Aftermath of failed diagnosis of late-presenting congenital diaphragmatic hernias.

A congenital posterolateral diaphragmatic (Bochdalek) hernia generally presents with symptoms within a day after birth. This article reports on 3 children whose hernias produced symptoms for the first time beyond a week of age. One 3-year-old child died acutely with symptoms resembling that of a tension pneumothorax. In 2 children symptoms only developed at 12 and 23 days of age. They were initially thought to have lower lobe pneumonias and delayed diagnosis led to the death of one. Although the late presentation of a congenital posterolateral diaphragmatic hernia is rare, it is important to recognise it because with appropriate therapy all such children should have a normal life expectancy, whereas unsuspected hernias in older children carry a mortality that is even worse than that of neonatal cases. The first requisite for the diagnosis of a congenital diaphragmatic hernia (CDH) is a high index of suspicion. Cystic lesions or masses in the lower lung fields should suggest the possibility of a CDH with herniated abdominal content at any age. Congenital diaphragmatic hernias should be included in the differential diagnosis of apparent lower lobe pneumonias in all children below a month of age.