A congenital diaphragmatic hernia (CDH) results from the inadequate formation of the diaphragm during embryogenesis and causes a cascade of events which can present in a newborn child varying clinically from mild to very severe to fatal. The incidence of CDH is 1 in 2,500 to 1 in 3,500 live births and occurs 90% of the time in the posterolateral aspect of the diaphragm known as a Bochdalek hernia with over 85% occurring on the left side (1). The diaphragmatic defect in the embryo allows for abdominal viscera to enter the thoracic cavity causing a mass effect on the developing lungs resulting in pulmonary hypoplasia and pulmonary hypertension. The degree of clinical severity is often proportional to the size of the defect (Figure 1) (2,3). Although the consequences of other hernias can be avoided when repaired surgically, often there is no quick fix to this underlying dysgenesis of the lungs. In fact, past review of immediate repair demonstrated a worsening in the physiology of CDH neonates, which helped shift repair to a more delayed approach (4). These issues are most often addressed through medical management Review Article on Fetal Surgery

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Problem: Extremely low‐birth‐weight (ELBW) infants require fortification of human milk (HM) to prevent growth failure. Bovine milk–based fortifiers (BOV‐f) may be associated with feeding intolerance and necrotizing enterocolitis. Evidence suggests that an exclusive HM diet (EHMD) using HM‐based fortifier (HM‐f) may improve these outcomes. Intervention: EHMD was introduced as a quality improvement project to improve feeding tolerance in ELBW infants. Method: Implementation included establishing EHMD feeding protocol and growth monitoring. We compared infants receiving HM with BOV‐f (n = 49) with infants receiving an EHMD (n = 15). The primary outcome was a reduction of no oral intake days due to feeding intolerance. Results: The EHMD cohort had a more advanced GA (28 vs 26 weeks; P = .03), more males (66.7% vs 42.9%; P = .02), and higher incidence of SGA (40.0% vs 18.4%; P = .16) compared with the HM‐f group. The EHMD cohort had fewer days with no oral intake (2 vs 5; P < .005), which is insignificant when adjusted for small for gestational age (SGA) (P = .26). The EHMD cohort vs. the HM‐f cohort had a significant decrease in weight and length z‐scores from birth to discharge (−1.09 vs −0.26 [P = .002]; −1.76 vs −0.83 [P = .02]). Inadequate weight gain persisted after adjustment for SGA. Interventions were performed to increase caloric intake and institute milk preparation changes. Conclusion: EHMD improved feeding tolerance in our ELBW infants. Observed growth failure might be skewed by SGA prevalence. We highlight that implementation of EHMD requires close growth assessment, especially for SGA infants.

N ecrotizing enterocolitis (NEC) is one of the most common indications for neonatal abdominal surgery. An earlier diagnosis of NEC may reduce subsequent morbidity and mortality. 1 Along with clinical suspicions and laboratory tests, an abdominal x-ray (KUB) is