Cardiopulmonary Morbidity in Adults Born With Congenital Diaphragmatic Hernia

Long-term outcomes beyond childhood in patients treated for congenital diaphragmatic hernia- a systematic review

Advancements in the management of congenital diaphragmatic hernia (CDH) have significantly improved survival rates, shifting the focus toward long-term outcomes in adult survivors. However, limited awareness of CDH sequelae among adult physicians complicates the transition from pediatric to adult care. This systematic review aims to provide a comprehensive evaluation of the most common long-term complications in CDH survivors aged 16 years and older following neonatal surgical repair. A literature search of PubMed, MEDLINE, EMBASE, Web of Science, and Cochrane Library was conducted according to PRISMA guidelines and registered on PROSPERO. Nineteen studies met inclusion criteria, encompassing 250 adult survivors (mean age: 22.1 years). Chronic lung disease was observed in 33% of patients, with 28% experiencing dyspnea during daily activities and exertion. Gastroesophageal reflux disease (GERD) was present in 45%, and severe scoliosis was identified in 2.4%. Quality of life was generally reported as good, though 30% experienced depression and lower scores in vitality and mental health domains. CDH survivors frequently encounter multisystem morbidities, including pulmonary, gastrointestinal, and musculoskeletal challenges. Structured transition programs and multidisciplinary follow-up are essential to address these needs and ensure continuity of care into adulthood. Further research is warranted to optimize outcomes and develop standardized protocols for this growing population.

Quality of Life, Wellbeing and Participation in Adults Born With Congenital Diaphragmatic Hernia

BACKGROUND

As more neonates born with congenital diaphragmatic hernia (CDH) survive, interest in long-term morbidities and their health-related quality of life (HRQoL) is growing. For adolescents and young adults with CDH, information on HRQoL is anecdotal. Therefore, our aim was to evaluate HRQoL and its determinants in a recently studied cohort of adult CDH survivors.

METHODS

We conducted a prospective, nationwide observational cohort study in CDH patients born 1989 to 2001. Demographic and clinical characteristics were collected, and participants completed questionnaires assessing HRQoL, participation and autonomy, fatigue, and emotional and behavioral wellbeing. Descriptive and inferential statistical analyses were performed.

RESULTS

Sixty-one CDH patients aged 19-31 years were included. Overall, participants experienced normal HRQoL for both physical (mean (SD) z-score: 0.03 (1.01); p = 0.088) and mental (z-score -0.23 (1.05); p = 0.316) components. Their participation and autonomy exceeded that of a reference population with one chronic disorder (p < 0.001), but they experienced significantly more fatigue (z-score: -0.46 (1.24); p = 0.006); which was severe in 16 %. Patients reported significantly more frequent internalizing problems, particularly within the 'somatic complaints' domain (p = 0.004). Among positive determinants of physical HRQoL were attendance of regular education, a higher exercise capacity, and better outdoors autonomy. Positive determinants of mental HRQoL included undergoing primary diaphragmatic repair and having fewer internalizing problems.

CONCLUSIONS

CDH patients perceive their HRQoL to be comparable to that of the general population, achieving similar participation and autonomy. However, fatigue warrants attention during long-term follow-up, and psychological counseling in childhood and adolescence may be beneficial for addressing emotional problems.

LEVEL OF EVIDENCE

Not applicable.

ESR Essentials: imaging of common paediatric pulmonary diseases-practice recommendations by the European Society of Paediatric Radiology

Chest imaging in children presents unique challenges due to varying requirements across age groups. For chest radiographs, achieving optimal images often involves careful positioning and immobilisation techniques. Antero-posterior projections are easier to obtain in younger children, while lateral decubitus radiographs are sometimes used when expiratory images are difficult to obtain and for free air exclusion. Chest CT protocols should be age-dependent to minimise radiation exposure and motion artefacts. MRI is primarily used in specialised centres to reduce radiation exposure, requiring specific expertise and sedation in younger children. Respiratory distress syndrome is a leading cause of morbidity in preterm neonates, diagnosed through characteristic radiographic findings and a history of prematurity. Bronchopulmonary dysplasia is the most common complication of extreme preterm birth and chronic oxygen therapy; imaging is used for predicting outcomes for the assessment of severe cases. Transient tachypnoea of the newborn and meconium aspiration syndrome are common in term infants, with specific imaging characteristics aiding in their differentiation. Congenital lung malformations present diagnostic and management challenges, with imaging playing a crucial role in diagnosis and surgical planning. Finally, imaging is essential in detecting complications from pneumonia in children, such as empyema and necrotic pneumonia, or in identifying foreign object aspiration. CLINICAL RELEVANCE STATEMENT: This review summarises current radiology practice of paediatric chest pathologies, aiding in the accurate diagnosis and management of neonatal and congenital pulmonary conditions and pneumonia complications, ultimately improving patient outcomes through precise imaging interpretation and targeted clinical intervention. KEY POINTS: Chest radiographs should be systematically assessed for pathology. Ensure accurate differential diagnosis of neonatal lung diseases by collecting information on gestational age, method of delivery, presenting symptoms, ventilation type, and fetal ultrasound findings. Radiographs and ultrasound are initial diagnostic tools for paediatric pulmonary disease; CT should be reserved for complex cases. Referral to paediatric hospital should be considered when the use of chest MRI is indicated.

Long-term follow-up in congenital diaphragmatic hernia

With improvements in initial care for patients with congenital diaphragmatic hernia (CDH), the number of CDH patients with severe disease who are surviving to discharge has increased. This growing population of patients faces a unique set of long-term challenges, multisystem adverse outcomes, and post-intervention complications requiring specialized multidisciplinary follow-up. Early identification and intervention are essential to mitigate the potential morbidity associated with these challenges. This manuscript outlines a general framework for long-term follow-up for the CDH patient, including cardiopulmonary, gastrointestinal, neurodevelopmental, surgical, and quality of life outcomes.

Arterial hypertension in infants with congenital diaphragmatic hernia following surgical repair

Pulmonary hypertension (PH) and cardiac dysfunction are established comorbidities of congenital diaphragmatic hernia (CDH). However, there is very little data focusing on arterial hypertension in CDH. This study aims to investigate the incidence of arterial hypertension in neonates with CDH at hospital discharge. Archived clinical data of 167 CDH infants who received surgical repair of the diaphragmatic defect and survived for > 60 days were retrospectively analyzed. Blood pressure (BP) values were averaged for the last 7 days before discharge and compared to standard BP values for sex, age, and height provided by the AHA in 2004. BP values reaching or extending the 95th percentile were defined as arterial hypertension. The use of antihypertensive medication was analyzed at discharge and during hospitalization. Arterial hypertension at discharge was observed in 19 of 167 infants (11.3%) of which 12 (63%) were not receiving antihypertensive medication. Eighty patients (47.9%) received antihypertensive medication at any point during hospitalization and 28.9% of 152 survivors (n = 44) received antihypertensive medication at discharge, although in 45.5% (n = 20) of patients receiving antihypertensive medication, the indication for antihypertensive medication was myocardial hypertrophy or frequency control. BP was significantly higher in ECMO compared to non-ECMO patients, despite a similar incidence of arterial hypertension in both groups (13.8% vs. 10.1%, p = 0.473). Non-isolated CDH, formula feeding, and minimal creatinine in the first week of life were significantly associated with arterial hypertension on univariate analysis. Following multivariate analysis, only minimal creatinine remained independently associated with arterial hypertension.   Conclusion: This study demonstrates a moderately high incidence of arterial hypertension in CDH infants at discharge and an independent association of creatinine values with arterial hypertension. Physicians should be aware of this risk and include regular BP measurements and test of renal function in CDH care and follow-up. What is Known: • Due to decreasing mortality, morbidity is increasing in surviving CDH patients. • Pulmonary hypertension and cardiac dysfunction are well-known cardiovascular comorbidities of CDH. What is New: • There is a moderately high incidence of arterial hypertension in CDH infants at discharge even in a population with frequent treatment with antihypertensive medication. • A more complicated hospital course (ECMO, higher degree of PH, larger defect size) was associated with a higher risk for arterial hypertension.

Major surgical conditions of childhood and their lifelong implications: comprehensive review

BACKGROUND

In recent decades, the survival of children with congenital anomalies and paediatric cancer has improved dramatically such that there has been a steady shift towards understanding their lifelong health outcomes. Paediatric surgeons will actively manage such conditions in childhood and adolescence, however, adult surgeons must later care for these 'grown-ups' in adulthood. This article aims to highlight some of those rare disorders encountered by paediatric surgeons requiring long-term follow-up, their management in childhood and their survivorship impact, in order that the adult specialist may be better equipped with skills and knowledge to manage these patients into adulthood.

METHODS

A comprehensive literature review was performed to identify relevant publications. Research studies, review articles and guidelines were sought, focusing on the paediatric management and long-term outcomes of surgical conditions of childhood. The article has been written for adult surgeon readership.

RESULTS

This article describes the aforementioned conditions, their management in childhood and their lifelong implications, including: oesophageal atresia, tracheo-oesophageal fistula, malrotation, short bowel syndrome, duodenal atresia, gastroschisis, exomphalos, choledochal malformations, biliary atresia, Hirschsprung disease, anorectal malformations, congenital diaphragmatic hernia, congenital lung lesions and paediatric cancer.

CONCLUSION

The increasing survivorship of children affected by surgical conditions will translate into a growing population of adults with lifelong conditions and specialist healthcare needs. The importance of transition from childhood to adulthood is becoming realized. It is hoped that this timely review will enthuse the readership to offer care for such vulnerable patients, and to collaborate with paediatric surgeons in providing successful and seamless transitional care.

The role of extracorporeal life support and timing of repair in infants with congenital diaphragmatic hernia

Extracorporeal life support (ECLS) serves as a rescue therapy for patients with congenital diaphragmatic hernia (CDH) and severe cardiopulmonary failure, and only half of these patients survive to discharge. This costly intervention has a significant complication risk and is reserved for patients with the most severe disease physiology refractory to maximal cardiopulmonary support. Some contraindications to ECLS do exist such as coagulopathy, lethal chromosomal or congenital anomaly, very preterm birth, or very low birth weight, but many of these limits are being evaluated through further research. Consensus guidelines from the past decade vary in recommendations for ECLS use in patients with CDH but this therapy appears to have a survival benefit in the most severe subset of patients. Improved outcomes have been observed for patients treated at high-volume centers. This review details the evolving literature surrounding management paradigms for timing of CDH repair for patients receiving preoperative ECLS. Most recent data support early repair following cannulation to avoid non-repair which is uniformly fatal in this population. Longer ECLS runs are associated with decreased survival, and patient physiology should guide ECLS weaning and eventual decannulation rather than limiting patients to arbitrary run lengths. Standardization of care across centers is a major focus to limit unnecessary costs and improve short-term and long-term outcomes for these complex patients.

Long-term follow-up of patients with congenital diaphragmatic hernia

Neonates with congenital diaphragmatic hernia encounter a number of surgical and medical morbidities that persist into adulthood. As mortality improves for this population, these survivors warrant specialized follow-up for their unique disease-specific morbidities. Multidisciplinary congenital diaphragmatic hernia clinics are best positioned to address these complex long-term morbidities, provide long-term research outcomes, and help inform standardization of best practices in this cohort of patients. This review outlines long-term morbidities experienced by congenital diaphragmatic hernia survivors that can be addressed in a comprehensive follow-up clinic.

Long-Term Evaluation of the Shape of the Reconstructed Diaphragm in Patients with Left-Sided Congenital Diaphragmatic Hernia Using Serial Chest Radiographs and Correlation to Further Complications

Background: Defining risk factors for long-term comorbidities in patients after neonatal repair of congenital diaphragmatic hernia (CDH) is an important cornerstone of the implementation of targeted longitudinal follow-up programs. Methods: This study systematically assessed serial chest radiographs of 89 patients with left-sided CDH throughout a mean follow-up of 8.2 years. These geometrical variables for the left and right side were recorded: diaphragmatic angle (LDA, RDA), diaphragmatic diameter (LDD, RDD), diaphragmatic height (LDH, RDH), diaphragmatic curvature index (LDCI, RDCI), lower lung diameter (LLLD, RLLD) and thoracic area (LTA, RTA). Results: It was demonstrated that the shape of the diaphragm in patients with large defects systematically differs from that of patients with small defects. Characteristically, patients with large defects present with a smaller LDCI (5.1 vs. 8.4, p < 0.001) at 6 months of age, which increases over time (11.4 vs. 7.0 at the age of 15.5 years, p = 0.727), representing a flattening of the patch and the attached rudimentary diaphragm as the child grows. Conclusions: Multiple variables during early follow-up were significantly associated with comorbidities such as recurrence, scoliotic curves of the spine and a reduced thoracic area. Some geometrical variables may serve as surrogate parameters for disease severity, which is associated with long-term comorbidities.