Department of Audiology, Speech and Learning, Children's Hospital Colorado. (Aurora, CO), Boulder, CO 80309, USA.
University of Colorado, Department of Psychiatry. (Aurora, CO), Boulder, CO 80309, USA.
J Pediatr Surg. 2021 Nov;56(11):1949-1956. doi: 10.1016/j.jpedsurg.2021.02.015. Epub 2021 Feb 19.
To identify factors associated with gastrostomy tube (GT) placement in infants with congenital diaphragmatic hernia (CDH).
Retrospective cohort study of 114 surviving infants with CDH at a single tertiary care neonatal intensive care unit from 2010-2019. Prenatal, perinatal and postnatal characteristics were compared between patients who were discharged home with and without a GT. Prenatal imaging was available for 50.9% of the cohort. Logistic regression was used to assess the association between GT placement and pertinent clinical factors. ROC curves were generated, and Youden's J statistic was used to determine optimal predictive cutoffs for continuous variables. Elastic net regularized regression was used to identify variables associated with GT placement in multivariable analysis.
GT was placed in 43.9% of surviving infants with CDH. Prenatal variables predictive of GT placement were percent predicted lung volume (PPLV) <21%, total lung volume (TLV) <30 ml, lung-head ratio (LHR) <1.2 or observed to expected LHR (O/E LHR) <55%. Infants who required a GT were diagnosed earlier prenatally (23.6 ± 3.4 vs. 26.4 ± 5.6 weeks). Patients whose stomach was above the diaphragm on prenatal ultrasound (up) had a higher odds of GT placement compared to those with stomachs below the diaphragm (down) position by a factor of 2.9 (95% CI: 1.25, 7.1); p = 0.0154. Postnatally, infants with GT had lower Apgar scores at 1 and 5 min, longer lengths of stay and higher proportion of flap closures. Infants with a type C or D defect and extracorporeal membrane oxygenation (ECMO) were associated with increased odds of needing a GT. Postnatal association included being NPO for >12 days, need for transpyloric (TP) feeds for >10 days, >14 days to transition to a 30 min bolus feed, presence of gastro-esophageal reflux (GER), chronic lung disease and pulmonary hypertension. In multivariable analysis, duration of NPO, time to TP feeds, transition to 30 min bolus feeds remained significantly associated with GT placement after adjusting for severity of pulmonary hypertension (PH), GER diagnosis and sildenafil treatment.
Identification of risk factors associated with need for long-term feeding access may improve timing of GT placement and prevent prolonged hospitalization related to feeding issues.
Level II (Retrospective Study).
确定与先天性膈疝（CDH）婴儿胃造口管（GT）放置相关的因素。
对 2010 年至 2019 年在单一三级新生儿重症监护病房存活的 114 例 CDH 婴儿进行回顾性队列研究。比较出院时带和不带 GT 的患者的产前、围产期和产后特征。该队列的 50.9%有产前影像学检查。使用逻辑回归评估 GT 放置与相关临床因素之间的关联。生成 ROC 曲线，并使用 Youden 的 J 统计量确定连续变量的最佳预测截断值。使用弹性网络正则化回归在多变量分析中识别与 GT 放置相关的变量。
43.9%的 CDH 存活婴儿放置了 GT。预测 GT 放置的产前变量包括预计肺容积百分比（PPLV）<21%、总肺容积（TLV）<30ml、肺-头比（LHR）<1.2 或观察到的预期 LHR（O/E LHR）<55%。需要 GT 的婴儿在产前诊断更早（23.6±3.4 周 vs. 26.4±5.6 周）。产前超声胃在上（UP）的患者与胃在下（DOWN）的患者相比，GT 放置的几率更高，为 2.9 倍（95%CI：1.25，7.1）；p=0.0154。在产后，GT 婴儿在 1 分钟和 5 分钟时的 Apgar 评分较低，住院时间较长，瓣口关闭比例较高。具有 C 型或 D 型缺损和体外膜氧合（ECMO）的婴儿需要 GT 的几率增加。产后相关性包括禁食>12 天、经幽门（TP）喂养>10 天、过渡到 30 分钟推注喂养>14 天、存在胃食管反流（GER）、慢性肺病和肺动脉高压。多变量分析表明，在调整肺动脉高压（PH）严重程度、GER 诊断和西地那非治疗后，禁食时间、TP 喂养时间、过渡到 30 分钟推注喂养时间与 GT 放置仍显著相关。
确定与长期喂养途径相关的危险因素可能有助于改善 GT 放置的时机，并防止与喂养相关的住院时间延长。
II 级（回顾性研究）。
