We previously advised on the perinatal and surgical management of newborns during the COVID-19 pandemic. Not only for the prevention and control of COVID-19, but also to promote the orderly diagnosis and treatment of neonatal surgical diseases, including routine diagnosis and treatment, child transport and emergency surgical management (Figs. 1, 2, 3). In the present study, we collected data from all CDH patients treated in our hospital during the COVID-19 outbreak and investigated the impact of the outbreak on the treatment of children with CDH.
Children with CDH often have pulmonary hypertension and respiratory failure after birth, with an overall mortality rate of 31–38%;[1, 8, 9] thus, immediate medical support and treatment after birth are essential for their survival. For CDH patients who met the surgical indications, our center continued to perform surgery as usual. During the pandemic (2020–2021), 41 children with a prenatal diagnosis of CDH were admitted to our center, an increase of 24.2% compared with 33 children before the pandemic (2018–2019), indicating that we did not reduce our medical activities due to the pandemic. There was no significant difference in patient age at admission between the two groups before and after the pandemic, indicating that after the strict implementation of the transfer procedure, the time of transfer to our hospital did not increase, and the treatment of these children was not delayed. None of the children transferred to our center developed SARS-CoV-2 infection, suggesting that the process of transferring the children from the maternity hospital to the children’s hospital did not increase the risk of SARS-CoV-2 infection.
There was no statistically significant difference between the two groups (NTG and STG) of CDH children in terms of the lesion site (left and right sides), the size of the defect, liver herniation, the presence of a hernia sac and whether a patch was used during the operation, indicating that the pandemic and the related prevention and control measures did not reduce or delay the treatment of critically ill patients in our center. The postoperative recurrence rate of CDH is 3%-26%,[10, 11] and the recurrence rate after MIS (minimally invasive surgery) is higher than that of open surgery. The postoperative recurrence rate in all children in the STG was 7.3%, and that of children in the STG who underwent thoracoscopic surgery was 6.1%. There were no significant differences in surgical approach, overall and postoperative survival rate and recurrence rate between the two groups. These data indicated that the implementation of pandemic prevention and control measures did not change the choice of surgical method for CDH in our center, and did not have an adverse impact on the prognosis of this population.
In order to improve the survival rate of children with CDH, since 2019, a method of fetal resuscitation by endotracheal intubation and mechanical ventilation before clamping the umbilical cord through EXIT has been adopted. A total of 6 patients underwent EXIT in 2018–2019 and 29 patients underwent EXIT in 2020–2021. The survival rates of the two groups were 83.3% (5/6) and 82.8% (24/29), respectively, and the difference was not statistically significant. No maternal complications, such as severe bleeding (blood loss ≥ 500 ml) and wound infection, or fetal complications related to EXIT occurred in the 35 patients who received EXIT treatment. These results showed that the pandemic did not cause additional risks to puerpera and fetuses receiving this new treatment method.
Due to the need for surgical procedures and indwelling central lines, prolonged mechanical ventilation, and nutritional deficiencies, infants with CDH are at increased risk of nosocomial infection.[13, 14] A previously published study shows that a diagnosed BSI is one factor that predicts mortality or prolonged length of stay. In this study, the incidence of nosocomial infection, length of stay and total medical expenses of hospitalized patients in the STG were significantly higher than those of patients in the NTG; further analysis found that the total intubation time, length of stay and cost of children with nosocomial infection were higher than those in the nosocomial infection-free group. It was shown that the occurrence of nosocomial infection is associated with prolonged hospital stay. These data are similar to existing research results. The prolonged hospital stay and additional costs for the treatment of infection led to an increase in the total cost, but the survival rate and recurrence rate of infected patients were not significantly different to those of patients without infection. Due to changes in medical expense pricing rules and medical insurance reimbursement policies in 2019–2020 in Beijing, the total hospitalization expenses for children admitted before and after that time changed accordingly. Based on our past experience, the actual cost burden of patients should be reduced as the proportion of national medical insurance reimbursement increases. However, the precise extent of the effect of insurance policy changes and infections is unclear, and more data are needed to clarify this issue.
This study was based on the analysis of real-world data from a single center, which may have led to some bias. Secondly, the results of our efforts during the pandemic have yet to be confirmed with longer follow-up times. In addition, the severity of the pandemic, public health resources, and cultural background vary from region to region, and some of our recommendations and methods may not be applicable to all regions.
In conclusion, our study showed that it is safe and feasible to treat children with CDH during COVID-19 when measures are put in place to reduce the risk of infection for patients and health care workers. Routine treatment and appropriate exploration of new therapies do not affect the outcome of children and do not increase the risk of SARS-CoV-2 infection for patients and medical staff. The incidence of nosocomial infection in children with prenatally diagnosed CDH admitted to hospital during the pandemic period is high, which deserves vigilance by clinicians. We hope that this study will be useful for physicians concerned with CDH.