REAL AND APPARENT MORTALITY FROM CONGENITAL DIAPHRAGMATIC-HERNIA

Some 50 cases of congenital diaphragmatic hernia (CDH) born in the aut hors' regional referral area over the 14 years from 1980 to 1993 were reviewed, contrasting 7 years when management included preoperative ve ntilatory stabilization with the preceding 7 when urgent surgery was p erformed. Six children experienced no respiratory distress and suffere d no mortality. For infants with respiratory distress in the first 6 h of life, ventilatory stabilization improved survival rates of those w ho reached the surgical centre from 45 per cent between 1980 and 1986 to 59 per cent between 1987 and 1993. A larger proportion of the total number of patients, however, continued to die without reaching the su rgical centre. The improvement in survival rate based on the true inci dence of CDH was from 28 per cent in the first period to 38 per cent i n the second. The apparent poor survival rate of patients born in cent ral obstetric units compared with those born in peripheral units (37 v ersus 75 per cent) can be attributed to patient selection; a larger nu mber of children born in central units were transferred for surgery (7 0 versus 57 per cent). There is no evidence that paediatricians have a ltered their referral practice to include prolonged ventilation outsid e the surgical unit since delayed surgery was advocated. Assessment of the impact of altering the management of CDH cannot be made without k nowing the number of patients who die before transfer to a neonatal su rgical unit. Any serious attempt to reduce the mortality rate of CDH m ust be directed to neonates who are not presently referred to the surg ical service.