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Logo of mjafiGuide for AuthorsAbout this journalExplore this journalMedical Journal, Armed Forces India
 
Med J Armed Forces India. 2006 January; 62(1): 93.
Published online 2011 July 21. doi:  10.1016/S0377-1237(06)80184-X
PMCID: PMC4923281

Management of Congenital Diaphragmatic Hernia

Dear Editor,

This is with reference to the “Radiological Quiz” published in MJAFI 2005;61:50 & 78. The authors mention that immediate action required in congenital diaphragmatic hernia, is inserting a feeding tube in stomach, stopping feeds and operating the patient as an emergency. A neonate with congenital diaphragmatic hernia usually presents with respiratory distress and may have anomalies of other organ systems. Respiratory distress in newborn is a contradiction to enteral feeds. In addition to inserting a feeding tube for decompression, it is essential that these babies are not resuscitated with bag and mask as this pushes air into intrathoracic stomach and viscera which further compresses the mediastinal structures. These babies should be intubated.

The treatment of congenital diaphragmatic hernia does not involve closure of diaphragm after reducing the viscera, as the physical compression is not the sole abnormality. The postnatal mass effect of the herniated viscera is a minor factor in the cardio respiratory compromise compared with the pulmonary hypertension and hypoplasia [1].

Congenital diaphragmatic hernia was once considered a surgical emergency. Recognition of the role of pulmonary hypertension in addition to pulmonary hypoplasia and the adverse effects of operative repair on pulmonary function has caused a shift in management approach. Opinion regarding the timing of surgical repair has gradually shifted from emergent repair to a policy of stabilization using a variety of ventilatory strategies prior to operation [2]. If the infant stabilizes and demonstrates stable pulmonary vascular resistance without significant right to left shunt, repair of the diaphragm is performed at 24-72 hours of age. If stabilization is not possible, most infants will require extra corporeal membrane oxygenation support (ECMO) initially in addition to surgical repair and ventilatory support.

References

1. Hartman GE. Diaphragmatic Hernia. In: Behrman RE, Kliegman RM, Jenson HB, editors. Nelson textbook of Paediatrics. 7th ed. Elsevier; Philadelphia: 2004. pp. 1353–1355.
2. Clark RH, Hardin WD, Hirschl RB, Jaksic T, Lally KP, Langham MR, Wilson JM. Current surgical management of congenital diaphragmatic hernia — a report of the congenital diaphragmatic hernia study group. J Pediatr Surg. 1998;33:1004–1009. [PubMed]

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