Larsen et al.

BMC Pediatrics (2020) 20:196

https://doi.org/10.1186/s12887-020-02072-2

RESEARCH ARTICLE Open Access

Congenital diaphragmatic hernia

presenting with symptoms within the first
day of life; outcomes from a non-ECMO
centre in Denmark
Ulla Lei Larsen1,2*, Søren Jepsen3, Thomas Strøm1, Niels Qvist4 and Palle Toft1

Abstract
Background: Between 1998 and 2015, we report on the survival of congenital diaphragmatic hernia (CDH)-infants
presenting with symptoms within the first 24 h of life, treated at Odense University Hospital (OUH), a tertiary referral
non-extracorporeal membrane oxygenation (ECMO) hospital for paediatric surgery.
Methods: We performed a retrospective cohort study of prospectively identified CDH-infants at our centre. Data
from medical records and critical information systems were obtained. Baseline data included mode of delivery and
infant condition. Outcome data included 24-h, 28-day, and 1 year mortality rates and management data included
intensive care treatment, length of stay in the intensive care unit, time of discharge from hospital, and surgical
intervention. Descriptive analyses were performed for all variables. Survivors and non-survivors were compared for
baseline and treatment data.
Results: Ninety-five infants were identified (44% female). Of these, 77% were left-sided hernias, 52% were
diagnosed prenatally, and 6.4% had concurrent malformations. The 28-day mortality rate was 21.1%, and the 1 year
mortality rate was 22.1%. Of the 21 non-survivors, nine died within the first 24 h, and 10 were sufficiently stabilised
to undergo surgery. A statistically significant difference was observed between survivors and non-survivors
regarding APGAR score at 1 and 5 min., prenatal diagnosis, body length at birth, and delivery at OUH.
Conclusions: Our outcome results were comparable to published data from other centres, including centres using
ECMO.
Keywords: Infants, Congenital diaphragmatic hernia, Outcomes, Extra corporeal membrane oxygenation,
Retrospective cohort study

* Correspondence: [email protected]
1
Research Unit for Department of Anaesthesiology & Intensive Care, Odense
University Hospital, Odense, Denmark; University of Southern Denmark,
Odense, Denmark
2
OPEN, Odense Patient Data Explorative Network, Odense University
Hospital/Institute of Clinical Research, University of Southern Denmark,
Odense, Denmark
Full list of author information is available at the end of the article

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Larsen et al. BMC Pediatrics (2020) 20:196 Page 2 of 8

Background Ethical permission

Congenital diaphragmatic hernia (CDH) is a rare, but The study was conducted after permission was obtained
serious congenital malformation. The reported overall from the Danish Patient Safety Authority (No: 3–3013-
mortality is between 40 and 48% depending on the 1121/1), and the Danish data protection agency (No: 15/
CDH-population, and an incidence of 0.08–0.38/1000 34128).
live born infants is described [1, 2]. The majority of
CDH-cases are left-sided, but right-sided and, in rare
cases, bilateral hernias may also occur [3]. A wide range The study group
of associated malformations and syndromes have been The study focussed on a cohort of consecutive live-born
described, with congenital heart malformations being CDH-cases from the western region of Denmark, born
the most frequent, with clear negative impacts on sur- at Odense University Hospital (OUH) or referrals from
vival [3]. peripheral hospitals in the region. Our centre is the only
In some cases symptoms are absent or subtle, and tertiary unit in the region treating CDH patients, and is
these may be serendipitously diagnosed by coincidence. one of two centres in Denmark. Thus, all children diag-
Late-presenting CDH has an overall good outcome [4], nosed with CDH from the western region of Denmark
when compared with infants presenting with symptoms were treated at OUH. None were transferred for treat-
in the neonatal period, which often require stabilising in- ment elsewhere. The region has a population of approxi-
tensive care therapy. Cardiopulmonary instability is the mately 3.2 million, covering more than half of the
main challenge, as lung hypoplasia and vascular bed ab- Danish population (The population of Denmark is 5.8
normalities cause pulmonary hypertension [5]. In severe million, Danmarks statistik/2019).
cases, further deterioration increases right ventricular
strain and eventually, circulatory failure may occur.
In recent decades, notable and improved survival of The study population
infants with CDH has generally been attributed to ad- All infants treated at OUH were registered under the
vances in cardiopulmonary resuscitation in the inten- following diagnosis: Congenital Diaphragmatic Hernia
sive care unit. These improvements have been related (ICD-10 code: DQ790). Infants were registered prospect-
to the introduction of “lung-protective ventilation,” ively, and all live-born infants were eligible for inclusion.
delayed surgery, and an increased focus on targeting We excluded infants presenting with symptoms 24 h
pulmonary hypertension and circulatory stabilisation after birth, thus defining symptomatic CDH as infants
issues [6]. Extracorporeal membrane oxygenation showing signs of life at birth, and presenting with symp-
(ECMO) is a well-established treatment modality for toms within the first 24 h of life.
neonates with reversible circulatory or respiratory fail-
ure, with a well-documented impact on survival [7].
Many ECMO-centres offer treatment to CDH-infants, The study period
when conventional treatments fail. However, despite A multidisciplinary CDH-infant management approach
improved technology, ECMO treatment is associated was implemented in 1997. The study period from 1998
with severe complications [8] and evidence of causal to 2015 was chosen to reflect this organisational change.
effect on long term survival in CDH-populations is Data were collected retrospectively from charts, med-
lacking [9, 10]. ical notes, electronic journals, and critical information
The objective of this study was to report 24-h, 28-day, systems. Data were obtained for all infants with symp-
and 1 year mortality rates in infants with symptomatic tomatic CDH, treated at the intensive care unit at OUH
congenital diaphragmatic hernia, treated at a tertiary from 1998 to 2015.
non-ECMO centre in Denmark. In addition, we describe Mortality was recorded as: within the first 24 h of life,
these infants in terms of pre- or postnatal diagnosis, re- 1–28 days, and 29–365 days. The following baseline data
ferral or in-hospital born, management (surgical and in- were noted: gestational age, birth weight and body
tensive care treatment), demographics and clinical data. length at birth, sex, prenatal diagnosis, mode of delivery,
Finally, we compare collected variables between survi- APGAR scores at 1, 5, and 10 min., referral or in-
vors and non-survivors. hospital born, location of hernia and other malforma-
tions. Other variables included: postnatal management
in the paediatric intensive care unit (PICU) (mode of
Methods ventilation, time on mechanical ventilation, vasopressor/
Study design inotrope treatment, sedation and pain management),
We performed a retrospective cohort study of prospect- surgical management, length of stay in PICU and length
ively registered infants with symptomatic CDH. of stay in hospital.
Larsen et al. BMC Pediatrics (2020) 20:196 Page 3 of 8

Postnatal management enteral administrated Sildenafil was introduced in the

Delivery of prenatally diagnosed infants was scheduled treatment of more severe cases presenting with pulmon-
at our institution. Infants diagnosed postnatally at other ary hypertension and refractory to iNO-treatment. Sil-
hospitals were transported to our institution for further denafil was continued after discharge and the paediatric
treatment. The management of CDH-infants at our hos- cardiologist team conducted weaning of the drug there-
pital, initially implemented in 1997, included a strategy after. Adequate circulation/perfusion was maintained
of early intubation and gentle ventilation. All infants using inotrope/vasopressor therapy. Dopamine and nor-
needing mechanical ventilation were started on high- epinephrine were first-line choices, but during the study
frequency oscillatory (HFO) ventilation (SensorMedics period, dobutamine was more often replaced by milri-
3100A/B HFO Ventilator, Viasys Healthcare, USA). Fur- none, as a second-line treatment in cases with severe
ther ventilation strategies and weaning were tailored to pulmonary hypertension. In some severe cases epineph-
the individual clinical situation, and could also include rine was also administrated.
conventional mechanical ventilation (CMV), continuous Our institution provides ECMO-treatment for adults
positive airway pressure (CPAP), or supplementary oxy- with cardiac failure. Treatment of infants > 2 kg can be
gen. All infants were sedated initially using continuous initiated and thereafter transferred to a paediatric
intravenous infusion or refractory morphine, fentanyl, ECMO-centre. None of the study cases were treated
and midazolam doses. Methadone, phenobarbital, and with ECMO, either at our institution or elsewhere.
clonidine were preferred for weaning and the treatment
of withdrawal symptoms. Infants were monitored by Statistical analyses
pre- and post-ductal saturation, continuous invasive Mortality was recorded as follows: before 24 h, 1–28
measurements of blood pressure via an arterial line – days, and 29–365 days. Descriptive analyses were per-
umbilical preferred, and central venous access was also formed on all cases; survivors and non-survivors. Base-
established. Our protocol also included the aggressive line data were presented as median values, or as
treatment of acidosis using sodium-bicarbonate. The tar- percentages. Continuous non-parametric data were sum-
get value for post-ductal saturation was > 95%. In severe marised as median and interquartile range values (25th
cases with pulmonary hypertension, treatment with iNO and 75th percentile), and categorical data were sum-
(inhaled Nitric Oxide) was initiated by the intensivist in marised as percentages. Groups of survivors and non-
charge, and adequate circulation and perfusion were survivors were compared using the Wilcoxon rank-sum
maintained with appropriate inotropes/vasopressors. test for continuous data, and the Chi-square test for cat-
Echocardiography and a plain chest x-ray were per- egorical data.
formed within the first 24 h of admission to PICU, and Treatment and management of the cases during
later when necessary. PICU-stay was presented as a percentage, or a median
Surgery was scheduled when infants were stable on value (time), with interquartile ranges (25th and 75th
minimal respiratory and circulatory support, without percentile). All analyses were performed using STATA/
further episodes of pulmonary hypertensive crises IC15.0 (Stata Statistical Software: Release 15. College
(adhering to the “delayed surgery strategy” [11]). Enteral Station, TX, USA: StataCorp LLC). P-values < 0.05 were
feeds were commenced from day one, and gradually in- considered statistically significant.
creased up to the calculated basic need if tolerated by
the infant. Parenteral nutrients were only supplied when Results
enteral feeding was not adequate, after approximately 1 We identified 120 patients with CDH; 95 presented with
week. In all cases, surgery was performed using open ab- symptoms during the first 24 h and were included in the
dominal access, and for large defects, a patch was study population. Twenty-five infants presented with
inserted. The routine use of a chest tube after surgery symptoms after 24 h of life and these cases were ex-
was not practiced. Pleurocentesis was performed when a cluded from the study. The flowchart is shown in Fig. 1.
mediastinal shift (compromising respiratory or circula- Nine infants died during the first 24 h (9.5%), 11 in-
tory function) was observed due to excess filling of the fants died at 1–28 days (11.6%), and one infant died after
intrapleural space with replacement fluid after surgery. day 28 (1.1%). In total 21 died < 1 year (Table 1). The ex-
The procedure was guided by chest x-ray, and in some cluded infants with late-onset symptoms (later than 24
cases ultrasound, to minimise the risk of further h) all survived.
complications. The one death noted after day 28, represents an infant
Changes in management over the study period were born prematurely at the gestational age of 30 weeks, with
noted; treatment with surfactants became more re- a birth weight of 1.1 kg, and presenting with a left-sided
stricted as no benefit had been shown in mature CDH hernia. No other malformations were noted, and initial
infants (administered only for premature cases) [12], and surgical repair was performed with patch repair. The
Larsen et al. BMC Pediatrics (2020) 20:196 Page 4 of 8

survivors were shorter than survivors (P value 0,002).

However, birth weight, sex, gestational age, indication
for caesarean section, associated malformations, and her-
nia location did not show any significant differences be-
tween groups.
The majority of the study population (77.2%) pre-
sented with left-sided hernias (71/92 – three were un-
documented). A right-sided hernia was present in 7/21
(33.3%) non-survivors, and 13/74 (17.6%) survivors, but
this observation was not statistically significant. Overall,
a right-sided hernia was noted in 20/92 (21.7%) infants.
One infant had a bilateral hernia and survived.
In our cohort, 25 infants (27.5%) had an APGAR score
at 1 min between 0 and 4, 26 infants (28.6%) had a score
between 5 and 7, and 40 infants (44.0%) scored > 7.
APGAR scores at both 1 and 5 min were significantly
lower for non-survivors.
For 38 infants, all three APGAR scores (1 min, 5 min,
10 min) were available. APGAR scores at 10 min were
only available in 39/95 infants and of these, seven were
non-survivors (median = 7). For APGAR scores at 10
min, no significant differences were noted between sur-
vivors and non-survivors. For infants with APGAR score
Fig. 1 Flowchart of cases included in the study population at 1 min < 7, 59% had missing APGAR data at 10 min.
and for those with APGAR score at 1 min > 7, 48% had
missing data. For infants with APGAR scores at 1 and 5
infant was successfully discharged from PICU after 29 min > 9, 44% had missing data at 10 min.
days, although re-admitted shortly for surgery due to Of the non-survivors, 10 (10/21) were initially suffi-
hernia recurrence. The infant was transferred back to ciently stabilised to undergo surgery, with five (50%) re-
the paediatric department of the local hospital, but died quiring patch repair when compared to survivors, where
(unknown event) before home discharge. 12 (16%) needed patch repair. Overall hernia recurrence
Baseline data are shown (Table 2). Baseline data from was noted in eight cases, where five (62.5%) initially
one infant was missing, and APGAR scores were not needed patch repair.
available for three infants. Associated malformations occurred in six cases, of which
Baseline data were compared between survivors and two were non-survivors. The most frequent malformation
non-survivors. We observed non-survivors were more was oesophageal atresia, with and without fistula. Also,
frequently diagnosed prenatally than survivors (P value chromosomal anomalies, cardiovascular, and minor urogeni-
0,017) also, birth length was significantly different; non- tal malformations were observed. PICU management and
treatment regimens are shown (Table 3). Not unexpectedly,
we observed more advanced treatments in the non-survivor
Table 1 Mortality and time of death for symptomatic CDH non- group, as all infants required mechanical ventilation, vaso-
survivors pressor/inotropic support and sedation. Stay durations on
Mortality Symptomatic CDH the group of survivors are also reported (Table 4).
28-day mortality 21.1% Placing a chest tube was not a routine procedure; how-
1-year mortality 22.1%
ever pleurocentesis was performed if clinically indicated.
Unfortunately, the procedure pleurocentesis was not in-
Death before 24 h 9/95
cluded in our study protocol and therefore this data was
Death before 48 h 11/95 not retrieved in a structured manner.
Death before surgery 11/95
Death before PICU discharge 20/95 Discussion
Death before hospital discharge 21/95 We observed that survival in our cohort compared
Death < 28 day 20/95
favourably with reports from other centres. Our data in-
cluded all cases of symptomatic CDH admitted during
Death < 1 year 21/95
the study period; this included cases with factors
Larsen et al. BMC Pediatrics (2020) 20:196 Page 5 of 8

Table 2 Baseline data on our CDH-population

Baseline data (N) All CDH cases Survivors Non-survivors P-value
(74) (21)
Sex (95), male 53 (55.8%) 40 (54.1%) 13 (61.9%) NS
Gestational age (94) 38.5 (36.6–40) 38.6 (36.7–40) 38.3 (36.1–39.8) NS
Birth weight, g (94) 3105 (2700–3550) 3150 (2700–3550) 3000 (2200–3350) NS
Birth length, cm (94) 50 (48–52) 50 (49–52) 48 (44–50) 0.002
Prenatal diagnosis (94) 49 (52.1%) 33 (44.6%) 16 (76.2%) 0.017
In-born, OUH (94) 50 (53.2%) 34 (45.9%) 16 (76.2%) 0.012
Caesarean Section (94) 32 (34%) 25 (33.8%) 7 (33.3%) NS
Associated malformations (94) 6 (6.4%) 4 (4.3%) 2 (9.5%) NS
Hernia location (94)
Left 71 (74.7%) 58 13 NS
Right 20 (21.1%) 13 7
Bilateral 1 (1.1%) 1 0
Not available 3 (3.2%) 2 1
APGAR 1 min (91) 7 (4–9) 8 (6–9) 4 (2–6) 0.000
APGAR 5 min (80) 7 (6–9) 8 (6–9) 5.5 (4.5–7) 0.002
APGAR 10 min (39) 8 (7–10) 8 (7–10) 7 (5–9) NS
Comparisons between survivors and non-survivors. Data are presented as percentages or median values and interquartile ranges (25th–75th percentile). Groups of
survivors and non-survivors were compared using the Wilcoxon rank-sum test for continuous data, and the Chi-square test for categorical data.
NS: Non-significant

believed to negatively impact on survival, e.g. low birth

Table 3 Intensive care and surgical management during the
study period
weight [13], prematurity [13], right-sided hernia [14],
prenatal diagnosis [13], and associated malformations
Management/Treatment All CDH cases Survivors Non-survivors
[15]. Other risk factors associated with mortality, i.e.
Mechanical ventilation 92 (97%) 71 (96%) 21 (100%)
liver-up [16] and the lung-to-head ratio [16] were not
HFO 75 (79%) 56 (76%) 19 (90%) assessed.
iNO 36 (38%) 18 (24%) 18 (86%) Of note, the CDH cases presenting with symptoms
Magnesium, iv 14 (15%) 6 (8%) 8 (38%) after 24 h of life (and excluded from this study) were ad-
Sildenafil, ga 13 (14%) 6 (8%) 7 (33%) mitted to the intensive care unit for postoperative care
Surfactant 13 (14%) 5 (7%) 8 (38%)
at a median age of 340.9 days (147.04–785 days). Includ-
ing all CDH cases at our hospital during the study
Vasoactive drugs 60 (63%) 39 (53%) 21 (100%)
period, both symptomatic and late-presentations (symp-
Nor-epinephrine 15 (16%) 6 (8%) 9 (43%) toms after 24 h of life); we note an overall mortality of
Dopamine 51 (54%) 34 (46%) 17 (81%) 17.5%.
Dobutamine 16 (17%) 9 (12%) 7 (33%) Comparisons of APGAR scores 1 + 5 min, showed sig-
Milrinone 14 (15%) 5 (7%) 9 (43%) nificantly lower values for non-survivors, which corre-
Epinephrine 12 (13%) 1 (1%) 11 (52%)
lated well with previously published data [17]. APGAR
scores at 10 min did not show the same trend. As infants
Sedatives 80 (84%) 59 (80%) 21 (100%)
with low scores at 1 min were more likely to have
Fentanyl 77 (81%) 57 (77%) 20 (95%)
Midazolam 54 (57%) 39 (53%) 18 (86%)
Table 4 Stay duration for CDH-survivors
Methadone 11 (12%) 11 (15%) 0 (0%) Survivors, N = 73 days
Phenobarbital 43 (45%) 37 (50%) 6 (29%) Time on mechanical ventilation 6.4 (2.9–16.4)
Clonidine 10 (11%) 9 (12%) 1 (5%) LOS-PICU 8.3 (4.4–18.6)
Operation 84 (88%) 74 (100%) 10 (48%) LOS- Hospital 26.1 (15.9–52.8)
Patch repair (operation) 17 (20%) 12 (16%) 5 (50%) Time on mechanical ventilation, number of days in intensive care unit, (length
of stay, LOS-PICU), and the total number of days in hospital (length of stay,
Recurrent hernia (operation) 8 (8%) 7 (10%) 1 (1%)
LOS-hospital) for CDH-survivors. Data from one infant is missing. Data are
Data are presented as percentages. iv intravenous, ga gastrointestinal represented as the median and interquartile ranges (25th – 75th percentile)
Larsen et al. BMC Pediatrics (2020) 20:196 Page 6 of 8

missing values at 10 min, we speculated that more se- guidelines, the CDH-EURO consortium (2015) stated
verely affected infants were already undergoing support- that the benefits of ECMO for CDH treatment remained
ive treatments within 10 min after birth, including unclear, and provided grade D recommendations for
sedation, making an APGAR score non-applicable. Also, initiating treatment. However, the following criteria were
infants with high APGAR scores at 1 and 5 min had a stated: preductal saturation < 85% or postductal
high percentage of missing values. We concluded that saturation < 70%, respiratory acidosis with a pH < 7.15,
APGAR scores at 10 min were not uniformly collected peak inspiratory pressure > 28 cm H2O, or mean airway
during the study period, and therefore should not be pressure > 17 cm H2O, metabolic acidosis with lactate
taken into account as a predictor of outcome in our ≥5 mmol/l and pH < 7.15, shock refractory to treatment
CDH-population. and with urine output < 0.5 ml/kg/h for at least 12–24 h,
We used HFO ventilation as the first-line mode of re- and oxygenation index (OI) ≥ 40 present for at least
spiratory support. Since data collection, the VICI-trail; a three hours [29]. These recommendations were
multicentre randomised study on primary ventilation consistent with the guidelines published in 2010 [30],
mode (CMV vs. HFO) was published [18]. The study and are marginally more conservative than those put for-
found no significant differences in primary outcomes ward by The Extracorporeal Life Support Organization
(death or bronchopulmonary dysplasia), but reported a (ELSO; www.elso.org).
benefit of CMV to secondary outcomes. The majority of The true impact of ECMO treatment for CDH man-
centres had access to ECMO, but no differences in out- agement is still not fully elucidated. The published data
comes were found between EMCO- and non-ECMO often represents different populations and treatment ap-
centres. A study limitation was a slow inclusion rate; proaches, making direct comparisons challenging. Fur-
therefore it was terminated early before the calculated thermore, studies addressing causal effects are lacking
sample size was reached [18]. for CDH populations.
Our centre is one of two in Denmark caring for infants Our study had several limitations. Despite adhering to
with CDH. We provide advanced intensive care for neo- the same management protocol throughout the study
nates and ECMO is currently not offered to CDH pa- period, adjustments and minor changes were made ac-
tients. However, our centre treats adult patients, and cording to justified best clinical practise [30]. Prenatal
when indicated for other diagnosis, infant ECMO treat- care improved as first- and second-trimester ultrasound
ment (minimum weight; 2 kg) can be initiated (by our monitoring was introduced as a routine procedure dur-
local team or by an ECMO-transport team) and there- ing pregnancy, thereby influencing the frequency of pre-
after transferred to a paediatric ECMO-centre. natally diagnosed cases. Prenatal diagnostics increased
Many established ECMO-centres provide treatment throughout the first, second, and third part of the study
for CDH-infants, when conventional therapy fails. As period; i.e. 19.4, 59.4 and 78.1%, respectively. The sur-
very few randomised trails evaluating ECMO treatment vival rates for these periods were 77.4, 81.3, and 75.0%,
include CDH-patients, the indication of impact on sur- respectively. From 2016 to 2019, the prenatal detection
vival is primarily based on case and retrospective cohort rate was 83.3%, and the survival rate was 83.3%
studies [9, 19]. Also, comparing outcome between cen- (unpublished data).
tres can be challenging due to differences in patient se- As we reported from a single centre (not an epidemio-
lection, variations in indications and cut-off values for logical study), our data may have been subjected to se-
initiating ECMO treatment [9, 20]. lection bias, i.e. the small number of associated
ECMO centres have increased their CDH-survival malformations at birth (6/94, 6.4%). The number of
after implementing or optimising ECMO-protocols and cases with associated malformations was less than ex-
mortality rates ranging from 5 to 24% have been re- pected, as other population-based/epidemiological stud-
ported [20–23]. Alongside ECMO-treatment, other mo- ies reported concurrent malformations in approximately
dalities targeting pulmonary hypertension and lung 32% live-born CDH cases [2]. We speculate this low fre-
protection have been implemented or refined over re- quency may have been due to counselling, either at local
cent decades [24]. Thus, centres without access to hospitals or our centre, resulting in elective terminations
ECMO, also report increased survival rates correlating if other malformations were present.
with the introduction of multidisciplinary and more ag- Another limitation was the lack of parameters
gressive multimodal treatment approaches. As described evaluating the degree of pulmonary hypoplasia. We
at our hospital, organisational and management changes reported on several indicators of poor outcomes, but
resulted in significant improvements in outcomes for not specifically the degree of pulmonary hypoplasia.
our CDH population, reducing mortality from 67 to 23% This factor is a significant contributor, alongside per-
[25]. Other centres have reported mortality rates be- sistent pulmonary hypertension, to CDH outcomes
tween 13 and 34% [26–28]. In recently published and is a main feature of CDH [31].
Larsen et al. BMC Pediatrics (2020) 20:196 Page 7 of 8

Lung-to-head ratio evaluates lung volume prenatally in Authors’ information

CDH infants, and is used as a prognostic marker for out- ULL: PhD-student, “Mortality and morbidity of symptomatic Congenital Dia-
phragmatic Hernia treated at Odense University Hospital, 1998–2015”.
come [16]. Magnetic resonance imaging is also used to
prenatally evaluate the degree of lung hypoplasia, how- Funding
ever, this modality has only recently been taken up at No funding was received for this study. The study will be part of a Ph.D.
our institution and was therefore not evaluated here project currently registered at the University of Southern Denmark.
[32]. Unfortunately, data for “liver-up”, lung-to-head ra-
Availability of data and materials
tio, and other possible risk factors were not registered in
The datasets used or analysed during this study are available from the
a consistent and structured manner throughout the corresponding author on reasonable request.
study period. Likewise, ventilator associated parameters
such as pCO2 and oxygenation index (OI) were not re- Ethics approval and consent to participate
trievable in a consistent manner, but would have added No procedures were performed on human participants.
Permission to collect data from charts, medical notes, electronic journals, and
valuable information to the study as possible indicators critical information systems journals, was obtained from the Danish Patient
of severity. Safety Authority (No: 3–3013-1121/1). The patients were identified by
Similarly, we only reported infant mortality. However, diagnosis code (ICD-10 code: DQ790).
Permission to manage and store data in compliance with the rules of
improved understanding and treatment of CDH, may re- protection of personal data was obtained by the Danish data protection
sult in more severely affected infants surviving, therefore agency (No: 15/34128).
it becomes relevant to evaluate post-intensive-care con- Data is stored using REDCap (Research Electronic Data Capture) in
collaboration with OPEN (Odense Patient Data Explorative Network), Odense
ditions that affect childhood morbidity and quality of University Hospital/Institute of Clinical Research, University of Southern
life, e.g. bronchopulmonary dysplasia (BPD), require- Denmark.
ments for tracheostomy, delayed neurodevelopment and
failure to thrive [33, 34]. Consent for publication
Not applicable.
Our data did not include spontaneous abortion cases,
terminated pregnancies due to a CDH prenatal diagno-
Competing interests
sis, or stillborn infants with CDH. Also, infants born The authors declare that they have no competing interests.
alive and diagnosed postnatally at other hospitals, but
Author details
not surviving transport to our centre, were not be in- 1
Research Unit for Department of Anaesthesiology & Intensive Care, Odense
cluded, in contrast to a similar infant born at our centre. University Hospital, Odense, Denmark; University of Southern Denmark,
Inclusion of these cases would have increased overall Odense, Denmark. 2OPEN, Odense Patient Data Explorative Network, Odense
University Hospital/Institute of Clinical Research, University of Southern
CDH mortality, an issue previously described as ‘The
Denmark, Odense, Denmark. 3Department of Anaesthesiology & Intensive
hidden mortality of CDH’, and discussed by other au- Care, Odense University Hospital, Odense, Denmark. 4Research Unit for
thors [1, 35]. This issue was not addressed here. Surgery, Odense University Hospital, Odense, Denmark: University of
Southern Denmark, Odense, Denmark.

Received: 25 October 2019 Accepted: 6 April 2020

Conclusions
We reported data on CDH survival, over an 18 year time
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