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Background Studies reporting on penetrating thoracic trauma in the pediatric population have been limited by small numbers and implied differences with the adult population. Our objectives were to report on a large cohort of pediatric patients presenting with penetrating thoracic trauma and to determine age-related impacts on management and outcome through comparison with an adult cohort. Methods A Level I trauma center registry was queried between 2006 and 2012. All patients presenting with penetrating thoracic trauma were identified. Patient demographics, injury mechanism, injury severity, admission physiology, and outcome were recorded. Patients were compared, and outcomes were analyzed based on age at presentation, with patients 17 years or younger defining our pediatric cohort. Results A total of 1,423 patients with penetrating thoracic trauma were admitted during the study period. Two hundred twenty patients (15.5%) were pediatric, with 205 being adolescents (13-17 years) and 15 being children (≤ 12 years). In terms of management for the pediatric population, tube thoracostomy alone was needed in 32.7% (72 of 220), whereas operative thoracic exploration was performed in 20.0% (44 of 220). Overall mortality was 13.6% (30 of 220). There was no significant difference between the pediatric and adult population with regard to injury mechanism or severity, need for therapeutic intervention, operative approach, use of emergency department thoracotomy, or outcome. Stepwise logistic regression failed to identify age as a predictor for the need for either therapeutic intervention or mortality between the two age groups as a whole. However, subgroup analysis revealed that being 12 years or younger (odds ratio, 3.84; 95% confidence interval, 1.29-11.4) was an independent predictor of mortality. Conclusion Management of traumatic penetrating thoracic injuries in terms of the need for therapeutic intervention and operative approach was similar between the adult and pediatric populations. Mortality from penetrating thoracic trauma can be predicted based on injury severity, the use of emergency department thoracotomy, and admission physiology for adolescents and adults. Children may be at increased risk for poor outcome independent of injury severity. Level of evidence Epidemiologic study, level III.

Herein is reported case of an otherwise healthy full-term infant girl who presented with numerous spontaneous intestinal perforations with congenital absence of intestinal muscularis mucosae and muscularis propria. Few other cases are reported in the English literature with varying presentations. We review those cases, theories of pathogenesis, embryology, and possible connections to various clinical presentations.

Purpose Loss of pigment epithelium–derived factor (PEDF), a potent inhibitor of angiogenesis, has been linked to progression of angiogenesis-dependent diseases. We postulated that decreased levels of endogenous PEDF in the kidney creates a tumor permissive environment for Wilms' tumor. Methods Fresh and frozen Wilms' tumor (n = 28), adjacent (n = 3), and normal kidney (n = 8) were immunostained and graded. The Wilms' tumor cells (SK-NEP-1), renal epithelial cells (NRK-52), and fresh tumor samples were grown in culture. Condition media were collected and analyzed by an in vitro angiogenesis assay and Western blot. The SK-NEP-1 cells were treated with PEDF and cell viability assessed. Results Wilms' tumors expressed less PEDF than normal and adjacent kidney. Pigment epithelium–derived factor protein secretion was abundant in NRK-52 cells but significantly decreased in Wilms' tumor. Pigment epithelium–derived factor acted as blockade to angiogenesis and it had a dose-dependent cytotoxic effect on Wilms' tumor epithelial cells. Conclusion Renal tubular epithelial cells are a rich source of PEDF in the normal kidney. Reduced levels of PEDF in Wilms' tumor remove a critical endogenous renal barrier to angiogenesis and tumor cell survival. Therapeutic replacement of PEDF may prove to be an effective strategy to combat Wilms' tumor progression.

Pigment epithelium-derived factor (PEDF), a potent endogenous inhibitor of angiogenesis, is highly expressed in the kidney. The authors postulated that systemic administration of PEDF would decrease Wilms' tumor growth in a xenograft model, and increased renal vascularity would result in a mouse null for PEDF.Tumors were induced in athymic mice using human anaplastic Wilms' tumor cells. Purified PEDF protein or vehicle was administered for 7 days beginning 2 to 3 weeks after inoculation. Tumors were stained with anti-PEDF and anti-Factor VIII antibodies. Mitoses and microvascular density (MVD) were counted per high-power field (hpf). PEDF-null mice were generated on a SV129/C57Bl6 background. Wild-type and null kidneys were assessed for MVD.Mean tumor weight in the 2-week group was 60% less than controls (P.05). The MVD and mitotic count in treated tumors were significantly less than controls (P.05). PEDF stained strongly in normal kidneys but was minimal to absent in Wilms' tumor. PEDF-null kidneys had increased MVD compared with wild-type (P.05).PEDF is expressed strongly in normal murine kidney, and loss of its angioinhibitory activity may contribute to pathologic angiogenesis in Wilms' tumor. Systemic PEDF suppresses WT growth by targeting both the tumor cells and its associated vasculature.

This statement is intended for health care professionals caring for neonates (preterm to 1 month of age). The objectives of this statement are to: 1. Increase awareness that neonates experience pain;2. Provide a physiological basis for neonatal pain and stress assessment and management by health care professionals;3. Make recommendations for reduced exposure of the neonate to noxious stimuli and to minimize associated adverse outcomes; and4. Recommend effective and safe interventions that relieve pain and stress.

A brief overview of extracorporeal membrane oxygenation and its use in infants and children is presented. The history, selection, operative procedure, daily management and complications are discussed. The international results are shown.

Ostomies are placed in children for different indications than in the older population. Many ostomies of childhood are placed because of congenital or neonatal problems that require temporary or long-term diversion to stabilize the neonatal patient. Necrotizing enterocolitis, the most common reason for placement of neonatal colostomies and ileostomies, is increasing in frequency as more prematurely born infants survive. Recently, there has been an increase in treatment of various biliary hypoplasia syndromes with biliary cutaneous diversion. Children with biliary hypoplasia syndromes are a challenging group of patients who frequently can be helped by ostomies. This article reviews current information on biliary cutaneous diversion for the biliary hypoplasia syndromes and intestinal diversion for necrotizing enterocolitis.

Three years ago we noted that the literature on physicians' refusal to provide requested treatment was sparse1. Since that time the issue has fueled an intense, two-pronged debate -- on futility and on the limits of patient autonomy. The debate over patient autonomy is a genuinely philosophical dispute; that over futility seems to be a relapse into nominalism. It is not the meaning of a word but the moral basis for the actions of the participants that ought to be the focus of our attention. The fractious debate on the meaning of futility, evidenced in a spate of recent . . .

We describe a case of a 3-year-old girl with Klippel-Trenaunay syndrome who presented with an enlarging abdominal mass caused by a serous borderline tumor of the fallopian tube. This case is notable for the rarity of this neoplasm in a premenarchal patient as well as the association with this syndrome. We briefly review these entities and the significance of malignancy in Klippel-Trenaunay syndrome.

Extracorporeal membrane oxygenation (ECMO) has been used for 20 years in neonates and children with cardiac and respiratory failure. The number of neonates treated with ECMO has increased exponentially, but the number of older children treated is small. The selection and exclusion criteria for pediatric ECMO are poorly defined, and the results vary because of variable selection criteria and institutional experience with the technique. In order to help define the role of pediatric ECMO, we reviewed our experience in nonneonatal pediatric respiratory failure. We have treated 22 patients ranging in age from 1 to 105 months and ranging in weight from 3 to 35 kg. Eighteen patients met the criteria for adult respiratory distress syndrome, two had respiratory scyncytial virus pneumonia, and one had severe barotrauma complicating the management of reactive airway disease. All patients were considered by the referring institutions and by us to be failing conventional management as evidenced by hypoxia, hypercarbia, excessive ventilatory pressures, or progressive barotrauma. All were considered likely to die with continued conventional management. Sixteen of the 22 patients had complications (73%), but half of the last 10 patients had no complications. Hemorrhagic complications occurred in 12 patients. Mechanical complications included membrane failure, raceway rupture, pump malfunction, and improper cannula positioning. Other complications included culture-proven infection and renal failure. Eleven of the 22 patients survived (50%); nine of the last 12 survived (75%). These results suggest that ECMO may be a useful technique in selected pediatric patients with respiratory failure. Survival and complication rates improve as experience with the technique increases.

The case of an 18-month-old male who underwent a right hepatic lobectomy for hepatoblastoma with extensive involvement of the retrohepatic vena cava is presented. The retrohepatic vena cava was replaced with an expanded polytetrafluoroethylene graft. This graft was proved patent by ultrasonography 2 years after operation. The child has no evidence of recurrent hepatoblastoma. The results of grafting the retrohepatic vena cava have been notoriously poor. It is widely believed that a prosthetic vena cava graft cannot be expected to remain patent. Our experience with polytetrafluoroethylene and previous reports using Dacron and polytetrafluoroethylene have shown that long-term patency of retrohepatic vena cava replacement with synthetic graft can be successful. (J VASC SURG 1990;12:367-70.)

Extracorporeal membrane oxygenation (ECMO), which has been shown to dramatically improve survival in selected neonatal patients, is now being used in some centers for pediatric patients with respiratory and cardiac failure. One of the major concerns with ECMO support is the permanent ligation of the right common carotid artery. We have used ECMO to support 10 pediatric patients with cardiac failure and 22 patients with respiratory failure. Thirty-one were cannulated via the common carotid artery and internal jugular vein on the right. Five of the last six patients with respiratory failure survived. One was on ECMO for 21 days, so the carotid artery was not amenable to repair. In the other four survivors the common carotid artery was reconstructed at the time of decannulation. In one patient, a segment of the artery was resected because of an intimal injury, and a primary anastomosis was performed. In all four, color Doppler studies of the artery prior to discharge were normal. None had clinical evidence of emboli, and a cranial computed tomography (CT) scan was normal in all four patients. These data suggest that in many pediatric patients supported with ECMO, reconstruction of the common carotid artery can be performed with low risk of embolic complications. Long-term follow-up is needed.

Congenital bronchoesophageal fistula is a rare anomaly that normally appears in adult life. Because of a recent case, we reviewed the literature on this lesion. There have been several reviews in the past but none has included all cases. The largest review included only two thirds of the cases (1966). Including our case, the number of reported cases is 100.

BACKGROUND There are two approaches to close gastroschisis. Primary closure (PC) is reduction and fascial closure; silo closure (SC) places viscera in a preformed-silo and reduces the contents over time. We have shifted from PC to SC. This study compared the outcomes of these two techniques. METHODS Records of babies with gastroschisis from 1994-2004 were reviewed. Closure type, ventilator days, days to full-feeds, hospital days, complications, and mortality were recorded. RESULTS Twenty-eight patients underwent PC; 20 patients had SC. Differences in ventilator days, days to full-feeds, and hospital days were not statistically significant. Nine PC patients developed closure-related complications vs. none in SC (P < 0.05). Eight PC vs. two SC patients had non-closure-related complications (P < 0.05). Four PC vs. zero SC patients developed necrotizing enterocolitis (P < 0.05). Five PC vs. one SC patients had ventral hernia (P < 0.05). No patient died. CONCLUSION PC resulted in higher incidence of reclosure, non-closure-related complications, and necrotizing enterocolitis. Consequently, we recommend SC as the preferred treatment.

Aims The optimal surgical treatment for extremely-low-birth-weight (ELBW) neonates with pneumoperitoneum is controversial. This study aimed to identify clinical factors associated with two known causes of pneumoperitoneum-necrotizing enterocolitis (NEC) and spontaneous intestinal perforation (SIP), and assesses the treatment outcome with primary peritoneal drainage (PPD) vs. laparotomy. Methods We reviewed and analyzed clinical characteristics and outcome from records of neonates with pneumoperitoneum treated at our institution from January 1999 to January 2003. Results Forty-six neonates (31 NEC, 15 SIP) were treated with either PPD (20 with NEC, 13 with SIP) or laparotomy (11 with NEC, 2 with SIP). In neonates who underwent PPD, those with NEC (vs. SIP) were less likely to have a patent ductus arteriosus, but were more likely to have been fed, have drains placed later in life, have a subsequent laparotomy, a longer total parental nutrition course, a higher 30-day mortality, and to take more days to begin enteral feeds. Conclusion The etiology of pneumoperitoneum (NEC vs. SIP) in ELBW neonates can usually be determined preoperatively. Neonates with SIP should have a drain placed while those with NEC should undergo laparotomy.

The aim of this study was to determine the prevalence of herbal medication use in the pediatric surgical patient population, because herbal medications can cause major perioperative complications.A questionnaire on all drug use before surgery was given to the parents of 1,100 consecutive pediatric surgical patients operated on at a metropolitan children's hospital between June 14, 2002 and August 14, 2002.Eighty-three percent of the surveys were returned. Twenty-one percent of the parents were herbal medication users, but only 4% of patients utilized herbal medications. An average of 2.4 different herbal medicines were in use by each child, and the most common herbal medications were echinacea, chamomile, and aloe. Forty-two percent of herbal medication-using patients were taking prescription medicines concurrently. Fifteen herbal medications-using patients underwent major surgery, and the average preoperative herbal cessation interval was 3.5 days. Children of parents who were herbal medication users and children reported to have chronic diseases were more likely to use herbal medicines (P.05). Ten percent of parents reported that the surgeon inquired about patient herbal medication use.This is the first report on herbal medication use in the pediatric surgical patient. The prevalence of herbal medication use is significantly higher in children of parents who use herbal medications and children whose parents consider them to be chronically ill. Surgeons need to specifically inquire about the use of herbal medication in their patients to prevent possible harmful interactions and perioperative complications.

Tumor stage and histology are the most important prognostic criteria in Wilms' tumors; however, a subset of patients remains who have favorable histology tumors and unexpectedly relapse. The authors postulated that increased microvascular density (MVD), a hallmark for angiogenesis, could identify patients at risk for relapse.A case-control study was used to compare relapse (n = 15) with nonrelapse tumors (n = 35). Tumor MVD was counted in 5 random high-powered fields (hpf) using anti-Factor VIII antibody and expressed as mean vessel count/hpf +/- SEM. MVD and clinical data were evaluated using univariate analysis and student's t test.The relapse group had higher MVD than the nonrelapse group (34.9 +/- 2.9 v 22.4 +/- 2; P.05). When evaluating the favorable histology (FH) group alone, there was higher MVD in the relapse group (32.4 +/- 2.7 v 19 +/- 1.8; P.05). MVD was found to be the only predictor of relapse when compared with age, sex, tumor weight, and histology.These results suggest that increased MVD can identify Wilms' tumor patients at high risk for relapse, especially those patients with favorable histology tumors. A larger study is warranted to determine the potential utility of MVD in stratification of Wilms' tumor patients.

BACKGROUND Early detection and treatment of acute rejection in cardiac transplant recipients significantly improves long-term survival. Endomyocardial biopsy is used routinely for diagnosing allograft rejection; however, in young children, this procedure carries some risk. We evaluated serum vascular endothelial growth factor (VEGF) as a potential surveillance marker of acute cellular rejection. METHODS Blood samples (n=62) were analyzed from 23 patients and compared with controls (n=18) using an ELISA for VEGF. Results were correlated with endomyocardial biopsy rejection grades. RESULTS Mean baseline VEGF levels of the transplant population were consistently higher than controls. Serum VEGF levels were significantly higher during acute cellular rejection when compared with the non-rejecting transplant group (700.7+/-154 pg/ml vs. 190.5+/-29 pg/ml). VEGF decreased two- to eightfold after immunosuppressive therapy in 9 of 11 rejection episodes. CONCLUSIONS These data suggest that VEGF may play a role in the pathogenesis of acute allograft rejection and it may serve as a reliable serologic surveillance marker.

Background The topical hemostatic effect of fibrin sealant that has been solvent/detergent treated and plasminogen depleted was evaluated in a multicenter prospective, randomized controlled study at the cannulation site wound of infants undergoing extracorporeal membrane oxygenation (ECMO). Methods The test group received standard cauterization and Fibrin sealant, while the control group was given cauterization alone to control hemostasis at this site. Efficacy data were available on 173 randomized study subjects of whom 149 met study entry criteria. All were managed according to standard ECMO practice. Results Fibrin sealant reduced the risk of bleeding, was associated with less shed blood, and was associated with shorter duration of hemorrhage. Further, control infants showed an increased bleeding risk with less depressed fibrinogen levels and prothrombin time elevations >18 seconds prior to ECMO. Conclusion Fibrin sealant is useful as a topical hemostatic agent in patients with coagulopathy not responding to standard surgical techniques.

Background Respiratory failure secondary to a variety of causes remains a significant cause of morbidity and mortality in the pediatric population. Newer therapies are appearing frequently in an attempt to decrease the number of deaths from this disease state. We briefly review the current literature on some of the newer modalities including: high-frequency ventilation, surfactant, liquid ventilation, and nitric oxide. We then present our experience from the past 11 years in the most invasive, yet successful, therapy for acute respiratory failure— extracorporeal membrane oxygenation (ECMO). Methods Retrospective review of all patients treated with ECMO from September 1983 to December 1994 was undertaken. Data were collected from bedside ECMO flow sheets and the standardized data entry forms submitted to the Extracorporeal Life Support Organization. All statistical analyses were performed using a standard statistical software program. Results During the study period, 194 neonates and 47 pediatric patients were treated with ECMO. The survival rate in the neonatal population is 82% and in the pediatric population it is 40%. The neonatal patients required an average of 153 hours of support while the pediatric patients required 220 hours (P = 0.008). Conclusions While the newer treatment modalities discussed may have an important role in treating neonatal and pediatric respiratory failure in the near future, ECMO remains a cornerstone of the modern treatment modalities. Although somewhat invasive, ECMO is effective therapy with increasing survival rates each year.

Extracorporeal membrane oxygenation (ECMO) has been used as a support system for neonates with pulmonary failure since 1975. During ECMO, thermal regulation, pulmonary gas exchange, and cardiac output can be partially or nearly completely provided by the circuit. The presumed resultant decrease in energy requirement has prompted the question of whether infants are in a catabolic or anabolic state of metabolism while on ECMO. Directly measuring the metabolic rate in babies on ECMO is difficult. However, studying the nitrogen balance in these infants may suggest an answer. Nitrogen balance was studied in 21 neonates spanning a single ECMO team's experience at two institutions. Children were studied at the Ochsner Clinic from 1986 to 1990 and at the University of Chicago Wyler Children's Hospital from 1990 to the present. The infants received total parenteral nutrition (TPN) as their only nutritional source during the entire ECMO course. During this time, 24-h urine collections were analyzed for urea nitrogen (UUN). The daily nitrogen balance was calculated by subtracting nitrogen output (estimated as the UUN) from nitrogen input (the measured amino acid content of the intravenous feeding). Fecal losses were not included in the nitrogen output since the infants were not enterally fed and rarely had stools while on ECMO. The kilojoules (1 kilocalorie = 4.2 kilojoules) and protein provided by the parenteral nutrition varied. Nitrogen intake exceeded nitrogen output by ECMO day 2 (the initial nitrogen balance determination). Infants receiving as little as 0.4 g/kg protein and 168 kJ/kg daily remained in positive nitrogen balance.

Thirty infants were diagnosed with extrahepatic biliary atresia (EBA) from July 1978 to July 1989; 28 have undergone a Kasai or Lilly-Altman modification of the Kasai portoenterostomy; 2 were excluded from surgery because they presented after 3 months of age and had advanced biliary cirrhosis. Immediate postoperative drainage (>30 ml/day was achieved in 24 patients (86%), with 14 (50%) surviving free of jaundice. The average follow-up was 2.25 years (range 3 months to 10 years); the longest survivor is 10.3 years old. The overall survival was 64%, and 5-year survival 50%. Of 24 infants operated on at

The leading cause of death in the pediatric population in the United States is trauma. A retrospective review of patients treated with extracorporeal membrane oxygenation (ECMO) for traumatic respiratory failure was performed. Eight children were treated at the Ochsner Medical Foundation and additional data on six children were available from the National Registry. Six children developed respiratory failure as a result of blunt trauma and eight as a result of near drowning. Standard venoarterial ECMO was used with a circuit very similar to that used in neonatal ECMO. Vascular access was via the common carotid artery and the internal jugular vein. Ventilatory support was weaned to minimal settings during ECMO. Central hyperalimentation and systemic antibiotics were used in all of the cases. Four of six children survived in the blunt trauma group; three of eight children survived in the near drowning group. Although significant conclusions cannot be drawn from a small group of patients the average pre-ECMO PO2 for survivors was 87 mm Hg, whereas for nonsurvivors the average PO2 was only 46 mm Hg. Ventilatory support for both groups was not remarkably different, and the average PCO2 was lower in the nonsurvivor group. The cause of death in this group of patients is usually multisystem organ failure. In the four patients treated at Ochsner who did not survive, all had positive blood cultures and presumed systemic sepsis. ECMO has been demonstrated to be very successful in neonatal respiratory failure. Predicting mortality and morbidity in pediatric respiratory failure has been more difficult.(ABSTRACT TRUNCATED AT 250 WORDS)

Oropharyngeal teratomas are rare congenital neoplasms that distort orofacial anatomy and often cause respiratory embarrassment at birth. Immediate management of such lesions should include establishment of a secure upper airway, radiographic exclusion of midline central nervous system anomalies, and early surgical excision to prevent asphyxia or permanent disfigurement. Perioperative assessment and surgical management are reported for three oropharyngeal teratomas.

The leading cause of death in the neonatal period is respiratory failure, and extracorporeal membrane oxygenation (ECMO) is an effective means of improving survival in select patients. Only neonates with severe hypoxia and acidosis are treated with ECMO. To determine the developmental outcome of the neonates we supported with ECMO, we reviewed the records of all our patients who are at least 6 months of age. The results of follow-up assessment were available for 57 patients and growth parameters were available for 43 patients. Examinations were done at 6 to 48 months (mean, 22.1). Growth parameters showed that 14% of the patients were below the tenth percentile for height and weight while 16.3% were below the tenth percentile for head circumference. Twenty-four patients were evaluated using the Bayley Scales of Infant Development consisting of a Mental Developmental Index (MDI) and a Psychomotor Developmental index (PDI). Normal scores (>84) were obtained in 75% on the MDI and in 88% on the PDI. Only two patients (8%) scored less than 85 on both portions. Twelve patients were evaluated using the McCarthy Scales of Children's Abilities. The mean score was 95 and nine patients (75%) had scores greater than 85. The Gessell was used to evaluate six patients and five were normal. The Denver Developmental Screening Test was used to evaluate 23 patients and all passed. The results of neurologic examination were documented in 57 patients. One patient had severe spastic quadriplegia with cerebral palsy. The neurological examination was normal in the other patients. Only one of 57 patients is profoundly delayed (2%) and 45 (79%) are normal. These results suggest that ECMO can be used in severe neonatal respiratory failure with normal developmental outcome in most patients. Severe developmental delay is unusual in patients treated with ECMO and it may be related to hypoxia and acidosis before ECMO.

The incidence of conjoined twins is approximately 1/100,000 births and 70% of the twins are female.’ Approximately 40 to 60% of conjoined twins are stillborn and an additional 35% survive only 1 day. These early deaths generally occur in the most severely malformed twins, especially those with thoracopagus joining and major cardiopulmonary malformation. Approximately 35% of the twins are the omphalopagus type, which comprises a wide spectrum ranging from shared liver, intestines and bladder to a mere skin bridge.* We report the anatomical findings and separation of the eighteenth reported case of minimally conjoined omphalopagus twins.3

Respiratory failure is the leading cause of death in the neonatal period. The anatomic and functional basis for this, particularly in full-term infants, most often is persistent pulmonary hypertension of the neonate (PPHN). This condition is reversible but can cause very severe and unrelenting respiratory failure and ultimate death when uncontrolled. Recent technologic advances have expanded the scope of therapy available for PPHN, resulting in increasing therapeutic success for these critically ill infants. This article reviews the anatomic and functional anomalies of PPHN, as well as the methods of diagnosis and discusses current treatment.

When animals breathed a mixture of cold helium-oxygen, while also exposed to it, their rectal temperature fell three times faster than when they were exposed to cold nitrogen-oxygen mixture. In further studies using a special chamber, the addition of helium to the inspired air and to the ambient air, promoted faster cooling than when helium was used in the inspired air alone or in the ambient air alone, demonstrating that helium can be used to regulate body temperature, when the gas temperature is controlled by a heat exchanger. Temperature regulation with helium may be useful for pediatric anesthesia, treatment of malignant hyperthermia, induction of hypothermia in neonatal cardiac surgery, and for resuscitation of hypothermic neonates.

This report describes four children with polysplenia syndrome seen in our hospital during the past year. Each had gastrointestinal abnormalities as their predominant problem, and two presented with gastrointestinal duplications not previously reported with this syndrome.

Thirty infants with congenital diaphragmatic hernia (CDH) who required therapy within the first day of life were treated in our institution over the past 3 years. Eighteen of these infants were not treated with extracorporeal membrane oxygenation (ECMO). Survival in this group was 83%. Twelve infants were treated with ECMO. Seven (58%) were weaned from ECMO and ventilator support with six (50%) long-term survivors. Minimum preoperative alveolar-arterial oxygen gradient (AaDO 2 ), maximum postoperative mean airway pressure (MAP), and pulmonary hypoplasia were evaluated. Bohn et al have prospectively shown that the relationship of PaCO 2 to mechanical ventilatory requirements accurately predicted survival in a group of 58 infants with CDH in whom ECMO was not a therapeutic option. This criteria would predict nonsurvival in all 12 of our patients treated with ECMO, including the seven survivors. Differences between our ECMO and non-ECMO groups were statistically significant for all three criteria. All P values P r =.03, P =.02). We conclude that the maximum postoperative MAP is an accurate predictor of survival in the treatment of CDH and can be correlated with the degree of pulmonary hypoplasia. Most deaths, however, are the result of persistent pulmonary hypertension of the newborn (PPHN) with right-to-left pulmonary shunting refractory to medical management. ECMO will provide a viable therapeutic option for infants with CDH who would otherwise not survive the neonatal period. ECMO should be considered for any infant failing conventional therapy because there is not enough data at this time to predict which infants cannot be salvaged with this modality.