96%). A cut-off point of 15 was chosen and was tested using the separate validation dataset. In validation data, the cut-off point 15 had a PPV of 96% (23 died of 24).

CONCLUSION

Scoring 15 or higher on the prediction score identifies neonates with CDH at a very high risk for mortality among those managed with ECMO and could be used in surgical decision making and counseling.

Analysis of 29 consecutive thoracoscopic repairs of congenital diaphragmatic hernia in neonates compared to historical controls

PURPOSE

The applicability of minimally invasive surgical techniques to pediatric surgical diseases continues to grow. Surgeons have hesitated to apply these methods to congenital diaphragmatic hernia (CDH) of Bochdalek because of the disease-associated pulmonary hypertension and patient fragility. We began performing thoracoscopic repair (CDH-T) in 2004 and have since completed 29 sequential repairs. To evaluate feasibility and outcomes, we compared this experience to a historical control group who underwent open repair (CDH-O) at the same institution by the same surgeons from 2001 to 2004.

METHODS

From January 2001 through November 2007, 72 neonates were evaluated jointly by the Neonatology and Pediatric Surgical services for CDH. Fifteen infants died before any corrective operation and were excluded from analysis. Demographics including gestational age, birth weight, Apgar scores, percent outborn, usage of extracorporeal life support, and associated anomalies were recorded. End points were complications, additional operative procedures, initial patch closure, recurrence, length of stay in non-extracorporeal membrane oxygenation patients, and postoperative mortality.

RESULTS

Demographic characteristics were similar between the 2 groups. There were no statistically significant differences in complications (71.5% vs 55%, P = .28), additional related operative procedures (42.9% vs 34.5%, P = .59), use of prosthetic patch (42.8% vs 51.7%, P = .60), recurrence (6.9% vs 20.7%, P = .25), length of stay (24 vs 34 days, P = .11), or postoperative mortality (21.4% vs 6.9%, P = .14) between the CDH-O and CDH-T groups, respectively. There was one conversion in the CDH-T group (3.4%).

CONCLUSIONS

To our knowledge, this is the largest reported series of CDH-T of neonatal CDH of Bochdalek. We have demonstrated the feasibility of performing this procedure thoracoscopically in an unselected population including children who have undergone prior extracorporeal life support. These results compare favorably with CDH-O, although further follow-up is required to determine the durability of the approach.

Effect of antenatal tetrandrine administration on endothelin-1 and epidermal growth factor levels in the lungs of rats with experimental diaphragmatic hernia

PURPOSE

The aim of this study was to evaluate the effect of the traditional Chinese medicine tetrandrine (Tet) and to determine its possible mechanism on expression of endothelin-1 (ET-1) and epidermal growth factor (EGF) in the lung of a rat model of nitrofen-induced congenital diaphragmatic hernia (CDH).

METHODS

A single oral dose (115 mg/kg) of nitrofen on day 9.5 of pregnancy was maternally administered to induce CDH. Pregnant rats were divided into 4 groups on day 18.5: control (n = 5), CDH (n = 5), CDH+dexamethasone (Dex) (n = 5), and CDH+Tet (n = 5). All fetuses were delivered by cesarean delivery on day 21.5. Accordingly, there were 4 groups of fetuses: control (n = 38), CDH (n = 25), CDH+Dex (n = 21), and CDH+Tet (n = 22). Lung tissue weight (LW) and body weight (BW) of each fetus were recorded, lung histologic evaluations and ET-1 and EGF immunohistochemistry staining were performed, and image analysis was performed after lung processing.

RESULTS

Five female rats in the control group produced 38 fetuses without CDH. CDH was observed in 68 of the 128 rat fetuses (53.1%) among the other 3 groups. The LW/BW ratio of the CDH group was significantly lower than those of the Dex and EGF groups (P < .05). The lungs of fetuses with CDH showed marked abnormal structure such as pulmonary hypoplasia and vascular remodeling, in contrast to improved pulmonary structure in lungs of fetuses in the CDH+Dex and CDH+Tet groups. Statistical differences in morphologic parameters (radial alveolar counts, percentage of alveoli, percentage of medial wall thickness, and vascular volume) were found (P < .05). The immunoreactivity of EGF and ET-1 in the CDH group was markedly stronger than that in the control, CDH+Dex, and CDH+Tet groups (P < .01). In addition, EGF and ET-1 expression in the CDH+Dex and CDH+Tet groups was stronger than that in the control group (P < .05). There was no difference in lung EGF and ET-1 immunoreactivity between CDH+Dex and CDH+Tet groups (P > .05).

CONCLUSION

Antenatal treatment with Tet may improve lung growth and vascular remodeling, and its mechanism seems to be involved in decreasing EGF and ET-1 expression. Tet administered maternally may be a hopeful new therapeutic option in the treatment of CDH and may be effective in helping to avoid the side effects of Dex.

Predictors of outcome in patients with congenital diaphragmatic hernia requiring extracorporeal membrane oxygenation

BACKGROUND

The role of extracorporeal membrane oxygenation (ECMO) in patients with congenital diaphragmatic hernia is still evolving. The use of ECMO is invasive with potential complications during instrumentation for cannulation and heparinization. There are no reliable predictors of outcome in patients requiring ECMO. We aimed to identify (a) the factors that could predict outcome and (b) the incidence and relation of complications during ECMO to outcome.

METHODS

"Pre" ECMO (age, sex, birth weight, blood gasses, and ventilator settings) and "on" ECMO variables (mode of ECMO, use of nitric oxide, surfactant, liquid ventilation, inotropes, timing of repair, and complications on ECMO) were analyzed to identify predictors of outcome.

RESULTS

Fifty-two patients were included. The overall survival was 58%. Mean duration of ECMO (181 +/- 120 vs 317 +/- 156 hours, P = .001), use of nitric oxide (6 vs 10, P = .049), and renal complications (4 vs 14; P < .001) differed between survivors and nonsurvivors. The survival of patients requiring ECMO support for more than 2 weeks is significantly lower than that of patients requiring ECMO support for less than 2 weeks (18% vs 68%, P = .005). Multiple logistic regression revealed ECMO duration of 2 weeks or more and renal complications to be associated with mortality.

CONCLUSION

No pre-ECMO variable could be identified as predictor of mortality. Prolonged duration of ECMO and renal complications on ECMO were independently associated with mortality.

Hypoxic respiratory failure in the late preterm infant

Hypoxic respiratory failure in late preterm infants has received increased attention in the last decade, and while the incidence is low, it accounts for a significant number of admissions to neonatal ICUs because of the large number of late preterm births in the United States and worldwide. Causes of respiratory distress include transient tachypnea of the newborn, surfactant deficiency, pneumonia, and pulmonary hypertension. The physiologic mechanisms underlying delayed transition caused by surfactant deficiency and poor fetal lung fluid absorption have been reviewed recently elsewhere. This article focuses on the less-explored problem of severe hypoxic respiratory failure in the late preterm infant and discusses potential strategies for management.

Myocardium expression of connexin 43, SERCA2a, and myosin heavy chain isoforms are preserved in nitrofen-induced congenital diaphragmatic hernia rat model

BACKGROUND

Previous morphological studies had produced controversial results with regard to heart development in congenital diaphragmatic hernia (CDH), whereas a few publications investigated cardiac function and myocardial maturation. Myocardium maturation is associated with age-dependent increasing of gene expression of gap junction protein connexin 43 (Cx43), adenosine triphosphatase of the sarcoplasmic reticulum (SERCA2a), as well as switching of myosin heavy chains (MHCs) from beta to alpha isoforms. Our aim was to evaluate myocardium maturity in nitrofen-induced CDH rat model.

METHODS

Fetuses from dated pregnant Sprague-Dawley rats were assigned to 3 experimental groups: control, nitrofen (exposed to nitrofen, without CDH), and CDH (exposed to nitrofen, with CDH). Myocardial samples collected from left ventricle free wall were processed to (i) quantification of messenger RNA (mRNA) of Cx43, SERCA2a, alpha and beta MHC isoforms, as well as beta-actin (housekeeping gene); and (ii) separation of MHC isoforms (alpha and beta isoforms) by sodium dodecyl sulfate polyacrylamide gel electrophoresis silver stained.

RESULTS

We demonstrated that there is no difference in myocardial gene expression of Cx43 (control, 1.0 +/- 0.1; nitrofen, 1.1 +/- 0.2; CDH, 1.3 +/- 0.2) and SERCA2a (control, 1.0 +/- 0.1; nitrofen, 0.9 +/- 0.1; CDH, 1.0 +/- 0.2). Myocardial gene expressions of alpha and beta mRNA of MHC isoforms were slightly decreased both in nitrofen and CDH fetuses when compared with control fetuses, but evaluation of the alpha-to-beta ratios of MHC isoforms at protein level revealed no significant differences between CDH and control (control, 16.9 +/- 2.5; CDH, 17.0 +/- 2.0).

CONCLUSIONS

Myocardial quantification of Cx43 and SERCA2a mRNA, as well as the expression pattern of MHC isoforms at protein levels, was similar in all studied groups. We predict, therefore, that acute heart failure commonly observed in CDH infants might be attributed predominantly to cardiac overload secondary to severe pulmonary hypertension rather than to myocardial immaturity.

The role of extracorporeal membrane oxygenation in the management of infants with congenital diaphragmatic hernia

Many infants with CDH can be managed with conventional mechanical ventilation and pharmacotherapy. However, some infants will require levels of ventilator support that are not compatible with survival. In these circumstances, extracorporeal membrane oxygenation (ECMO) has been used with varying results. The indication, type, and timing of ECMO in relation to surgery continue to evolve in an attempt to improve the outcome. At the same time, there is growing body of literature showing adverse outcomes among infants with CDH treated with ECMO, raising questions about the usefulness of ECMO in CDH. This paper reviews some of the controversies associated with the use of ECMO in CDH.

Antenatal vitamin A administration attenuates lung hypoplasia by interfering with early instead of late determinants of lung underdevelopment in congenital diaphragmatic hernia

BACKGROUND/PURPOSE

Early and late lung underdevelopment in congenital diaphragmatic hernia (CDH) is likely caused by nonmechanical (directly mediated by nitrofen) and mechanical (mediated by thoracic herniation) factors, respectively. The authors investigated if vitamin A enhances lung growth because of effects on both early and late determinants of lung hypoplasia.

METHODS

Twenty-seven pregnant Wistar rats were exposed on embryonic day (E)9.5 to 100 mg of nitrofen or just olive oil. From nitrofen-exposed pregnant rats, 12 were treated at day 9.5 or 18.5 with 15,000 IU of vitamin A. Lungs were harvested at E18, E20, and E22, weighed, and analyzed for DNA and protein contents. Left and/or right lung hypoplasia was estimated by assessment of the ratios of lung to body weight and left to right lung weight. Fetuses were assigned to 5 experimental groups: baseline (exposed neither to nitrofen nor vitamin A), nitrofen (exposed to nitrofen without CDH), CDH (exposed to nitrofen with CDH), nitr+vitA (exposed to nitrofen without CDH and treated with vitamin A), and CDH+vitA (exposed to nitrofen with CDH and treated with vitamin A).

RESULTS

Incidence of hernia was significantly reduced in fetuses treated with vitamin A. When vitamin A was administered at E9.5, the authors observed similar effect on lung hypoplasia measured through ratio of lung to body weight at E18 in the nitrofen and CDH groups (nitrofen 1.92% +/- 0.05%, CDH 1.92% +/- 0.04%), whereas lung hypoplasia was attenuated relative to baseline (2.45% +/- 0.05%) in 5% and 4% in nitrofen (nitr+vitA 2.05% +/- 0.03%) and CDH (CDH+vitA 2.08% +/- 0.04%) groups, respectively. At E20, lung hypoplasia was increased in CDH compared with nitrofen groups (nitrofen 2.52% +/- 0.1%, CDH 2.39% +/- 0.05%), whereas vitamin A attenuated lung hypoplasia, in relation to baseline (3.20% +/- 0.07%), 14% in both nitrofen-exposed groups (nitr+vitA 2.96% +/- 0.03%, CDH+vitA 2.83% +/- 0.03%). At E22, lung hypoplasia was significantly higher in CDH group than nitrofen group (nitrofen 2.13% +/- 0.06%, CDH 1.48% +/- 0.03%), whereas lung hypoplasia was attenuated in 9% of both nitrofen-exposed groups (nitr+vitA 2.35% +/- 0.06%, CDH+vitA 1.69% +/- 0.05%) in relation to baseline group (2.38% +/- 0.04%). Administration of vitamin A at E18.5 produced no significant effects on lung growth.

CONCLUSIONS

The authors conclude from these results that antenatal administration of vitamin A attenuates lung hypoplasia in CDH by interfering with early determinants of lung underdevelopment. This finding may have clinical implications because prenatal diagnosis of human CDH commonly occurs after 16 weeks' gestation when late determinants of lung hypoplasia likely predominate.

Surfactant replacement therapy on ECMO does not improve outcome in neonates with congenital diaphragmatic hernia

BACKGROUND PURPOSE

Respiratory failure in neonates with congenital diaphragmatic hernia (CDH) may in part be caused by a primary or secondary surfactant deficiency. Knowledge of the optimal approach to surfactant replacement in neonates with CDH and respiratory failure is limited. The aim of this study was to determine if surfactant replacement on extracorporeal membrane oxygenation (ECMO) results in improved outcomes in neonates > or =35 weeks' gestation with unrepaired CDH.

METHODS

Using the CDH Study Group Registry, the authors identified 448 neonates with CDH who were > or =35 weeks' gestation, had no major anomalies, were treated with ECMO within the first 7 days of life, and underwent repair on or after ECMO therapy. Patients in 2 groups were compared: group 1 (- Surf, n = 334) consisted of patients who received no surfactant and group 2 (+ Surf, n = 114) consisted of patients who received at least 1 dose of surfactant while on ECMO. An analysis of all patients in both groups was performed. Additionally, subgroup analyses stratified by gestational age were performed for patients 351/7 to 366/7 weeks' gestation and for patients > or =37 weeks' gestation. Primary end-points for the study were survival and length of ECMO run. Secondary end-points were length of intubation, need for supplemental oxygen at 30 days of life, and at discharge to home. Demographic, clinical, and outcome variables were examined using Fisher's Exact tests for categorical variables and using unpaired t tests for continuous variables. Odds ratios were calculated for categorical end-point variables.

RESULTS

Demographic and clinical variables were similar between groups. Analyses of aggregate data showed no significant differences between groups in length of ECMO run, survival, number of days intubated, and percent of patients requiring supplemental oxygen at 30 days or discharge. Subgroup stratification by gestational age did not show significant differences between groups in any of the outcome variables.

CONCLUSIONS

The data from this study suggest that surfactant replacement on ECMO for neonates with congenital diaphragmatic hernia does not provide significant benefit in the infant's clinical course with respect to survival, length of ECMO course, length of intubation, or subsequent need for supplemental oxygen.

Is surfactant therapy beneficial in the treatment of the term newborn infant with congenital diaphragmatic hernia?

OBJECTIVES

To determine the impact of surfactant replacement on survival, need for extracorporeal membrane oxygenation (ECMO), and chronic lung disease in term infants with prenatally diagnosed congenital diaphragmatic hernia (CDH).

STUDY DESIGN

Prenatally diagnosed infants born at > or =37 weeks' gestation with immediate distress at delivery and no other major congenital anomalies, who were enrolled in the CDH Registry, were analyzed. For univariate analysis, chi 2 tests were used for categoric variables and unpaired t tests for nominal variables. Multiple logistic regression was used to calculate adjusted odds ratios.

RESULTS

Eligible infants (n = 522) were identified. Demographic variables were similar between the surfactant-treated (n = 192) and nonsurfactant-treated (n = 330) groups, with the exception of race (white, 88.0% vs 71.2%; P =.0007). The use of ECMO and incidence of chronic lung disease were higher (59.8 vs 50.6, P =.04; 59.9 vs 47.6, P =.0066) and survival lower in the surfactant-treated cohort (57.3 vs 70.0, P =.0033). Adjusted logistic regression for use of ECMO, survival, and chronic lung disease resulted in odds ratios inconsistent with an improved outcome associated with surfactant use.

CONCLUSIONS

This analysis shows no benefit associated with surfactant therapy for term infants with a prenatal diagnosis of isolated CDH.

Congenital diaphragmatic hernia: a survey of practice in Scandinavia

There is no consensus on the treatment of congenital diaphragmatic hernia (CDH), and practice seems to vary between centres. The main purpose of the present study was to survey current practice in Scandinavia. Thirteen paediatric surgical centres serving a population of about 22 million were invited, and all participated. One questionnaire was completed at each centre. The questionnaire evaluated management following prenatal diagnosis, intensive care strategies, operative treatment, and long-term follow-up. Survival data (1995-1998) were available from 12 of 13 centres. Following prenatal diagnosis of CDH, vaginal delivery and maternal steroids were used at eight and six centres, respectively. All centres used high-frequency oscillation ventilation (HFOV), nitric oxide (NO), and surfactant comparatively often. Five centres had extracorporeal membrane oxygenation (ECMO) facilities, and four centres transferred ECMO candidates. The majority of centres (7/9) always tried HFOV before ECMO was instituted. Surgery was performed when the neonate was clinically stable (11/13) and when no signs of pulmonary hypertension were detected by echo-Doppler (6/13). The repair was performed by laparotomy at all centres and most commonly with nonabsorbable sutures (8/13). Thoracic drain was used routinely at seven centres. Long-term follow-up at a paediatric surgical centre was uncommon (3/13). Only three centres treated more than five CDH patients per year. Comparing survival in centres treating more than five with those treating five or fewer CDH patients per year, there was a tendency towards better survival in the higher-volume centres (72.4%) than in the centres with lower volume (58.7%), p =0.065.

Risk of need for extracorporeal membrane oxygenation support in neonates with congenital diaphragmatic hernia treated with inhaled nitric oxide

BACKGROUND

Congenital diaphragmatic hernia (CDH) is often associated with severe pulmonary hypoplasia resulting in hypoxemic respiratory failure unresponsive to advanced medical management including the use of inhaled nitric oxide (iNO). For these patients, extracorporeal membrane oxygenation (ECMO) serves as the last potentially effective treatment choice. Since the efficacy of iNO in this patient population is not known and since most neonatal intensive care units using iNO for the treatment of these critically ill neonates do not provide ECMO, the ability to more accurately predict which patient is at risk for failing medical management with iNO and requires a timely transfer to an ECMO center can be life saving. Therefore, in this study, we sought to determine the risk factors for the need for ECMO in a cohort of 27 neonates with isolated left CDH and hypoxemic respiratory failure treated with iNO.

STUDY DESIGN

In this retrospective study, 27 patients with left CDH were identified during a 2-year period. During the study period, strict clinical guidelines had been used to standardize iNO therapy, to provide adequate lung inflation and cardiovascular support, and to recognize treatment failures and the need for ECMO. Logistic regression analysis was used to study the relationship between the need for ECMO and a set of suspected risk factors.

RESULTS

When subjected to logistic regression analysis, only the presence of a pneumothorax remained significantly associated with the need for ECMO (OR=22; 95% CI=2.18 to 222), while none of the other variables examined such as mean airway pressure, FiO2, PaO2, or PaCO2 were predictors for the need of ECMO after 6 hours of treatment with iNO.

CONCLUSION

These data indicate that a prompt transfer to an ECMO center should be initiated for hypoxemic patients with CDH receiving medical management with iNO if they develop an air leak syndrome.

Current therapy of infants with congenital diaphragmatic hernia

Congenital diaphragmatic hernia (CDH) is a life-threatening anomaly with a significant mortality rate. Despite widespread prenatal diagnosis, few parameters have been well defined to aid in prediction of outcome of these infants. Antenatal maternal steroid administration and foetal surgery are not proven interventions. Postnatal treatment has changed over the last 10 years, with avoidance of hyperventilation and ventilator-induced lung injury resulting in improved survival. Therapies such as inhaled nitric oxide, exogenous surfactant administration and extracorporeal membrane oxygenation (ECMO) have undergone limited study, but show no clear benefit in this population. With improved outcome, principally due to avoidance of barotrauma, greater opportunity exists for long-term evaluation of survivors. To date, continuing problems with pulmonary function, nutrition and growth, effects of right ventricular hypertension and developmental issues have been identified. Through co-ordinated, multidisciplinary evaluation of CDH survivors, improved long-term outcome for these challenging patients can be attained.