ARTICLE

A Clinical Prediction Rule for the Severity of

Congenital Diaphragmatic Hernias in Newborns
AUTHORS: Mary Elizabeth Brindle, MD, MPH,a Earl Francis
Cook, ScD,b Dick Tibboel, MD, PhD,c Pamela A. Lally, MD,d
and Kevin P. Lally, MD, MSc,d on behalf of the Congenital
Diaphragmatic Hernia Study Group
aDepartment of Surgery, University of Calgary, Calgary, Alberta,
Canada; bDivision of General Internal Medicine and Primary Care,
Brigham and Womens Hospital, Boston, Massachusetts;
cErasmus MCSophia Childrens Hospital, Rotterdam,
Netherlands; and dDepartment of Pediatric Surgery, Utah Health
Medical School and Childrens Memorial Hermann Hospital,
Houston, Texas

KEY WORDS
clinical prediction, congenital diaphragmatic hernia, populationbased, survival

WHATS KNOWN ON THIS SUBJECT: Predicting high-risk

populations in congenital diaphragmatic hernia (CDH) can help
target care strategies. Prediction rules for infants with CDH often
lack validation, are aimed at a prenatal population, and are of
limited generalizability. We cannot currently discriminate the
highest risk neonates during the crucial period shortly after
birth.
WHAT THIS STUDY ADDS: This clinical prediction rule was
developed and validated on an international database. It
discriminates patients and high, intermediate, and low risk of
mortality; is easy to apply; and is generalizable to most infants
with CDH.

ABBREVIATIONS
CDHcongenital diaphragmatic hernia
CDHSGCongenital Diaphragmatic Hernia Study Group
Dr Brindle conceptualized and designed the study, and drafted
the initial manuscript; Dr Cook provided guidance with the
statistical design of the study, analyses, and interpretation of
the data and critically reviewed the manuscript; Dr Tibboel
assisted with interpretation of data and manuscript revisions;
Dr P. Lally coordinated and supervised data collection in the
Congenital Diaphragmatic Hernia Study Group database,
provided insight and feedback in terms of interpretation of the
data, and critically reviewed the manuscript; and Dr K. Lally
provided oversight in terms of study design and interpretation
and critically reviewed and revised the manuscript. All authors
approved the nal manuscript as submitted.
www.pediatrics.org/cgi/doi/10.1542/peds.2013-3367
doi:10.1542/peds.2013-3367
Accepted for publication May 15, 2014
Address correspondence to: Mary Elizabeth Brindle, MD, MPH,
2888 Shaganappi Trail NW, Calgary, AB T3B6A8 Canada. E-mail:
[email protected]
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright 2014 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no nancial relationships relevant to this article to disclose.
FUNDING: This study was funded by the Alberta Childrens
Hospital Foundation Professorship.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated
they have no potential conicts of interest to disclose.

abstract
BACKGROUND: Congenital diaphragmatic hernia (CDH) is a condition
with a highly variable outcome. Some infants have a relatively mild
disease process, whereas others have signicant pulmonary hypoplasia and hypertension. Identifying high-risk infants postnatally may
allow for targeted therapy.
METHODS: Data were obtained on 2202 infants from the Congenital
Diaphragmatic Hernia Study Group database from January 2007 to October 2011. Using binary baseline predictors generated from birth
weight, 5-minute Apgar score, congenital heart anomalies, and chromosome anomalies, as well as echocardiographic evidence of pulmonary hypertension, a clinical prediction rule was developed on
a randomly selected subset of the data by using a backward selection
algorithm. An integer-based clinical prediction rule was created. The
performance of the model was validated by using the remaining data in
terms of calibration and discrimination.
RESULTS: The nal model included the following predictors: very low
birth weight, absent or low 5-minute Apgar score, presence of chromosomal or major cardiac anomaly, and suprasystemic pulmonary hypertension. This model discriminated between a population at high risk
of death (50%) intermediate risk (20%), or low risk (,10%). The model
performed well, with a C statistic of 0.806 in the derivation set and 0.769 in
the validation set and good calibration (Hosmer-Lemeshow test, P = .2).
CONCLUSIONS: A simple, generalizable scoring system was developed
for CDH that can be calculated rapidly at the bedside. Using this model,
intermediate- and high-risk infants could be selected for transfer to
high-volume centers while infants at highest risk could be considered
for advanced medical therapies. Pediatrics 2014;134:e413e419

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e413

Congenital diaphragmatic hernia (CDH)

is a condition that is associated with
signicant morbidity and mortality as
well as a proportionately high cost to
the health care system.1 The overall
survival of infants with this condition is
highly variable,26 as is their care, although the standardization of postnatal care has evolved over the years.7
This is illustrated by the dramatic differences in survival between infants
undergoing patch repair compared
with those amenable to primary repair.8,9 A method to identify these highand low-risk infants in the postnatal
period but early in the course of their
disease would offer the opportunity to
tailor therapies based on severity. Unfortunately, such a model has been
elusive. A well-constructed clinical
predictive rule can stratify these
infants into populations at high and low
risk of death. This method would aid in
the identication of infants who might
benet from transfer to high-volume
centers. In addition, identication of
those infants at the greatest risk of
mortality will help select an appropriate target population for trials and
targeted therapies.
Prediction rules have previously been
developed to predict outcomes for
infants with CDH within the Congenital
Diaphragmatic Hernia Study Group
(CDHSG) database and others. Many of
these models have been developed in
small populations, are difcult to apply,
and suffer from a lack of validation, poor
discrimination, or poor generalizability.1013 The aim of the present study was
to create and validate a generalizable
and easily applied clinical prediction
rule to determine infants at high, intermediate, and low risk of death by
using simple clinical parameters as
well as echocardiographic measures of
pulmonary hypertension.
Methods
Data were acquired from the CDHSG, and
institutional review board approval was

e414

attained (University of Calgary institutional review board, ethics no. 20776).

The CDHSG data set is an international,
disease-specic registry including 59
centers across 10 countries goal is to
include all neonates with the diagnosis
of CDH from the time of diagnosis to
discharge. Data are entered manually
and cross-checked for accuracy. Missing
data points are queried back to the
center for availability; inconsistent data
points are queried for accuracy. Data
are reported back to the center periodically for center quality assurance and
validation. The total data set comprises
.7000 subjects. Beginning in January
2007, data were collected regarding echocardiographic measures of pulmonary
hypertension.
We reviewed the data on patients entered into the database between January 2007 and October 2011. Data elds
include those variables that would be
available at the time of rst echocardiogram. These consist of demographic
information and known neonatal predictors of mortality, including gestational age, birth weight, Apgar score,
inborn/outborn status, major cardiac
anomalies (classied as all anomalies
other than patent foramen ovale or
patent ductus arteriosus), chromosomal anomalies, and gender; also included were features pertaining to the
diaphragmatic defect such as side of
defect and prenatal liver position. In
addition, measures of pulmonary hypertension estimated on the rst
echocardiogram were included (echocardiogram was performed at a mean
of 0.7 day of life in the data set). Specically, presence of right to left
shunting through a patent ductus
arteriosus or estimates of pulmonary
pressures were used. Echocardiographic measures of pulmonary hypertension were recoded to create
composite measures, combining similar predictors as a binary variable. We
created a binary variable of high pul-

BRINDLE et al

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monary pressure in which this pressure was dened as right to left

shunting or pulmonary pressures estimated as higher than systemic pressure reecting previously described
echocardiographic denitions of pulmonary hypertension.14
Potential predictors were recoded into
binary variables based on appropriate
clinical cutoffs established a priori or
by the median measure of the variable
to create a clinical prediction rule that
is easily applied. A total of 12 potential
predictor variables were generated.
The data set was divided into 2 groups
by using a computerized 1-to-1 randomization process. One group was
designated as a derivation set for developing the prediction model and the
other was a testing or validating set. The
crude distributions of baseline predictors for those who did and did not die
were examined through univariate
analysis. These were not used to determine entrance into the clinical predictive model, which was generated by
using all potential predictors.
Variables that had .5% of data points
missing were recreated as indicator
variables comprising a value for
missing and included within logistic
regression analysis performed on the
derivation set. Selection of the manner
in which variables would be included in
the analysis was made depending on
the predictiveness of missingness
within the model and how that could be
interpreted in a clinical context.
A logistic regression with a backward
elimination algorithm was performed
to create a prediction model with
a signicance level of 0.01 for exclusion.
Presence or absence of severe pulmonary hypertension was forced into the
model. This model was developed on the
derivation population and tested on the
validation population. The performance
of this model in identifying those
patients at high risk of death was tested
by comparing the frequency of death

ARTICLE

before discharge in the population

believed to be at high risk (.50% risk of
mortality) as well as those estimated at
very high risk of death according to the
prediction model (.75% risk) in both
derivation and validation models. The
calibration of the model was further
assessed by using the Hosmer-Lemeshow
goodness-of-t test. Discrimination of the
model was evaluated through assessment of the area under the receiver
operating curve (C statistic). Further
assessment of the degree of optimism of
the model was obtained through crossvalidation. The model was restricted to
those infants having data on echocardiographic measures of pulmonary hypertension. Including an outcome measure of
missing for all variables during model
creation assessed the impact of missing
data.
Based on the signicant coefcients in
the clinical predictive model, an equation was created dividing all coefcients by the lowest signicant
coefcient and rounding to the closest
whole integer. These were used to
provide a score for individual patients within the derivation group. Based
on the range of scores and mortality
rates for these infants, low-, intermediate-,
and high-risk categories were created
based on the total score, and the
ability for this score to predict outcome was evaluated in the validation
group.

RESULTS
Infants in the CDHSG database have
a mortality rate of 28%. They are generally term infants with a median gestational age of 38 weeks and a median
birth weight of 3.00 kg. Associated
cardiac anomalies are uncommon
(28%), and major cardiac anomalies
and chromosomal anomalies are rare
(8.3% and 4.6%, respectively).
With the exception of the side of the CDH
defect, baseline characteristics of
infants with CDH who died were sig-

nicantly different from those who did

not die (Table1). Neonatal factors associated with increased mortality on
crude univariate analysis included low
birth weight, prematurity, low Apgar
score at 5 minutes, presence of major
congenital heart disease, and chromosomal abnormalities. In addition,
the prenatal location of liver in the
chest and increased measures of pulmonary hypertension were all associated with increased mortality in crude
univariate analyses.
Logistic regression was performed
within the derivation data set, including all variables with those having
signicant missing data transformed
into indicator variables with a value for
missingness. This analysis identied
that missing data were predictive of
mortality for 5-minute Apgar score,
prenatal liver position, and echocardiographic ndings. Missingness for
gestational age was not associated
with mortality. The liver position variable was removed from the analysis
entirely, and the analysis was restricted to those patients with an
echocardiogram performed and those
with gestational age recorded. Fiveminute Apgar score was recoded as
a nominal variable with 3 measures
(high, low, or missing) and included in
the analysis.
The backward elimination algorithm
with a signicance of 0.01 for exclusion
identied 6 predictors of mortality: low
birth weight, low measured 5-minute
Apgar score, the lack of a 5-minute
Apgar score, the presence of major
cardiac anomalies, the presence of
chromosomal abnormalities, and the
presence of signicant pulmonary hypertension (Table 2). This prediction
model demonstrated good discrimination based on the area under the receiver operating curve (C statistic,
0.806 in the derivation model and 0.769
in the validation model) (Table 3). The
model was also found to be good at

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discriminating between those population at low, intermediate, and high

risk of death (Table 4).
The model demonstrated good calibration as indicated by the HosmerLemeshow goodness-of-t test (P =
.217) (Table 3). Cross-validation provided an estimation of optimism of the
model of 0.065 for the C statistic, which
is similar to the 0.037 found in the difference between the derivation and
validation model.
The CDH scoring equation was created
as described earlier by using all predictors with signicant coefcients. All
coefcients were then divided by 2.634
(the coefcient of low birth weight) to
obtain the following equation:
1low birth weight 1 1:031low Apgar
1 1:77missing Apgar
1 1:55severe pulmonary hypertension
1 1:98major cardiac anomaly
1 1:49chromosomal anomaly

By rounding to the nearest integer, the

following nal equation was created,
with a possible range of 0 to 8:
1low birth weight 1 1 low Apgar
1 2missing Apgar
1 2 severe pulmonary hypertension
1 2major cardiac anomaly
1 1chromosomal anomaly
5total CDH score

This score resulted in identication of

infants at low, intermediate, and high
risk of death (,10%, 25%, or 50%)
based on the total score (0, 12, or
$3). The distribution of scores was
decided based on their performance in
the derivation group (Table 5). The
discrimination of this simplied model
still performed well, as similar mortality predictions were found within the
validation group (Table 4). The C statistic demonstrated fair discrimination
of the points-based model with a value
of 0.721.
e415

TABLE 1 Baseline Characteristics of Infants With CDH Who Did and Did Not Die (N = 2022)
Baseline Characteristics
Male
Prenatal diagnosis present
Liver in the chest on prenatal US
Outborn
Major cardiac abnormality present
Chromosomal abnormality present
Other anatomic abnormality present
Median gestational age at birth, wk
Preterm (,37 wk GA)
Median birth weight, kg
Low birth weight (,1500 g)
Nonleft-sided defect
Median 5-min Apgar score
Low Apgar score (,7)
Presence of severe pulmonary hypertension on rst
echocardiogramb

All Patients
(N = 2022)

No. Missing
Data

Patients Who
Died (n = 561)

Patients Who Did

Not Die (n = 1456)

P Valuea

1264 (62.7)
1343 (66.8)
709 (44.3)
1101 (54.5)
168 (8.31)
94 (4.7)
351 (17.4)
38 (3739)
424 (23.4)
3.00 (2.603.38)
417 (20.8)
337 (16.7)
7 (68)
692 (37.0)
682 (39.4)

10
16
421
6
5
5
5
208
208
21
21
8
151
155
292

327 (58.5)
450 (80.5)
170 (77.3)
262 (46.7)
102 (18.2)
60 (10.7)
143 (25.5)
38 (3539)
181 (35.6)
2.71 (2.203.15)
203 (36.7)
103 (18.4)
6 (47)
310 (61.8)
285 (63.6)

933 (64.2)
888 (61.4)
539 (39.0)
839 (57.7)
66 (4.5)
34 (2.3)
208 (14.3)
38 (3739)
243 (18.6)
3.09 (2.723.42)
214 (14.8)
233 (16.0)
8 (69)
382 (28.0)
397 (31.0)

,.0001
,.0001
,.0001
,.0001
,.0001
,.0001
,.0001
,.0001
,.0001
,.0001
,.0001
.20
,.0001
,.0001
,.0001

Data are presented as n (%) or median (interquartile range). GA, gestational age; US, ultrasound.
a For all binary comparisons, Fishers exact test was performed; for continuous variables, the Wilcoxon rank sum tests were applied.
b Right to left shunt or estimate of suprasystemic pulmonary pressures on echocardiogram.

TABLE 2 OR for Mortality of Predictors in Derivation Model (Backward Elimination P = .01 for
Inclusion)
Baseline Characteristic
Male
Prematurity (,37 wk)
Low birth weight (,1500 g)
Outborn
Nonleft-sided defecta
5-min Apgar score
Low Apgar score (,7)
Unable to obtain Apgar score
First echocardiogram
Severe pulmonary hypertensionb
Major cardiac anomaly
Chromosomal abnormality

Adjusted OR (95% CI)

P Value

2.634 (1.7224.029)

,.0001

2.718 (1.8733.945)
4.678 (2.4229.036)

,.0001
,.0001

4.073 (2.8375.846)
5.220 (2.7919.761)
3.928 (1.6109.584)

,.0001
,.0001
,.0001

CI, condence interval; OR, odds ratio.

a Right-sided or bilateral.
b Severe pulmonary hypertension (right to left shunt or suprasystemic pulmonary pressures estimated).

DISCUSSION
We developed a validated clinical prediction rule that identies infants at
low, intermediate, and high risk of death
at the time of the rst echocardiogram.
Given the international scope of this database and the range of participating
institutions, this model will likely perform well in most infants with CDH.
There is considerable value in a prediction rule that can help identify populations at high risk for mortality.
Prenatal imaging holds promise for
prediction in many studies but is inconsistently available, and results suffer
e416

from poor reliability across centers.1518

There are many postnatal studies that
look at the factors associated with
mortality in CDH, but there are few
clinical prediction models for CDH.
A prediction model was developed from
the CDHSG in 2001 containing the 5minute Apgar score and birth weight.13
Although this model performed well
when validated by using a separate
data set,11 the performance of this
original model is inferior to the current
model in its discriminatory abilities
and is somewhat more cumbersome to
apply despite having only 2 variables.

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Schultz et al10 developed a clinical

prediction model based on blood gas
analysis. This model discriminated between a population with a 66% survival
and a population with an 83% survival.
Although the model performed well in
the initial validation study, it did not
perform well in further validation
studies.11 The rule we have developed
has been validated, and it performs
well in terms of discrimination and
calibration. It identied infants within
different risk strata and is applied by
using a points-based system.
There are a number of statistical elements that should be recognized when
constructing and interpreting a clinical
prediction rule. Variables in a clinical
prediction rule do not need to be and
are frequently not independent. There
may also be interaction between variables that are not apparent in the application of the rule. These factors do
not impact the performance of the
constructed model but are important to
recognize if the results were to be
further extrapolated.
Generalizability of predictive equations
is often greatly inuenced by available
data. Many infants do not have a 5minute Apgar score within the CDHSG

ARTICLE

TABLE 3 Comparison of CDH Mortality Risk Model Performance in Derivation and Validation
Groups
Derivation Model
Performance measures of model comparing derivation and
validation groups
AIC
Goodness of t (Hosmer and Lemeshow)
C statistic (area under curve)
Difference in C statistic
Estimation of optimism of model
Cross-validation

Validation
Model

773.969
7.0469 (P = .217) DF = 5
0.806

855.721
0.769
0.037 (3.7%)

C statistic = 0.758
Difference in C statistic=
0.065

AIC, Akaike Information Criterion: 2LogL + 2(#regression coefcients).

TABLE 4 Risk Score and Survival in Derivation and Validation Sets

Derivation set
Died
Lived
Validation set
Died
Lived

0 (Low Risk, %)

12 (Intermediate Risk, %)

38 (High Risk, %)

11 (4.0)
267 (96.0)

78 (23.2)
259 (76.8)

131 (58.5)
93 (41.5)

19 (6.6)
268 (93.4)

90 (24.9)
271 (75.1)

116 (48.7)
122 (51.3)

TABLE 5 Distribution of Survival by Total Risk Score in Derivation Set

Died, (%)
Lived, (%)

11 (4.0)
267 (96.0)

33 (21.7)
119 (78.3)

45 (24.3)
140 (75.7)

76 (55.1)
62 (44.8)

40 (60.6)
26 (39.4)

11 (68.8)
5 (31.2)

4 (100)
0

data set. This absence is likely due to the

fact that infants without an Apgar score
at 5 minutes are being resuscitated or
intubated. The absence of an Apgar
score might predict poor outcome,
a nding that we have demonstrated.
Apgar scores are a standard part of the
neonatal evaluation. The reasons why
infants are missing Apgar scores within
this data set are likely similar to other
data sets from comparable populations. Rather than eliminate patients
with no 5-minute Apgar score from our
predictive model (a decision that would
limit the generalizability of the model to
those infants who were relatively stable
within the rst minutes of life), we have
included the absence of Apgar score as
an independent predictor.
We were particularly interested in investigating the predictive value of echocardiographic data, and 292 (14.4%)

patients were missing data on this variable. We have limited the application of
this rule to infants who have undergone
echocardiographic evaluation. It is likely
that those infants missing data on
echocardiographic estimates of pulmonary hypertension are systematically
different from those with echocardiographic data. By restricting the applicability of the clinical prediction rule to
those with echocardiographic data, we
have likely eliminated a population that is
at higher risk of mortality. This suggestion is supported by the subset analysis,
which revealed that those patients
missing echocardiographic data had
a mortality rate of 38.7%.
There are a number of limitations to this
study. We created this clinical prediction
rule from the CDHSG database, which is
the largest CDH-specic database in
existence. However, the CDHSG is a vol-

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untary database rather than a registry,

and it therefore may not reect the true
population of infants with CDH. In addition, in this registry, there is no standardized method of reporting variables
such as echocardiographic measures of
pulmonary hypertension, and thus there
is likely signicant variability between
centers. For simplicity, we created binary
variables for our predictors, which
produce a model that is easy to apply but
loses some of its accuracy. One binary
predictor created is that of pulmonary
hypertension. This variable includes the
presence of ductal shunting or relies on
a reported estimation of pulmonary pressures without a standardized method
of measurement prescribed. This method
may lead to inaccuracies and variability
but including right to left shunting
through the patent ductus arteriosus as
well as estimations of suprasystemic
pressure is likely to reect the population of infants with the highest pulmonary pressures.14 Because the
echocardiographic measures were frequently attained in the rst 24 hours, it
could be anticipated that the residual
effects of fetal circulation might diminish the signicance of early echocardiogram ndings. Although we did
nd echocardiographic measures to be
predictive in our model, an echocardiogram performed at a later time frame
may have a greater predictive value.
We have included missingness of the
5-minute Apgar score as a predictive
variable within our rule. Although this
factor has proven to be a robust predictor within our validation set, we assumed that the reasons for missing an
Apgar score would be similar for patients on whom we will apply this model,
which may not always hold true.
Prenatal predictors offer great promise in
terms of determining prognosis. In developing our model, it was clear that
prenatal liver position was highly predictive of mortality but was very poorly
reported within the CDHSG data set.
e417

Patients missing these data also had

higher mortality. Clinical prediction rules
integrating prenatal predictors have not
currently been developed, although many
studies have been performed that demonstrate the value of prenatal predictors
such as lung to head ratio,19 MRI estimations of lung volumes,20 and liver position.21 With advancements in prenatal
imaging, a prenatal scoring system could
help direct clinical care pathways for the
fetus as well as the neonate. However,
more consistent application and reporting
of prenatal imaging would be required to
make such a model generalizable. In the
interim, it should be left to the judgment of
the clinician on how to incorporate ndings such as prenatal liver position
depending on institutional practice and
the reliability of that measure.
The variation in care across institutions
is a limitation of the CDHSG data set.
However, a prediction rule generated
from this data set has greater generalizability because it reects the current, variable population on whom it
will be applied.

We have developed a clinical predictive

rule that allows for identication of
a large population of infants that can be
successfully managed at low-volume
centers closer to their families. In the
validation population of 886, almost
one-third (n = 287) were identied in
a low-risk group with a mortality rate
of ,10%. In countries with a large
geographic area, smaller centers will
frequently be the rst hospitals that
manage infants with CDH. Increasingly,
there is a recognition that centers with
larger volumes may have improved
outcomes in CDH.2,2224 The burden on
the family and health care system that
would be involved in the transfer of all
patients with CDH to high-volume centers could be diminished through
identication of a population with
a lower risk of mortality that can be
cared for in smaller volume institutions; those at higher risk could then be
considered for transport to those
centers with greater expertise. This
practice is already accepted in many
European countries.

This rule also identies a very high-risk

population that can be targeted in
practice guidelines and clinical trials.
These are the patients for whom the
greatest benets are likely to be
achieved in directed therapies. In smallvolume clinical trials, methods of
targeting studies to those patients at
highest risk increases the likelihood
that a true benet will be detected as
well as diminishing the cost and unnecessary exposure of a low-risk population
to experimental therapies.

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Surg. 1984;19(6):666671
Mohseni-Bod H, Bohn D. Pulmonary hypertension in congenital diaphragmatic hernia. Semin Pediatr Surg. 2007;16(2):126
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Reiss I, Schaible T, van den Hout L, et al;
CDH EURO Consortium. Standardized postnatal management of infants with congenital diaphragmatic hernia in Europe: the
CDH EURO Consortium consensus. Neonatology. 2010;98(4):354364
Brindle ME, Brar M, Skarsgard ED; Canadian Pediatric Surgery Network (CAPSNet).
Patch repair is an independent predictor of
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Lally KP, Lally PA, Lasky RE, et al; Congenital
Diaphragmatic Hernia Study Group. Defect
size determines survival in infants with
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rics. 2007;120(3). Available at: www.pediatrics.org/cgi/content/full/120/3/e651

Schultz CM, DiGeronimo RJ, Yoder BA;
Congenital Diaphragmatic Hernia Study
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Baird R, MacNab YC, Skarsgard ED; Canadian Pediatric Surgery Network. Mortality
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hernia. J Pediatr Surg. 2008;43(5):783787
Numanoglu A, Morrison C, Rode H. Prediction of outcome in congenital diaphragmatic hernia. Pediatr Surg Int. 1998;
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Keller RL, Tacy TA, Hendricks-Munoz K, et al.
Congenital diaphragmatic hernia: endothelin-1,
pulmonary hypertension, and disease severity.

Standardized timing and methods of

performing echocardiography may
signicantly improve the role of this
powerful diagnostic test in predicting
patient risk. Further validation of this
model within an external population
will be of benet in future studies.

ACKNOWLEDGMENTS
The authors acknowledge Dr Shimon
Sheykevich, who provided statistical
programs used in the analyses, and
the many centers that participate in
the CDHSG.

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A Clinical Prediction Rule for the Severity of Congenital Diaphragmatic Hernias

in Newborns
Mary Elizabeth Brindle, Earl Francis Cook, Dick Tibboel, Pamela A. Lally and Kevin
P. Lally
Pediatrics 2014;134;e413; originally published online July 14, 2014;
DOI: 10.1542/peds.2013-3367
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright 2014 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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A Clinical Prediction Rule for the Severity of Congenital Diaphragmatic Hernias

in Newborns
Mary Elizabeth Brindle, Earl Francis Cook, Dick Tibboel, Pamela A. Lally and Kevin
P. Lally
Pediatrics 2014;134;e413; originally published online July 14, 2014;
DOI: 10.1542/peds.2013-3367

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
/content/134/2/e413.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2014 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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