Elsevier

Surgery

Volume 148, Issue 2, August 2010, Pages 404-410
Surgery

Society of University Surgeons
Congenital diaphragmatic hernia in the preterm infant

https://doi.org/10.1016/j.surg.2010.03.018Get rights and content

Background

Congenital diaphragmatic hernia (CDH) remains a significant cause of death in newborns. With advances in neonatal critical care and ventilation strategies, survival in the term infant now exceeds 80% in some centers. Although prematurity is a significant risk factor for morbidity and mortality in most neonatal diseases, its associated risk with infants with CDH has been described poorly. We sought to determine the impact of prematurity on survival using data from the Congenital Diaphragmatic Hernia Registry (CDHR).

Methods

Prospectively collected data from live-born infants with CDH were analyzed from the CDHR from January 1995 to July 2009. Preterm infants were defined as <37 weeks estimated gestational age at birth. Univariate and multivariate logistic regression analysis were performed.

Results

During the study period, 5,069 infants with CDH were entered in the registry. Of the 5,022 infants with gestational age data, there were 3,895 term infants (77.6%) and 1,127 preterm infants (22.4%). Overall survival was 68.7%. A higher percentage of term infants were treated with extracorporeal membrane oxygenation (ECMO) (33% term vs 25.6% preterm). Preterm infants had a greater percentage of chromosomal abnormalities (4% term vs 8.1% preterm) and major cardiac anomalies (6.1% term vs 11.8% preterm). Also, a significantly higher percentage of term infants had repair of the hernia (86.3% term vs 69.4% preterm). Survival for infants that underwent repair was high in both groups (84.6% term vs 77.2% preterm). Survival decreased with decreasing gestational age (73.1% term vs 53.5% preterm). The odds ratio (OR) for death among preterm infants adjusted for patch repair, ECMO, chromosomal abnormalities, and major cardiac anomalies was OR 1.68 (95% confidence interval [CI], 1.34–2.11).

Conclusion

Although outcomes for preterm infants are clearly worse than in the term infant, more than 50% of preterm infants still survived. Preterm infants with CDH remain a high-risk group. Although ECMO may be of limited value in the extremely premature infant with CDH, most preterm infants that live to undergo repair will survive. Prematurity should not be an independent factor in the treatment strategies of infants with CDH.

Section snippets

Data

The Congenital Diaphragmatic Hernia Study Group (CDHSG) was formed in 1995 to compile data on live-born neonates with CDH to allow assessment of therapies and outcome. Data are collected on all inborn or transferred infants with CDH to form the Congenital Diaphragmatic Hernia Registry (CDHR). The CDHSG is a voluntary collaboration of international tertiary referral centers providing care for CDH patients who provide data to a central registry (participating centers specified in the appendix).

Results

In all, 5,069 live-born infants with CDH were identified from the CDHR. GA data were available in 5,022 patients. Also included were 3,895 term infants (77.6%) and 1,127 preterm infants (22.4%). Most defects were left-sided (81.5%) with 1% bilateral lesions. Preterm infants had a higher percentage of chromosomal anomalies (8.1% vs 4.0%; P < .0001) and major cardiac defects (11.8% vs 6.1%; P < .0001). Descriptive statistics for all variables are shown in Table I.

Discussion

Despite advances in neonatal critical care, prematurity remains a significant contributor to neonatal mortality in infants with CDH. The incidence of prematurity has increased in the last decade and remains a major cause of mortality in all neonates.12 Although the severity of pulmonary hypoplasia and hypertension are the major determinants of overall survival for infants with CDH, some mortality may be attributed to prematurity because of an increase in associated anomalies. Ninety-five

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The authors are part of the writing committee for the Congenital Diaphragmatic Hernia Study Group. The members of the Congenital Diaphragmatic Hernia Study Group are listed in the appendix.

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