In young infants under 6 months, plication should be performed after verification of the diagnosis. We developed an algorithm for these patients (Fig. 52.2) (Joho-Arreola et al. 2005). In our institution, we used a thoracic approach as described by Bisgard (Cilley and Coran 1995). In all patients with unilateral paralysis, plication was performed through the seventh intercostal space with a lateral thoracotomy and fixation of the diaphragm on the ventral tenth costal arch. In three cases with bilateral pareses, only one side was plicated similarly with good result. Our results are comparable with the findings of Lemmer et al. which showed in a study of 74 children with congenital heart disease and DP after operation that mechanical ventilation, ICU stay and hospital stay are prolonged in newborns and young infants without plication (Lemmer et al. 2007). Baker et al. performed in 17 patients after DP plication fluoroscopy assessing diaphragm motion. Excursion of the plicated diaphragm was 77 % of the contralateral side. There was a trend toward improved function over time (Baker et al. 2008).

In a follow-up of 22 adult patients, Versteegh et al. could show that the patients after plication improved in seated vital capacity, supine vital capacity and FEV₁. On the transient dyspnoea index, a remarkable improvement was noted in dyspnoea (Versteegh et al. 2007).

In children undergoing univentricular heart repair with non-pulsatile circulation like after Fontan operation, early diaphragm fixation seems to reduce morbidity like pleural effusions, ascites, duration of hospital stay and need for readmission (Talwar et al. 2010). Video-assisted thoracoscopic plication of the diaphragm has been described in a small case series in children and adults with good results (Freeman et al. 2006; Hines 2003). Hines described five patients between one week and 2 years who were successfully operated with a short ICU stay time (Hines 2003).

Diaphragmatic pacing has been used in adults and older children but not in infants. It requires an intact phrenic nerve and is not an option in bilateral paralysis. It is usually used in children with a nonsurgical origin of paralysis.