Surfactant does not improve survival rate in preterm infants with congenital diaphragmatic hernia

Presented at the 55th Annual Meeting of the Surgical Section of the American Academy of Pediatrics, New Orleans, Louisiana, October 31-November 2, 2003.
https://doi.org/10.1016/j.jpedsurg.2004.02.011Get rights and content

Abstract

Background

Use of exogenous surfactant in congenital diaphragmatic hernia (CDH) patients is routine in many centers. The authors sought to determine the impact of surfactant use in the premature infant with CDH.

Methods

Data on liveborn infants with CDH from participating institutions were collected prospectively. Surfactant use and timing and outcome data were analyzed retrospectively. The authors evaluated the prenatal diagnosis patients as well. The outcome variable was survival to discharge. Odds ratios with confidence intervals were calculated.

Results

Five hundred ten infants less than 37 weeks’ gestation were entered in the CDH registry. Infants with severe anomalies (n = 80) were excluded. Information on surfactant use was available for 424 patients. Infants receiving surfactant (n = 209) had a greater odds of death than infants not receiving surfactant (n = 215, odds ratio, 2.17, 95% CI: 1.5 to 3.2; P < .01). In prenatally diagnosed infants with immediate distress, there was a trend toward worse survival rates among those receiving surfactant at 1 hour (52 patients) versus those that did not (93 patients; odds ratio, 1.93, 95% CI: 0.96 to 3.9; P < .07).

Conclusions

Surfactant, as currently used, is associated with a lower survival rate in preterm infants with CDH. The use of surfactant replacement in premature infants with CDH can be recommended only within the context of a randomized clinical trial.

Section snippets

Materials and methods

The CDH Study Group is a voluntary collaboration of tertiary referral centers providing care for CDH patients. All live-born infants with CDH who are born at or transferred to a participating center are entered into the database. Data were collected prospectively until death or discharge from the hospital on all live-born patients with CDH starting in 1995 in 82 participating hospitals (appendix). We used data from patients born between January 1995 and December 2002. Information was entered

Results

At the time of this report, there were 2,376 patients entered into the CDH registry from a total of 82 centers. Most centers were in the United States, but information was submitted from 9 other countries. Overall survival rate for all patients was 67%. There were 510 infants less than 37 weeks’ gestation entered in the registry. Eighty patients had a major chromosomal or cardiac anomaly and were excluded from analysis. Information on surfactant use and outcome was available for 424 of the

Discussion

The extent that a primary surfactant deficiency contributes to respiratory failure in the neonate with congenital diaphragmatic hernia remains controversial. Although some studies have suggested surfactant deficiency in humans, others dispute this. No difference was seen in phospholipid and fatty acid composition of phosphatidycholine and phosphatidylglycerol or lecithin to sphingomyelin (L/S) ratios in bronchoalveolar lavage of neonates with CDH when compared with age-matched controls.23

References (25)

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Supported in part by a grant from the Surgical Section of the American Academy of Pediatrics.

The following investigators, who assume responsibility for the overall content, prepared this manuscript: Kevin P. Lally, Pamela A. Lally, Max R. Langham, Ronald Hirschl, Fernando R. Moya, Dick Tibboel, and Krisa Van Meurs.

The members of the Congenital Diaphragmatic Hernia Study Group are listed in the appendix.

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