Feeding stable infant with right-sided CDH

[Andrej Vitushka]

Dear colleagues,

We have now 34 weeks girl with mild RDS and right-sided congenital diaphragmatic hernia. Her vitals is stable, RDS is managed well by nasal CPAP. There is a liver in right thorax proven by CT. The Xray is below.

My question is should we feed this baby enterally and how? Many thanks. 

[Hamed]

Hi @Andrej Vitushka This is interesting, we usually avoid using CPAP in CDHto avoid dilatation of guts loops and further herniation with cardiovascular compromisation, however, this case seems to only have it`s liver herniation in the chest. I see the OG tube is somewhat in a high position in the lower 1/3 of the esophagus. 

Concerning feeding, in our setting, we start feeding after surgical repair of CDH and not before. However, this case`s X-ray seems like lt. sided diaphragmatic paralysis or paresis and is already on CPAP, thus I would start feeding if surgery is not expected within a few days

[Andrej Vitushka]

@Hamed, thanks a lot!. It is a tricky case. CDH wasn't detected prenatally. CPAP was started because of mild RDS and CDH on Xray was somewhat surprising. As the baby was doing well on CPAP we decided do not intubate. Feeding tube was corrected and now CPAP is withdrawn.

[Stefan Johansson]

Interesting case - I'd guess that "our" surgeons would opt for early repair also for a 34-weeker. What is the birth weight? 

We'd do the same as in @Hamed's unit, i.e. put on mechanical ventilation (until surgery is done) and feed post-surgically.

@Andrej Vitushka hope this helps and that you did not unexpected suggestions  Please share feedback how things develop

[Andrej Vitushka]

Many thanks. Birhtweight is 2140 grams. About 7 hours after my post CPAP has been withdrawn because respiration and blood pressure were stable. We decided not to feed enterally before surgery. Referring to surgical center scheduled for tomorrow.   

I wonder is it mandatory to switch to mech ventilation in this case if RDS was decreasind and it is known that only liver is thorax? Would it be more  harmful for the baby?

[Stefan Johansson]

If you are close to the surgical unit (like same building), I would not necessarily do it. Especially if you know only the liver is in the thorax.

If you need to go on the road (transportation), I would prefer intubation and mech vent regardless, to secure the airway, just in case. Probably they will operate soon after arrival anyway, so time on ventilator is not so much a critical factor.

[Andrej Vitushka]

OK, @Stefan Johansson. I've got the point. Thank a lot. Patient now is in the surgical center preparing for the operation. 

[yalsaba]

Are you sure it is CDH OR diaphragmatic eventration. Differentiation is not easy ???

[tarek]

I think this isveventration of the diaphragm and not diaphragmatic hernia

There is no problem to start feeding as we can see all the gut below the diaphragm 

If you are not going to operate now and patient RR is showing tachypnea start with OGT according feeding protocols regarding his weight

If he is tolerating this eventration and not tachypnic start oral feeding if his wt> 1.5 kg and increase gradually

Dig for the history as it may be traumatic delivery 

Check his moro reflex nicely to r/o Erb's

[Stefan Johansson]

@yalsaba @tarek very good point!

[Andrej Vitushka]

@tarekI am also think that is diaphragmatic eventration. But I know no way to prove it without operation 😊. Thanks for suggestions. 

[tarek]

@Andrej Vitushka

There is

By flouroscopy

[Andrej Vitushka]

@tarek could you please specify the method more extensively? Thanks 

[tarek]

Diaphragmatic disease usually manifests as elevation at chest radiography. Functional imaging with fluoroscopy (or ultrasonography or magnetic resonance imaging) is a simple and effective method of diagnosing diaphragmatic dysfunction, which can be classified as paralysis, weakness, or eventration. Diaphragmatic paralysis is indicated by absence of orthograde excursion on quiet and deep breathing, with paradoxical motion on sniffing. Diaphragmatic weakness is indicated by reduced or delayed orthograde excursion on deep breathing, with or without paradoxical motion on sniffing. Eventration is congenital thinning of a segment of diaphragmatic muscle and manifests as focal weakness. see the video

E51_DC1_Movie4.mp4

[Andrej Vitushka]

@tarekwow! It's cool! Thanks!