title: Congenital diaphragmatic hernia in the preterm infant.
abstract: 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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Surgery, University of Texas Medical School Houston and Children's Memorial Hermann Hospital, Houston, TX 77030, USA. kuojen.tsao@uth.tmc.edu
authors.forename: KuoJen
authors.initials: K
authors.lastname: Tsao
authors.forename: Nathan D
authors.initials: ND
authors.lastname: Allison
authors.forename: Matthew T
authors.initials: MT
authors.lastname: Harting
authors.forename: Pamela A
authors.initials: PA
authors.lastname: Lally
authors.forename: Kevin P
authors.initials: KP
authors.lastname: Lally
mesh_terms: D015199:Extracorporeal Membrane Oxygenation; D005260:Female; D005865:Gestational Age; D006548:Hernia, Diaphragmatic / Q000401:mortality / Q000601:surgery; D065630:Hernias, Diaphragmatic, Congenital; D006801:Humans; D007231:Infant, Newborn; D007234:Infant, Premature; D008297:Male; D016017:Odds Ratio; D011247:Pregnancy; D011379:Prognosis; D011446:Prospective Studies; D012042:Registries; D016019:Survival Analysis; D016896:Treatment Outcome
references.citation: Pediatrics. 2008 Apr;121(4):788-801
references.pmid: 18381544
references.citation: Pediatrics. 2007 Sep;120(3):e651-7
references.pmid: 17766505
references.citation: J Pediatr Surg. 2002 Mar;37(3):357-66
references.pmid: 11877648
references.citation: J Pediatr Surg. 2004 Jun;39(6):829-33
references.pmid: 15185206
references.citation: Ann Thorac Surg. 2003 Jan;75(1):250-6
references.pmid: 12537224
references.citation: Lancet. 1962 Mar 31;1(7231):659-63
references.pmid: 13875198
references.citation: Am Surg. 2003 Jan;69(1):45-52
references.pmid: 12575780
references.citation: Arch Dis Child Fetal Neonatal Ed. 2007 Sep;92(5):F356-60
references.pmid: 17213271
references.citation: Pediatrics. 2003 Sep;112(3 Pt 1):532-5
references.pmid: 12949279
references.citation: JAMA. 1994 Feb 2;271(5):382-4
references.pmid: 8054005
references.citation: Birth Defects Res A Clin Mol Teratol. 2003 Apr;67(4):261-7
references.pmid: 12854661
references.citation: Arch Dis Child. 1993 Jul;69(1 Spec No):68-70
references.pmid: 8192736
references.citation: J Pediatr Surg. 2006 Jun;41(6):1049-53
references.pmid: 16769332
references.citation: J Paediatr Child Health. 2003 Apr;39(3):206-9
references.pmid: 12654144