Protocolized approach to the management of congenital diaphragmatic hernia: benefits of reducing variability in care

J Pediatr Surg. 2010 Jun;45(6):1343-8. doi: 10.1016/j.jpedsurg.2010.02.104.


Purpose: Variable approaches to the care of infants with congenital diaphragmatic hernia (CDH) by multiple providers may contribute to inconsistent care. Our institution developed a comprehensive evidence-based protocol to standardize the management of CDH infants. This report reviews patient outcomes before and after the implementation of the protocol.

Methods: Retrospective chart review of CDH infants managed with individualized care (preprotocol group, January 1997-December 2001, n = 22) or on the protocol (Protocol group, January 2002-July 2009, n = 47). Survival and other categorical variables were compared by chi(2) analysis, and continuous variables were compared using 1-sided analysis of variance analysis, with significance defined as P < .05.

Results: Survival to discharge was significantly greater in the Protocol group (40/47; 85%) than the preprotocol group (12/22; 52%; P = .006), although mean gestational age, mean birth weight, and expected survival were not statistically different between the 2 groups. The use of supportive therapies, including high-frequency jet ventilation, inhaled nitric oxide, and extracorporeal life support, was similar between groups as well.

Conclusions: Since the implementation of a management protocol for infants with CDH, survival has improved significantly compared with expected survival and preprotocol controls. Reduction in the variability of care through use of an evidence-based protocol may improve the survival of CDH infants.

Publication types

  • Comparative Study

MeSH terms

  • Administration, Inhalation
  • Clinical Protocols*
  • Extracorporeal Circulation / methods
  • Female
  • Follow-Up Studies
  • Gestational Age
  • Hernia, Diaphragmatic / physiopathology
  • Hernia, Diaphragmatic / therapy*
  • Hernias, Diaphragmatic, Congenital*
  • High-Frequency Ventilation / methods
  • High-Frequency Ventilation / standards
  • Humans
  • Infant, Newborn
  • Male
  • Nitric Oxide / administration & dosage
  • Practice Guidelines as Topic
  • Quality Assurance, Health Care / statistics & numerical data*
  • Reproducibility of Results
  • Retrospective Studies


  • Nitric Oxide