Snapshot A newborn infant girl is evaluated 2 hours after birth for signs of trouble breathing. The patient was born via an uncomplicated vaginal delivery at 39 weeks of gestation to a 32-year-old mother. The girl's APGAR scores were 9 at 1 minute of life and 10 at 5 minutes after delivery, with a score of 2 for respiration with a vigorous cry at both time points. Her temperature is 96.9°F (36.1°C), pulse is 168/min, and respirations are 58/min. On physical examination, the patient's point of maximal impulse is markedly displaced to the right and lung sounds are absent on the left side. A chest radiograph is obtained and shown in the image. Introduction Overview a congenital diaphragmatic hernia occurs due to congenital defects in the diaphragm, causing bowel to protrude through the diaphragm into the thorax Epidemiology Incidence 1 in 3000 newborns Demographics 90% of patients present in the neonatal period or within 1 year of age Location commonly presents on the left posterolateral side ETIOLOGY Pathophysiology muscular entities and pleuroperitoneal membrane of the diaphragm fail to develop normally diaphragm develops between 4-12 weeks of gestation Bochdalek hernia failure of pleuroperitoneal membrane closure in utero causes a defect in the posterior attachment of the diaphragm Morgagni hernia failure of formation of the anteromedial portion of the diaphragm, where the septum transversum and the anterior-inferior thoracic wall intersect results in displacement of bowel into the thorax Presentation Symptoms dyspnea and/or respiratory distress cyanosis occurs within the first 24 hours of life if neonatal onset chest tightness or fullness Physical exam ↓ breath sounds on the affected side bowel sounds in the thorax displaced point of maximal impulse cyanosis scaphoid abdomen due to herniation of abdominal contents into thorax Imaging Chest radiograph findings bowel and stomach are present in the chest cavity shifting of the mediastinum to one side Treatment Medical resuscitation with ventilatory support indications respiratory distress modalities conventional mechanical ventilation high-frequency oscillatory ventilation (HFOV) ECMO (extracorporeal membrane oxygenation) indications reserved for patients who fail to improve with both conventional mechanical ventilation and HFOV nasogastric tube for decompression Surgical surgical repair of the hernia definitive treatment Complications Small bowel obstruction risk factors late-presenting congenital diaphragmatic hernia in neonates left-sided hernia associated with ↑ bowel complications (liver protects from herniation on the right side) adhesions from surgical repair of hernia treatment surgery for small bowel obstruction repair