Surgical Management of the Newborn with Congenital Diaphragmatic Hernia

Tsao, KuoJen; Lally, Kevin P.

doi:10.1159/000320244

Cited by 19 publications

(13 citation statements)

References 205 publications

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“…The first question, although philosophical, is critical. Our understanding of the benefits of repair are incomplete, but most literature supports the idea that reduction of the herniated visceral contents from the thoracic cavity and closure of the diaphragmatic defect are important in the long-term but provide little immediate benefit to the patient [115]. Reducing herniated contents back to the abdomen to permit expansion of the compressed lungs does not result in immediate improvement in PPHN and hypoxemia.…”

Section: Reviewmentioning

confidence: 99%

Congenital Diaphragmatic hernia – a review

Chandrasekharan

Rawat

Madappa³

et al. 2017

matern health, neonatol and perinatol

219

151

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Congenital Diaphragmatic hernia (CDH) is a condition characterized by a defect in the diaphragm leading to protrusion of abdominal contents into the thoracic cavity interfering with normal development of the lungs. The defect may range from a small aperture in the posterior muscle rim to complete absence of diaphragm.The pathophysiology of CDH is a combination of lung hypoplasia and immaturity associated with persistent pulmonary hypertension of newborn (PPHN) and cardiac dysfunction. Prenatal assessment of lung to head ratio (LHR) and position of the liver by ultrasound are used to diagnose and predict outcomes. Delivery of infants with CDH is recommended close to term gestation. Immediate management at birth includes bowel decompression, avoidance of mask ventilation and endotracheal tube placement if required. The main focus of management includes gentle ventilation, hemodynamic monitoring and treatment of pulmonary hypertension followed by surgery. Although inhaled nitric oxide is not approved by FDA for the treatment of PPHN induced by CDH, it is commonly used.Extracorporeal membrane oxygenation (ECMO) is typically considered after failure of conventional medical management for infants ≥ 34 weeks’ gestation or with weight >2 kg with CDH and no associated major lethal anomalies. Multiple factors such as prematurity, associated abnormalities, severity of PPHN, type of repair and need for ECMO can affect the survival of an infant with CDH. With advances in the management of CDH, the overall survival has improved and has been reported to be 70-90% in non-ECMO infants and up to 50% in infants who undergo ECMO.

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Section: Reviewmentioning

confidence: 99%

Congenital Diaphragmatic hernia – a review

Chandrasekharan

Rawat

Madappa³

et al. 2017

matern health, neonatol and perinatol

219

151

View full text Add to dashboard Cite

show abstract

“…Congenital diaphragmatic hernia (CDH) is a rare congenital anomaly that occurs in approximately one per 2 000-4 000 births. Mortality rates decreased singnifi cantly during the past decades with reported ranges from 10 % to 35 %, depending on case selection and center allocation [ 16 ] . The life-threatening disorder is characterized by severe lung hypoplasia and pulmonal arterial hypertension (PAH), which are known to be the major determinants of overall survival in CDH [ 3 ] .…”

Section: Introduction ▼mentioning

confidence: 99%

Serum Cytokine Levels in Neonates with Congenital Diaphragmatic Hernia

Schaible¹,

Veit²,

Tautz³

et al. 2011

Klin Padiatr

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Cytokines play an important role in immune regulation and fetal lung development. The systemic inflammatory response in newborns with congenital diaphragmatic hernia (CDH) has not been characterized so far. We compared various concentrations of cytokines in serum from newborns with CDH and in healthy term neonates. We analyzed cytokine patterns of CDH newborns under extracorporeal membrane oxygenation (ECMO) and mechanical ventilation (MV).38 newborns with CDH were included: ECMO group (n=13) and non-ECMO group (n=25). Healthy term neonates served as controls (n=13). Serum samples were obtained prospectively after birth and during therapy.Concentrations of IFN-α, IL-3,-6,-7,-8,-10, MIP-1α,-1β and TNF-α in serum of newborns with CDH were higher than in umbilical cord blood of term neonates. Infants with severe CDH requiring ECMO therapy had higher postnatal IL-8,-10, and MIP-1α levels than newborns with milder disease in the non-ECMO treated group. IL-10 progressively decreased during the first 3 days following birth under ECMO. In contrast, the chemokine MIP-1α remained elevated during ECMO therapy compared to mechanically ventilated CDH newborns.The pattern of cytokines in the serum of newborns with CDH showed significant elevations compared to term neonates. Our findings indicate that CDH is associated with systemic inflammatory response immediately after birth. ECMO and MV show a similar increase of IL-1α and IP-10 in CDH newborns assuming a persistent pulmonary inflammatory reaction irrespective of the conducted treatment.

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“…And depending on the treatment modalities used, it may be days to weeks before an infant is able to receive oral feeds. 31 Although this science has not yet expanded to the CDH population specifically, the known gastrointestinal, respiratory, and neurodevelopmental benefits of human milk can and should not be ignored. 33 If we are to make decisions for infants, keeping in mind their true best interests, then there should be no dilemma in the matter of decision making related to enteral infant feeding.…”

Section: A Case For Best Interest In Infant Feeding Decisions: Human mentioning

confidence: 99%

An Ethical Case for the Provision of Human Milk in the NICU

Froh

Spatz

2014

Advances in Neonatal Care

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Despite recommendations from the World Health Organization, the United Nations Children's Fund, the American Academy of Pediatrics Section on Breastfeeding, and others, only a small percentage of infants in the United States receive exclusive human milk for the first 6 months of life. In the United States, decisions related to infant feeding are determined by surrogate or proxy in place of the neonatal voice, using the "best interest principle" as the guiding ethical focus. Given the established research on the benefits of an exclusive human milk diet compared with artificial nutrition (infant formula), infant feeding decisions made for the critically ill neonate should rest entirely in the infant's best interest, not solely in parental authority. If the mother's own milk is not available or its use is contraindicated, the American Academy of Pediatrics recommends donor human milk. However, the preverbal voice of the neonate makes it difficult to isolate the best interest of the infant separated from the family unit. Using a case exemplar, it is proposed that the means in which infant feeding decisions are made for the critically ill infant should rest entirely in the infant's best interest, not parental authority, during the course of care in the hospital setting. The best interest principle, surrogate decision making, parental authority, and proxy consent are reviewed. Furthermore, a case for the best interest principle to further illustrate the importance of the infant's voice in relationship to enteral feeding decisions is provided. Finally, implications for clinical practice are offered.

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Surgical Management of the Newborn with Congenital Diaphragmatic Hernia

Cited by 19 publications

References 205 publications

Congenital Diaphragmatic hernia – a review

Congenital Diaphragmatic hernia – a review

Serum Cytokine Levels in Neonates with Congenital Diaphragmatic Hernia

An Ethical Case for the Provision of Human Milk in the NICU

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