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Prevalence and perinatal risk factors of growth retardation in congenital diaphragmatic hernia survivors

BMC Pediatrics volume 25, Article number: 295 (2025) Cite this article

Abstract

Background

Growth retardation (GR) is one of the major morbidities in congenital diaphragmatic hernia (CDH). This study aimed to investigate the prevalence and perinatal risk factors of growth failure in CDH survivors.

Methods

We retrospectively reviewed the medical records of isolated CDH patients with gestational age ≥ 35 weeks who survived to 3 years of age. Weight and length(height) were measured at 1 year, 2 and 3 years of age. GR was defined when the Z-score of weight or height was below − 2.0. We analyzed and compared the prenatal and clinical characteristics, including anthropometric data, fetal lung volume measurement, and treatment modalities during initial hospitalization, between the GR group and the non-GR group.

Results

Of the 116 patients with isolated CDH, 86 patients survived to NICU discharge (74.1%). A total of 77 patients who survived 3 years of age with follow-up growth parameters available were included in the study analysis. The rates of GR at 1 year, 2 and 3 years of age was 15.6% (12/77), 14.3% (11/77), and 23.4% (18/77) respectively. Patients with GR at any of the three time points were classified into the GR group (20/77, 26%). Compared with the non-GR group, GR group had lower weight at birth. The incidence of systemic corticosteroid use, mostly with hydrocortisone, were greater in the GR group than the non-GR group. The parameters that indicate disease severity, including observed-expected lung-to-head ratio, liver herniation, inhaled nitric oxide use, ECMO, patch repair did not differ between the two groups. Multivariate analysis revealed that low birthweight and systemic corticosteroid use were associated with increased odds of GR. Cumulative corticosteroid exposure was associated with impaired height growth, particularly during the first two years.

Conclusion

For the first 3 years of age, GR was observed a significant portion of CDH survivors. Early identification of high-risk patients and targeted interventions, including minimizing corticosteroid exposure and optimizing nutritional support, may improve growth outcomes in this vulnerable population.

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Introduction

The overall survival rate of congenital diaphragmatic hernia (CDH) has significantly improved over the past decades. This advancement is attributed to postnatal management strategies such as gentle ventilation, the appropriate use of extracorporeal membrane oxygenation (ECMO), and advances in surgical techniques [1]. As survival rates for CDH have increased, attention has shifted toward addressing long-term morbidities among survivors [2]. Among these morbidities, growth failure is an early concern, with potentially profound implications such as cognitive impairment, decrease in pulmonary function, and reduced overall quality of life [3, 4].

Previous studies have reported the incidence of growth retardation (GR) in CDH survivors with a range of 8.2% to 68.8% at one year of age [5,6,7]. This wide range is due to variability in disease severity and differences in treatment strategies among institutions and time periods. The pathophysiology of GR in CDH is considered multifactorial but remains elusive [2]. Factors such as acute catabolic stress during neonatal period, feeding problems due to gastroesophageal reflux or oral aversion, and increased caloric requirements resulting from respiratory morbidities seem to contribute to growth failure in a complex interplay.

Some studies have shown that GR can extend into childhood and adolescence beyond infancy [7,8,9]. The relationship between stunted growth and poor neurodevelopment is well-established in preterm and term infants [10, 11]. Early interventions may be needed to aid catch-up growth in CDH patients. Therefore, this study aimed to investigate the recent prevalence of GR and perinatal risk factors associated with GR in CDH survivors during early childhood at the age of 1 to 3 years.

Methods

Study participants

We retrospectively reviewed the medical records of CDH patients with gestational age ≥ 35 weeks who survived to 3 years of age. Patients born between January 2014 and March 2020 and admitted to Asan Medical Center, Seoul, Korea, which serves as a tertiary referral center for neonatal care were included. Patients with major congenital anomalies, Morgagni hernia, or diaphragmatic eventration were excluded. Patients without follow-up data up to 3 years of age were also excluded from the study. Ethical approval was obtained from the Institutional Review Board of Asan Medical Center (No. 2023 − 1286).

Data collection

Anthropometric data, including weight and length were collected at (1) 1 year, (2) 2 years, and (3) 3 years of age. These measurements were converted into Z-scores based on the World Health Organization Child Growth Standards. GR was defined as a weight or length Z-score below − 2.0 at any of the three assessment points (1, 2, or 3 years). We chose to define the GR group as infants who met growth faltering criteria at any point up to 3 years to capture the dynamic nature of growth in CDH survivors.

We extracted data on prenatal and clinical characteristics including gestational age, birth weight, sex, Apgar scores, delivery method, presence of liver herniation, and laterality of diaphragmatic defect. Observed-to-expected lung-to-head ratios (O/E LHR) were calculated by expert obstetricians as previously described [12]. In brief, O/E LHR values were obtained in the second and/or third trimesters of pregnancy and manual tracing method to delineate the lung boundaries at the level of the four-chamber view of the heart was employed.

Clinical interventions during initial hospitalization, such as the use of inhaled nitric oxide (NO), ECMO, patch repair, high frequency oscillatory ventilation, any inotropes, systemic corticosteroid were collected. Cumulative dose of corticosteroids was calculated based on the equivalent dose of hydrocortisone for various steroid regimens, including dexamethasone and methylprednisolone. Postnatal variables such as tube feeding at discharge, length of hospital stay, duration of mechanical ventilation, home oxygen therapy at discharge, medication for pulmonary hypertension and bronchopulmonary dysplasia (BPD) status were collected.

Postnatal treatment protocol for CDH

Postnatal management protocol including ventilator strategies, ECMO protocol and surgical repair for infants with CDH in our center was previously described [12]. Inotropes were used to treat hypotension and pulmonary hypertension. The use of hydrocortisone was at the attending physician’s discretion, generally prescribed for refractory hypotension but there were instances when it was routinely initiated from the 1st day of life. Dexamethasone or methylprednisolone was occasionally administered to facilitate weaning from ECMO or mechanical ventilators.

Statistical analysis

The study population was divided into two groups based on the presence of GR (GR group) and those without (non-GR group). We compared the clinical variables of between the GR group and the non-GR group. Comparisons between the groups were made using chi-square tests for categorical variables and independent t-tests or Mann-Whitney U tests for continuous variables, as appropriate. Multivariate logistic regression analysis with variable selection was performed to identify perinatal risk factors associated with GR. Variables with a p-values below 0.1 in the univariate logistic regression analysis were used in a multivariable logistic regression analysis. To evaluate the goodness-of-fit of each logistic regression model, we performed Hosmer-Lemeshow tests, considering p > 0.05 to indicate adequate fit. A dose-response relationship between cumulative corticosteroid exposure and GR was analyzed using generalized linear mixed model with logit link. Separate analyses were conducted for weight retardation (Z-score <-2) and height retardation (Z-score <-2). The corticosteroid dosage was treated as a continuous variable, and its association with the likelihood of GR was evaluated at 1, 2, and 3 years of age. A p-value of < 0.05 was considered statistically significant. All statistical analyses were conducted using SAS V9.4 (SAS, Cary, NC).

Results

Of the 116 patients diagnosed with isolated CDH, 86 patients (74.1%) survived to discharge from neonatal intensive care unit. A total of 77 patients who survived to 3 years of age with available follow-up growth parameters were included in the analysis (Fig. 1).

Fig. 1
figure 1

Flowchart of the study population. CDH = congenital diaphragmatic hernia, GA = gestational age, NICU = neonatal intensive care unit

Full size image

The mean gestational age and birthweight were 38.3 ± 1.1 weeks, 2986.4 ± 475.8 g, respectively. There were 43 (56%) males in the study cohort. ECMO was applied in 10.4% and inhaled NO was used in 29.9% of the study population, respectively. Systemic corticosteroids were used in 35% (27/77) of survivors. Hydrocortisone (n = 26) was the predominantly used corticosteroid regimen, followed by dexamethasone (n = 4) and methylprednisolone (n = 1).

GR was identified in 15.6% (12/77) at 1 year of age. At 2 and 3 years of age, the rate of GR was 14.3% (11/77) and 23.4% (18/77), respectively. Patients with GR at any of the three time points were classified into the GR group (20/77, 26.0%).

The baseline characteristics and comparative analyses between the GR group and non-GR group are shown in Table 1. Compared with the non-GR group, GR group had lower body weight at birth. A greater proportion of patients in the GR group were treated with systemic corticosteroids during initial hospitalization (55.0% vs. 28.1%). The parameters that indicate disease severity including O/E LHR, liver herniation, inhaled NO use, ECMO treatment, need for patch repair, and duration until full enteral feeding did not differ between the two groups. The rates of BPD at postnatal day 30, use of pulmonary hypertension medication at discharge, duration of mechanical ventilation, and the need for home oxygen therapy at discharge did not differ between the two groups.

Table 1 Baseline characteristics of the GR group vs. the non-GR group in congenital diaphragmatic hernia
Full size table

In univariate analysis, birth weight, length at birth, small for gestational age and use of systemic corticosteroids were associated with GR. Multivariate analysis revealed that low birthweight (< 2.5 kg) and use of corticosteroids were associated with increased odds of GR (Table 2). As shown in Supplemental Table 1, steroid use was significantly associated with GR at 1 year, whereas low birth weight remained a significant predictor throughout 3 years. The growth trajectories during the first 3 years were compared to patients who exposed to systemic corticosteroids versus those not exposed (Fig. 2). At 1 year of age, the systemic corticosteroid-treated group demonstrated significantly lower weight Z-scores compared to the non-treated group. This difference diminished over time, with no significant differences observed at 2 and 3 years of age. Similarly, the systemic corticosteroid-treated group showed significantly lower height Z-scores at 1 year of age. However, no significant differences in height Z-scores were observed at 2 and 3 years. We investigated the dose-response relationship between the corticosteroid exposure and the risk of GR for weight and height. The cumulative dose of corticosteroids was significantly associated with delayed linear growth, as demonstrated in the risk of height Z-scores < -2 measured at 1 year and 2 years of age. However, there was no significant association between the cumulative dose of corticosteroids and weight over the first 3 years (Table 3).

Table 2 Univariate and multivariate analysis of risk factors associated with growth retardation in congenital diaphragmatic hernia
Full size table
Fig. 2
figure 2

Growth trajectories of weight and height Z-scores over 3 years in steroid-treated and non-treated CDH survivors. (A) Weight Z-scores: Boxplots of weight Z-scores at 1, 2, and 3 years. Steroid-treated patients (light gray) had significantly lower Z-scores at 1 year of age compared to non-treated patients (dark gray) (p = 0.006), with no significant differences at 2 and 3 years of age. (B) Height Z-scores: Boxplots of height Z-scores at 1, 2, and 3 years. Steroid-treated patients had significantly lower Z-scores at 1 year of age (p = 0.016), with no significant differences at 2 and 3 years of age. Boxes represent the interquartile range, horizontal lines indicate medians, and whiskers extend to 1.5 times the interquartile range

Full size image
Table 3 Logistic regression model examining the relationship between the cumulative dose of corticosteroid and the growth outcome until 3 years of age
Full size table

Discussion

This study provides insights into the recent prevalence and perinatal risk factors associated with growth failure in survivors with CDH. Our data indicate a significant 26% incidence of GR among CDH survivors during early childhood, up to 3 years of age.

The prevalence of GR in CDH survivors has been variably reported in the literature, with discrepancies likely attributable to differences in patient populations, management protocols, and different definitions of GR. Previous studies, including CDH survivors born between 2000 and 2011 and defining GR as Z-score below − 2, have reported GR prevalence rates ranging from 8.2 to 28.6% at 1 or 2 years of age [5, 9, 13]. Our study found a similar incidence of GR to previous studies, indicating that GR remains a significant and persistent issue among CDH survivors during early childhood.

The association of GR with low birth weight observed in this study is consistent with previous studies [5, 13]. Low birth weight has been well-documented as a predictor of poorer growth outcomes [14]. The causes of GR may involve a complex interplay of neonatal morbidities, suboptimal nutritional intake, and factors that contribute to intrauterine growth restriction. Likely in preterm infants, low birth weight acts as a risk factor for chronic respiratory morbidity in CDH, which might affect weight gain and growth velocity during early childhood [15]. Although our study excluded cases with non-hernia-related anomalies, i.e., non-isolated CDH, the presence of intrauterine growth restriction and/or postnatal GR in our study cohort does not entirely exclude the possibility of an underlying genetic anomaly. Advanced genetic diagnostic techniques, such as whole exome sequencing, can identify a significant portion of pathogenic variants even in fetus with CDH without apparent associated anomalies, some of which are linked to intrauterine growth restriction [16].

Prematurity is a well-known risk factor for GR [17]. Although we excluded infants born before 35 weeks’ gestation, approximately 14% of our cohort were born at late-preterm (35–36 weeks). Notably, these late-preterm births occurred 2.5 times more frequently in the GR group than in the non-GR group, suggesting that even moderate prematurity may adversely influence postnatal growth. We selected a 35-week threshold to focus on near-term and term infants managed under our center’s standardized protocols, minimizing heterogeneity introduced by more premature births.

In the present study, key perinatal indicators of disease severity in CDH, such as requirement for ECMO, did not reveal a significant difference between the GR and non-GR groups. This finding contrasts with our initial expectations and a long-term follow-up study extending up to 12 years of age, where ECMO-treated CDH survivors exhibited more pronounced growth stunting and poor weight gain compared to non-ECMO-treated counterparts [7]. The lack of clear association between ECMO and GR in our study may be attributed to variations in the study period, and differing management protocols across study centers. It is noteworthy that our study reported a lower ECMO rate of approximately 10% among CDH survivors, which may reflect lower disease severity or differences in ECMO indications and survival rates. Recognizing that patients on ECMO face more difficulties in feeding achievement and increased energy expenditure compared to their non-ECMO counterparts, these factors may contribute to potential nutritional deficiencies and GR, in addition to the underlying severe pulmonary hypoplasia. In CDH, fetal lung volume is associated with respiratory morbidities during early infancy [18] and later in early childhood [19]. Chronic inflammation and increased work of breathing can lead to increased metabolic demands and compromised nutritional status, contributing to GR in childhood [8, 20]. Our study, however, did not conclusively demonstrate a clear association between fetal lung volume, measured by O/E LHR, and GR, although there was a trend toward a higher rate of tube-feeding dependency at discharge.

In our study, early steroid exposure was significantly associated with GR in CDH survivors, particularly manifesting as delayed weight gain and height growth during infancy. This novel finding highlights the complexity of growth potential in CDH survivors, which can be influenced by hemodynamic instability and treatment-related factors including the administration of corticosteroid during early neonatal period. In children, long-term steroid use typically induces GR through various mechanisms, such as suppression of growth hormone, interference with bone formation, and muscle loss [21, 22]. However, studies investigating the impact of early postnatal steroid exposure on subsequent GR are scarce. Consistent with our findings, a retrospective study tracking preterm infants born at less than 32 weeks of gestational age up to four years of age found that patients exposed to corticosteroid exhibited delayed weight gain and height growth during the first year compared to the non-GR group, with no differences observed thereafter [23]. This suggests that while early steroid use may temporarily affect growth, its effects do not persist beyond infancy. A recent report has raised concerns about a notable increase in the proportion of children weighing less than 10th percentile at the age of 5 among infants born at term after antenatal steroid exposure [24]. Evidence regarding the clinical significance of adrenal insufficiency in CDH, or the potential survival benefits of hydrocortisone therapy is lacking [25, 26]. Therefore, our study suggests the need for new criteria for early steroid use in CDH patients at potentially high risk of GR, regardless of their term birth status.

The greater impact of cumulative corticosteroids on height compared to weight in CDH survivors can be attributed to their suppression of chondrocyte proliferation at growth plates and disruption of the growth hormone-insulin like growth factor-1 axis, both of which are essential for linear bone growth [21, 22]. In contrast, weight recovery is more responsive to nutritional support once steroid treatment is discontinued [23]. This highlights the vulnerability of skeletal growth to early glucocorticoid exposure and underscores the need for cautious steroid use to minimize its long-term impact on height during critical growth periods.

In our cohort, only 7.8% of CDH survivors were discharged on tube feeding, which is lower than previously reported rates of 20–32% [27, 28]. The reason for this lower rate of tube-feeding dependence is unclear, but it may reflect our institution’s emphasis on pre-discharge oral stimulation therapy and feeding consultations, enabling earlier transition to full oral feeds. While tube feeding helps prevent inadequate nutrition, we found no significant difference in discharge tube-feeding rates between patients with and without GR.

In this study, we found no correlation between short-term respiratory morbidities and growth outcomes. While the relationship between growth and the severity of respiratory morbidities in preterm infants is well established, research on the interaction between growth and respiratory outcomes in CDH survivors is limited [29]. Terui et al. identified a correlation between home oxygen therapy and poorer growth outcomes in CDH survivors [13]. However, this correlation was not evident in our study, which included only four cases of home oxygen therapy.

There are several limitations to this study. The retrospective single-center study design and the potential for missing data inherent to such studies may affect the generalizability of the results. The follow-up period of three years, the most critical period for catch-up growth, while reflecting early growth patterns, may not fully capture the growth trajectory into later childhood and adolescence. Moreover, the lack of detailed post-discharge data including home feeding practices and evolving respiratory status, may have impacted the assessment of growth outcomes. Finally, the individual impact of different steroid regimen on growth outcome could not be assessed due to the small sample size of CDH survivors exposed to dexamethasone therapy.

In conclusion, our study reaffirmed the significant prevalence of GR among CDH survivors during early childhood, emphasizing the importance of early and targeted interventions to prevent GR, such as minimizing early corticosteroid use and implementing aggressive nutritional support.

Data availability

No datasets were generated or analysed during the current study.

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Authors and Affiliations

  1. Department of Pediatrics, Asan Medical Center Children’s Hospital, University of Ulsan College of Medicine, Seoul, Korea

    Soo Hyun Kim, Sung Hyeon Park, Ha Na Lee, Jiyoon Jeong, Euiseok Jung & Byong Sop Lee

  2. Department of Clinical Epidemiology and Biostatistics , University of Ulsan College of Medicine, Seoul, Korea

    Jungbok Lee

  3. Department of Pediatric Surgery, Asan Medical Center Children’s Hospital, University of Ulsan College of Medicine, Seoul, Korea

    Hyunhee Kwon & Jung-Man Namgung

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  1. Soo Hyun Kim
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Contributions

SH Kim, SH Park, HN Lee, and J Jeong contributed to the acquisition of data. J Lee performed statistical analyses and contributed to data interpretation. H Kwon, E Jung, and J-M Namgung provided clinical insights and supervised the data collection process. BS Lee conceptualized and supervised the study. SH Kim and BS Lee drafted the manuscript. All authors critically reviewed and approved the final manuscript for submission.

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Correspondence to Byong Sop Lee.

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Kim, S.H., Park, S.H., Lee, H.N. et al. Prevalence and perinatal risk factors of growth retardation in congenital diaphragmatic hernia survivors. BMC Pediatr 25, 295 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12887-025-05631-7

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BMC Pediatrics

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