Many of you will know that I am responsible for the inhaled NO systematic review in the Cochrane database.  One part of that review examines the data for iNO use in infants with diaphragmatic hernia. Unfortunately there were only about 80 babies with diaphragmatic hernias for whom we could find data. That is the data from the Ninos CDH trial, and the CDH stratum of Clark’s trial. Among this small number of babies there was no evident benefit of iNO, in fact a few more of the iNO treated babies ended up on ECMO than the controls, but given the small numbers that could just be chance.

A new publication (Campbell BT, Herbst KW, Briden KE, Neff S, Ruscher KA, Hagadorn JI. Inhaled Nitric Oxide Use in Neonates With Congenital Diaphragmatic Hernia. Pediatrics. 2014;134(2):e420-e6) reports iNO use among over 1700 babies with CDH. More than half of them received iNO at some point, and it was very variable between hospitals, ranging from 34% to 92% of their CDH babies receiving iNO.

The question now is, is that wrong? What is the right proportion? Should it be 0? My own practice is not to use iNO routinely in babies with CDH, given the data that we have, but that the data are so limited, that I would rather try iNO if a baby is approaching ECMO criteria. So rather than starting iNO fairly early in most babies with pulmonary hypertension, I start it prior to calling the ECMO team. I don’t know if that is right, and we probably treat more than 34% and less than 92% of our CDH babies with iNO.