Outcome In Congenital Diaphragmatic Hernia Research Articles

Trends in the treatment and outcome of congenital diaphragmatic hernia over the last decade

Congenital diaphragmatic hernia (CDH) remains a challenging and life-threatening congenital anomaly. The aim was to evaluate whether treatment and survival has changed during the last decade. We retrospectively analysed all consecutive infants with CDH referred to two European tertiary paediatric surgical centres over 11 years (January 1999 to December 2009). Minimum follow-up was 1 year. χ(2) test for trend was used to evaluate significance. There were 234 infants. There was no significant variation over time in the proportion of infants receiving high frequency oscillatory ventilation (HFOV) (p = 0.89), inhaled nitric oxide (iNO) (p = 0.90) or extracorporeal membrane oxygenation (ECMO) (p = 0.22). 205 infants (88 %) were stabilised and underwent surgical repair; of these, 186 (79 %) survived after surgery. Over time there was a significant increase in the proportion of infants undergoing surgical repair (p = 0.018) without a concomitant significant improvement in survival (p = 0.099). This multicentre analysis indicates that the survival rate of infants with CDH referred to two European paediatric surgical centres is high (79 %). The use of HFOV, iNO and ECMO has not changed in recent years. We observed a significant increase in the proportion of infants who undergo surgery but this has not resulted in a significant increase in the overall survival rate.

1707 Rate and Management Pattern of Congenital Diaphragmatic Hernia at Maternity Hospital, Kuwait

Introduction & Objectives:Congenital diaphragmatic hernia (CDH) occurs in around 1 in 2000 live births and associated with high mortality rate reaching up to 50%, even with prenatal diagnosis and recently...

Outcomes of congenital diaphragmatic hernia: a 12‐year experience

To determine outcomes for babies with congenital diaphragmatic hernia (CDH) diagnosed prenatally and postnatally presenting to a tertiary unit. Fetal medicine database and neonatal surgical unit admission books were reviewed to identify cases of CDH over a 12-year period (Jan 1998- Dec 2009). A total of 132 cases of CDH were diagnosed prenatally and 39 cases diagnosed postnatally. Mean gestation at diagnosis was 22 weeks (range 13-37 weeks). Karyotyping was abnormal in 15.9%; abnormal karyotype in 3.6% of fetuses without other structural anomalies compared with 38.9% when other anomalies were identified. In 45 cases (34.1%) pregnancy was terminated. Two stillbirths occurred (2.3% of ongoing pregnancies). One hundred twenty-four babies were live born, of whom 98 babies underwent surgery. Survival to discharge of all live born babies was 72.6%; survival following surgery was 91.8%. Birthweight had a significant effect on survival (odds ratio 0.22, 95% confidence intervals 0.08-0.66). Survival for live born babies prenatally diagnosed was significantly lower (65.9%) than those diagnosed postnatally (92.3%). Abnormal karyotype was more common when CDH was associated with other anomalies. In multivariate analysis, lower birthweight and prenatal diagnosis had a significant impact on survival. Only prenatally diagnosed CDH survival figures should be utilised in prenatal counselling.

Neonatal Respiratory Care

Acute respiratory failure caused by different origins continues to be the major etiology of morbidity and mortality in critical neonates. There has been much advancement in neonatal respiratory care, but a few neonates with severe respiratory failure continue to be candidates for extracorporeal membrane oxygenation or survive with chronic lung diseases (CLD). Therefore, searching for ideal respiratory care strategies to reduce the morbidity and mortality rates is crucial for caring critical neonates. The main aim of this special issue was focused on the existing and potential strategies or techniques in neonatal respiratory care. In this special issue, we have invited a few papers that address such issues. Meconium aspiration syndrome (MAS) is a common cause of severe respiratory failure in term infants. The associations of persistent pulmonary hypertension of newborn (PPHN), pulmonary air leaks, and other morbidities sometimes make the respiratory care a difficult challenge to neonatologists. Three papers address current respiratory care in MAS. In a paper by K. Swarnam et al. they have a detail review on the epidemiology, pathophysiology, and managements in many different views of MAS. In another paper, P. Dargaville focuses on the application of mechanical respiratory supports in MAS, as well as the role of adjunctive respiratory therapies. In a paper, by C. Fischer et al., they demonstrate the epidemiology of MAS in term neonates using a population-based retrospective study for all births from 2000 to 2007 in a French region (Burgundy). In addition, bronchopulmonary dysplasia (BPD)/chronic lung disease (CLD) continues to be a major cause of neonatal morbidity in spite of significant progress in the treatment of preterm neonates. We have two articles discussing the pharmacologic approaches for prevention and treatment of BPD/CLD. S. Gupta et al. focus on the use of corticosteroids in one paper, and K. Tropea reviews all possible medications and the future potential stem cell therapy in another one. Furthermore, research papers discussing other important clinical issues in neonatal respiratory care are included. In a paper by S. Rastogi et al., they report their analysis on the factors associated with the successful weaning from nasal continuous positive airway pressure (NCPAP). In a paper by A. Gentili et al., they report their analysis on the duration of preoperative stabilization in predicting outcome of congenital diaphragmatic hernia. In a paper by K. Hole et al., they report the impact of neonatal resuscitation training in neonatal mortality rates in Malawi, Africa. Mei-Jy Jeng Tsu F. Yeh Peter A. Dargaville Thomas H. Shaffer Jen-Tien Wung

Perinatal outcome of congenital diaphragmatic hernia in an Australian tertiary hospital

Congenital diaphragmatic hernia (CDH) is a potentially correctable anatomical defect that continues to represent a significant cause of stillbirth and neonatal death. To describe the outcomes of fetuses diagnosed antenatally with CDH. A retrospective cohort study of fetuses with CDH detected antenatally at our fetal medicine unit between January 1996 and December 2008. The study analyses factors associated with mortality in a setting where no fetal intervention for this condition is performed. Eighty-six cases were identified and 75.5% of infants were born alive. Mortality prior to corrective surgery was 7%. The survival rate for babies born at term with isolated CDH was 83%. Presence of an additional anomaly, herniated liver and preterm delivery were associated with increased mortality. Seventy-four percent of liveborn infants with either isolated CDH or other anomalies survived to discharge. Although the overall mortality rate for this condition remains high, fetuses with isolated CDH born at term have relatively high survival rates. This study provides data for counselling parents in tertiary centres with advanced neonatal care but where antenatal intervention for this condition has not been introduced.

Increase in fetal pulmonary artery diameters during late gestation is a predictor of outcome in congenital diaphragmatic hernia with liver herniation

Aim Liver herniation (LH) in congenital diaphragmatic hernia (CDH) may not be a reliable prognostic indicator. We measured pulmonary artery (PA) diameters in CDH + LH as an alternative. Methods Of 41 consecutive cases of prenatally diagnosed left-sided CDH treated from 2002 to 2010, 19 had CDH + LH and 22 had CDH − LH. Ultrasonography and magnetic resonance imaging were used to assess LH and echocardiography to measure PA diameters during the third trimester (fetal; 32-34 weeks), at birth, and on day 2 of life. Results In CDH + LH survivors (9/19; 47%), fetal right PA (RPA) diameters were significantly larger than in nonsurvivors (2.58 ± 0.56 vs 1.82 ± 0.35 mm; P < .01), but left PA (LPA) diameters were not (1.73 ± 0.38 vs 1.59 ± 0.22). In survivors, fetal RPA was greater than 2 mm in all but one case, and both PA diameters increased significantly by birth (RPA, 2.58 ± 0.56 vs 3.52 ± 0.54; LPA, 1.73 ± 0.38 vs 2.60 ± 0.40; both P < .01). Final diameters at birth in survivors were at least 2.5 and 2.0 mm, respectively. In nonsurvivors, both PAs were significantly smaller (RPA, 3.52 ± 0.54 vs 2.04 ± 0.31; LPA, 2.60 ± 0.40 vs 1.68 ± 0.18; P < .01), with no observed increase by birth. Survival in CDH − LH was 82% (18/22). Conclusion PA diameter appears to be correlated with prognosis in infants with CDH + LH.

Prenatal lung-head ratio: threshold to predict outcome for congenital diaphragmatic hernia

Objective: The literature suggests that lung-head ratio (LHR) and liver position may inconsistently predict outcome for congenital diaphragmatic hernia (CDH). We reviewed our inborn neonates with isolated left-sided CDH to determine whether these variables predicted survival and to estimate the optimal LHR threshold. Methods: Prenatal LHR and liver position were obtained from 2002 to 2009. The primary endpoint was survival. Results: LHR was greater in survivors after adjusting for gestational age (median 1.40 versus 0.81; p < 0.001). LHR demonstrated excellent diagnostic discrimination, with area under receiver operating characteristic (ROC) curve 0.93 (95% CI 0.86–0.99). LHR threshold of 1.0 was 83% sensitive and 91% specific in predicting survival. An optimal LHR threshold of 0.85 predicted survival with 95% sensitivity and 64% specificity, reducing false negatives (survivors with low LHR). LHR > 0.85 predicted survival after adjustment for gestational age (OR = 33.6, 95% CI = 5.4–209.5). Liver position did not predict survival. Conclusions: Prenatal LHR >0.85 predicts survival for infants with isolated left-sided CDH without compromising discrimination of survivors from non-survivors. The diagnostic utility of LHR may be confounded by gestational age at measurement. Stringent LHR threshold may minimize false-negative attribution and improve utility of this measurement as predictor of survival.

Incidence and Outcome of Congenital Diaphragmatic Hernia in Styria

s S11 termination of pregnancy, four (4,3%) cases of intrauterine fetal death or stillbirth and one case had to be excluded due to the lack of data. 55 (57,9%) cases of CDH were diagnosed prenatally, 40 (42,1%) were diagnosed postnatally. Prenatal detection rate increased over the years (1985-1989 36,4% vs. 2005-2009 72,7%). A surgical repair was carried out in 54 (68,4%) of the 79 liveborn babies; 49 (90,7%) of them survived at least the first postnatal week. The overall survival beyond one week of life was 68,4%. An abnormal karyotype was found in ten (10,5%) infants and 57,1% had associated major anomalies. Conclusion: With a prevalence of 3/10.000 births and the described results, this study on CDH fully supports the findings of other population-based surveys. Detection rate and survival increased over the study period.

Congenital diaphragmatic hernia (CDH) in wales 1989–2010

AimsTo determine the incidence, co-morbidities and outcome of congenital diaphragmatic hernia (CDH) in Wales.MethodsThis retrospective database review used 2 data-sets-CARIS (Congenital Anomaly Register & Information Service, Wales) to determine incidence,...

The right ventricular systolic to diastolic duration ratio: a simple prognostic marker in congenital diaphragmatic hernia?

(i) To compare the ratio of right ventricular systolic to diastolic duration (SD/DD) in infants with congenital diaphragmatic hernia (CDH) and normal controls and (ii) to examine its association, if any, with outcomes in CDH. Retrospective chart and echocardiographic review of consecutive neonates (<1 month old) with CDH and term controls without structural heart defects. Right ventricular SD/DD was calculated by a single reader. Infants with CDH (n = 29) were comparable to controls (n = 27) in their mean (SD) age [2.2 (3.3) vs. 2 (4.0) days], birthweight [3 (0.67) vs. 3 (0.69) kg] and proportion of males (48.2% vs. 72.4%). The DD and SD/DD were significantly abnormal in the CDH group, compared to controls. Among infants with CDH, those who died (n = 15) and those who died or required ECMO (n = 17) had significantly shorter DD and higher SD/DD ratio. At a cut-off of 1.3, SD/DD ratio had a sensitivity of 92.8 (95% CI 64-99%) and specificity of 61.5 (32-85%) for prediction of mortality. Significant independent associations with mortality were observed with antenatal diagnosis (p = 0.003) and higher SD/DD ratio (p = 0.04). The right ventricular SD/DD ratio is a sensitive objective prognostic marker in infants with CDH. Further studies incorporating SD/DD ratio as a guide to intervention are warranted.

Impact of prenatal evaluation and protocol-based perinatal management on congenital diaphragmatic hernia outcomes

Background/PurposeAlthough intuitive, the benefit of prenatal evaluation and multidisciplinary perinatal management for fetuses with congenital diaphragmatic hernia (CDH) is unproven. We compared the outcome of prenatally diagnosed patients with CDH whose perinatal management was by a predefined protocol with those who were diagnosed postnatally and managed by the same team. We hypothesized that patients with CDH undergoing prenatal evaluation with perinatal planning would demonstrate improved outcome. MethodsRetrospective chart review of all patients with Bochdalek-type CDH at a single institution between 2004 and 2009 was performed. Patients were stratified by history of perinatal management, and data were analyzed by Fisher's Exact test and Student's t test. ResultsOf 116 patients, 71 fetuses presented in the prenatal period and delivered at our facility (PRE), whereas 45 infants were either outborn or postnatally diagnosed (POST). There were more high-risk patients in the PRE group compared with the POST group as indicated by higher rates of liver herniation (63% vs 36%, P = .03), need for patch repair (57% vs 27%, P = .004), and extracorporeal membrane oxygenation use (35% vs 18%, P = .05). Despite differences in risk, there was no difference in 6-month survival between groups (73% vs 73%). ConclusionsPatients with CDH diagnosed prenatally are a higher risk group. Prenatal evaluation and multidisciplinary perinatal management allows for improved outcome in these patients.

Pulmonary artery size has prognostic value in low birth weight infants with congenital diaphragmatic hernia

The aim of this study was to examine the relationship between birth weight, pulmonary artery (PA) size, and outcome in congenital diaphragmatic hernia (CDH) to establish if PA size has prognostic value. The subjects for this study were 39 consecutive left-sided CDH patients treated at our institution according to the same protocol from 2002 to 2009. Other CDH patients with concurrent anomalies that eventually caused death or who became symptomatic more than 6 h after birth were excluded. Birth weight was used to create two groups; low birth weight (LBW; birth weight ≤ 2,500 g; n = 15) and normal birth weight (NBW; birth weight >2,500 g; n = 24). Right PA (RPA) and left PA (LPA) were measured by echocardiography (EC) during late pregnancy (fetal; gestational age (GA): 32-34 weeks), and on days 0, and 2 of life and compared. Mean birth weights were significantly different between the two groups; however, gender, mean GA, and outcome were similar. In LBW survivors, RPA was significantly larger than in non-survivors. PA size was not related to outcome in NBW. We are the first to show that RPA size has prognostic value in low birth weight infants with left-sided CDH.

Echocardiographic measures of ventricular function and pulmonary artery size: prognostic markers of congenital diaphragmatic hernia?

To compare echocardiographic measures of biventricular function and pulmonary artery size in infants with congenital diaphragmatic hernia (CDH) and normal controls, and examine their correlation, if any, with outcomes in CDH. We included consecutive neonates (<1 month old) with CDH and term controls without structural heart defects. Clinical and outcomes data were recorded and echocardiograms evaluated for right ventricular (RV) and left ventricular (LV) myocardial performance index (MPI), cardiac output index (CI) and McGoon index, among others. Statistical analyses (SPSS version 17, SPSS, Chicago, IL, USA) included between-group comparisons, using analysis of variance and χ(2)-test and binary regression, with significance set at P<0.05. Infants with CDH (n=34) were comparable with controls (n=35) in their age, weight, gestational age and gender. CDH was left sided in 24 (70%) neonates. Extracorporeal membrane oxygenation (ECMO) was required in 15 (45%) neonates; 18 (53%) infants survived. MPIs, CI and eccentricity index in systole were significantly worse in the CDH group, compared with controls and among CDH infants who died, compared with survivors. Infants with CDH who died or needed ECMO had significantly impaired MPIs and CI than survivors. On regression analyses, LV CI and MPIs were independently associated with mortality. Infants with CDH had significantly impaired ventricular function and pulmonary hypertension, compared with controls. In the CDH group, LV dysfunction was associated with death and adverse outcomes. Further studies incorporating echocardiographic indices as prognostic markers of CDH are warranted.

Epidemiology and outcome of congenital diaphragmatic hernia: a 9‐year experience

The aim of this study was to report the birth prevalence and short-term outcome of congenital diaphragmatic hernia (CDH) in a large geographically defined population, and to assess the feasibility of performing a randomised control trial (RCT) in this population. Data were collected on all cases of CDH reported to the East Midlands and South Yorkshire Congenital Anomalies Register between 1997 and 2005. A total of 194 cases of CDH were identified from 547,025 births; a birth prevalence of 3.5/10,000. Overall 1-year survival was 42%. In total, 69% of cases resulted in a live birth, of these 61% survived to 1 year; 73% were diagnosed antenatally and 22% postnatally, with 1-year survivals 30% and 71%, respectively. A total of 54% were isolated cases and 46% associated with another anomaly, with more live births (80% vs. 56%) and better 1-year survival (62% vs. 19%) with isolated CDH. Overall, only 83 babies were born alive with an isolated CDH: the only group suitable for inclusion in a RCT. In conclusion, given the small numbers of live isolated CDH cases it is impossible that any network alone would be able to perform a valid RCT of treatments, highlighting the need for collaborative international trials to address this complex condition.

Serum cytokine levels in congenital diaphragmatic hernia: predictive impact for the need for extracorporeal membrane oxygenation?

Background: Congenital diaphragmatic hernia (CDH) is a common cause of neonatal respiratory failure and a malformation associated with high mortality and morbidity. Extracorporeal membrane oxygenation (ECMO) is one of treatment options for CDH. Despite the ultrasound based lung-to-head ratio and the fetal lung volume determination, there is no reliable prenatal parameter for the clinical course and outcome of fetuses with CDH, in particular for the need of ECMO. Aim: The objective of the study was to investigate serum cytokine profiles and immune response from newborns with CDH requiring ECMO compared to CDH infants without ECMO and healthy newborns. Methods: We used multiplexed immunoassays based on Luminex beat technology to measure cytokines (Eotaxin, GCSF, GMCSF, IFNa2, IFNg, IL10, IL12p40, IL12p70, IL13, IL15, IL17, IL1a, IL1b, IL2, IL3, IL4, IL5, IL6, IL7, IL8, IP10, MCP1, MIP1a, MIP1b, TNFa, TNFb) in serum of newborns with CDH receiving ECMO (n=16) and conventional ventilation (n=27). Serum was collected before (baseline) and 24, 48 and 72 hours during ECMO and ventilation. Cord blood cytokines from healthy term newborns served as controls (n=13). Results: From the examined cytokines IFNg, IL12p70, IL13, IL15, IL17, IL1b, IL2, IL4, IL5, and TNFb were found to be under the detection limit of 3.2 pg/ml in CDH and healthy newborns. The concentrations of remaining cytokines at baseline were significantly elavated in newborns with CDH compared to controls. ECMO group showed higher median levels of IL10 and IL8at baseline compared to ventilated CDH infants (97.4 vs. 46.2 pg/ml and 48.3 vs. 30.6 pg/ml, both p&lt;0.05). With cardiopulmory bypass, IL10 concentration showed a significant decreasing pattern. Baseline serum level and change in IL10 were not associated with fetal lung volume, pre-ECMO oxygenation-index and outcome of CDH. Conclusion: These findings suggest that inflammatory reaction and activation is associated with CDH. Thus, the high circulating levels and decreasing pattern of anti-inflammatory IL10 in CDH patients under ECMO treatment indicate that IL10 may be useful as a marker of the severity of CDH and as parameter for the need of ECMO intervention.

Impact of Target Blood Gases on Outcome in Congenital Diaphragmatic Hernia (CDH)

Neonatal intensive care unit (NICU) stabilization strategies which normalize physiology according to predetermined blood gas targets may contribute to observed improved survival rates of patients with CDH. The purpose of our study was to compare risk-adjusted outcomes of CDH patients managed with or without blood gas targets established at NICU admission. Cases were collected from a national CDH network between May 2005 and November 2007. On NICU admission, the responsible neonatologist was asked to establish target ranges for pH, pCO (2), pO (2), and pre/post-ductal O (2) saturation. The outcomes analyzed were mortality, need for ECMO, days of mechanical ventilation/supplemental oxygen, and length of stay. Of 147 CDH infants, 63 had admission blood gas targets. Severity of illness and gestational age in both groups were comparable (SNAP-II score). Infants with blood gas targets had a significantly lower mortality than those without (Hazard ratio 0.27, p=0.006). Blood gas targets for the management of infants with CDH are associated with improved survival. Although the willingness to create and use stabilization targets to guide early NICU care may be a surrogate for other factors (experience, staffing, lack of interest), it is clearly associated with improved survival in CDH.

Long-term surgical outcomes in congenital diaphragmatic hernia: observations from a single institution

Long-term surgical outcomes in congenital diaphragmatic hernia: observations from a single institution

Risk factors and outcomes for congenital diaphragmatic hernia in neonatal intensive care unit patients

Objectives. Congenital diaphragmatic hernia (CDH) is one of the most common and serious congenital disorders seen in the neonatal intensive care unit (NICU) and it is associated with a high mortality. In order to determine the risk factors and outcomes of CDH, we summarized data from a 10 year period.Methods. A retrospective study was conducted on 38 CDH patients. Clinical characteristics and risk factors were compared and non-conditional logistic regression analysis was performed to determine independent predictors for mortality. Results. Thirty patients, from a total of 38, underwent surgery for CDH. The total survival rate in patients with CDH was 63.2%(24/38) and the overall operative mortality was 20.0% (6/30). There was a significant difference between CDH patients who survived (n=24) and those who died (n=14) in the age on admission, 5-minute Apgar score, onset of respiratory distress, cardiac malformations and presence of persistent pulmonary hypertension of newborn (PPHN). Using logistic regression analysis, the following factors independently predicted mortality: the age on admission (OR: 8.15, 95%CI: 1.43 to 46.41) and cardiac malformations (OR: 18.54, 95%CI: 1.32 to 259.62). Moreover, when we compared CDH patients who survived after surgery (n=24) with those who died (n=6), there was a significant difference in the admission age, 1-minute Apgar score, presence of PPHN, lung hypoplasia, time of stabilization prior to surgery, and highest oxygenation index after surgery. Conclusions. Mortality was very high in CDH patients and was associated with care procedures. Risk factors for mortality in neonatal CDH were the age on admission and associated malformations.&nbsp;

Long-term surgical outcomes in congenital diaphragmatic hernia: observations from a single institution

Background/Purpose Surgical complications are common in survivors of congenital diaphragmatic hernia (CDH), but little is known about long-term incidence patterns and associated predictors. Methods A cohort of 99 CDH survivors was prospectively followed at a single-institution multidisciplinary clinic. Data were gathered regarding the adverse surgical outcomes of hernia recurrence, chest and spinal deformity, and operative small bowel obstruction (SBO), and then were retrospectively analyzed in relation to perinatal and perioperative markers of disease severity to determine significant predictors. Statistical methods used included univariate and multivariate regression analysis, hazard modeling, and Kaplan-Meier analysis. Results At a median cohort age of 4.7 (range, 0.2-10.6) years, 46% of patients with patch repairs and 10% of those with primary repairs had a hernia recurrence at a median time of 0.9 (range, 0.1-7.3) years after repair. Chest deformity was detected in 47%. Small bowel obstruction and scoliosis occurred in 13%. Recurrence and chest deformity were significantly more common with patch repair, liver herniation, age at neonatal extubation greater than 16 days, oxygen requirement at discharge, and prematurity. The strongest predictor of SBO was patch repair. Multivariate analysis showed that patch repair was independently predictive of recurrence and early chest deformity (odds ratios of 5.0 and 4.8, confidence intervals of 1-24 and 1-21, P < .05). Use of an absorbable patch was associated with the highest risk of surgical complications. Conclusions For long-term survivors of CDH, specific perinatal and operative variables, particularly patch repair, are associated with subsequent adverse surgical outcomes.

Does Overnight Birth Influence Treatment or Outcome in Congenital Diaphragmatic Hernia?

We examined the effect of overnight birth on treatment and outcome (including initial cardiorespiratory stabilization) in newborns with congenital diaphragmatic hernia (CDH). CDH births between May 2005 and May 2008 were abstracted from a national CDH database. Overnight birth was defined as occurring between 8 PM and 8 AM. Patient characteristics, treatment, and outcomes were compared between birth time groups, including the subset of infants in whom a prenatal diagnosis of CDH had been made. Of 132 cases evaluated, 106 (80%) survived. Forty-nine babies (37%) were born overnight. Eighty-five infants (64%) with a prenatal diagnosis were evenly distributed between the birth time cohorts. Survival to discharge, surgical management, duration of mechanical ventilation, and length of hospital stay were comparable between the risk-matched (SNAP-II score) birth time groups. Overnight birth did predict a lower rate of cesarean section deliveries (P = 0.03). Escalation of ventilator mode, inability to achieve/maintain blood gas targets, development of pneumothorax, and need for extracorporeal membrane oxygenation were all considered "stabilization failures." Overnight birth predicted a failure to maintain or improve pH to within target range (P = 0.008). Overnight birth did not adversely affect outcome in this birth time comparison of newborns with CDH.