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Original Investigation |

Antireflux Procedures for Gastroesophageal Reflux Disease in Children:  Influence of Patient Age on Surgical Management FREE

Jarod McAteer, MD, MPH1,2; Cindy Larison, MA3; Cabrini LaRiviere, MD, MPH4; Michelle M. Garrison, PhD3; Adam B. Goldin, MD, MPH1,2
[+] Author Affiliations
1Division of Pediatric General and Thoracic Surgery, Seattle Children’s Hospital, Seattle, Washington
2Department of Surgery, University of Washington School of Medicine, Seattle
3Center for Child Health, Behavior and Development, Seattle Children’s Hospital, Seattle, Washington
4Department of Surgery, Louisiana State University, New Orleans
JAMA Surg. 2014;149(1):56-62. doi:10.1001/jamasurg.2013.2685.
Text Size: A A A
Published online

Importance  Gastroesophageal reflux disease (GERD) is a common diagnosis in infants and children, but no objective criteria exist to guide the diagnosis and treatment of this disease in this population. The extent to which age influences decisions about surgical treatment in childhood GERD is unknown.

Objective  To identify factors associated with progression to antireflux procedures (ARPs) in children hospitalized with GERD.

Design, Setting, and Participants  Retrospective cohort study using inpatient data from 41 US children’s hospitals in the Pediatric Health Information System database. We included patients younger than 18 years discharged from January 1, 2002, through December 31, 2010, with primary diagnostic codes for GERD (n = 141 190). We evaluated demographics, comorbidities, and diagnostic procedures descriptively and with a multivariate Cox proportional hazards regression model.

Exposure  Patient age.

Main Outcomes and Measures  Proportional hazard of progression to ARP during admission.

Results  Of the 141 190 patients meeting study criteria, 11 621 (8.2%) underwent ARPs during the study period. More than half of patients undergoing ARPs (52.7%) were 6 months or younger. Although most patients in the ARP group had preoperative upper gastrointestinal tract fluoroscopy (65.0%), these patients did not undergo a uniform workup. The hazard of progression to an ARP was significantly decreased in children aged 7 months to 4 years (hazard ratio, 0.63 [P < .001]) and 5 to 17 years (0.43 [P < .001]) relative to children younger than 2 months. Hazard ratios were independently increased for comorbid diagnoses of failure to thrive, neurodevelopmental delay, cardiopulmonary anomalies, cerebral palsy, and aspiration pneumonia and among patients with tracheoesophageal fistula and diaphragmatic hernia. Each additional GERD-related hospitalization was associated with a 10% increased risk of an ARP.

Conclusions and Revelance  Antireflux procedures are most commonly performed in children during a period of life when regurgitation is normal and physiologic and objective measures of GERD are difficult to interpret. To identify meaningful outcomes after ARP, indications must be clear and standardized. We must clarify the appropriate workup for infants and young children with GERD and better define “failure of medical management” in this population.

Figures in this Article

Gastroesophageal reflux disease (GERD) is a common pediatric diagnosis that affects as many as 7% of infants and children.1,2 However, clinicians have become increasingly aware of the difficulty in diagnosing GERD and, more importantly, in discriminating GERD from physiologic regurgitation, especially in infants.3 Often, children are diagnosed clinically after showing a response to an initial trial of medications; in other words, the diagnosis is presumed after a successful response of reported symptoms to antireflux medication.2 Childhood GERD is therefore diagnosed most commonly by clinical evaluation, without the use of objective measures. This diagnosis often adheres to patients over time until the symptoms wane as a result of the natural history of regurgitation or an objective test result disproves the presence of the disease.

Although a few reports describe the variation in symptoms and characteristics of this population by age and underlying medical comorbidities, most of the reports are retrospective single-institutional case series, and those reports that involve multiple institutions generally limit their descriptions to the presence or the absence of neurologic disorders.46 Similarly, although some investigations have suggested that infants with GERD are more likely than older children to undergo an antireflux procedure (ARP), to our knowledge no study has examined that trend while controlling for other comorbidities that may serve as indications for ARPs.6

In an effort to understand the population of infants and children with GERD requiring repeated hospitalizations and the subpopulation of this group with progression to ARPs, we identified the population of infants and children hospitalized with GERD to understand the broader characteristics of this group. We hypothesized that infants younger than 2 months would be more likely to undergo ARPs than would older children after adjusting for other clinical covariates.

Data Source

We conducted a retrospective cohort study of inpatients in the Pediatric Health Information System database, which includes demographic, diagnostic, and treatment data from 41 freestanding children’s hospitals covering 85% of major metropolitan areas in the United States. Discharge diagnoses are assigned using the International Classification of Diseases, Ninth Revision (ICD-9). The study protocol was reviewed and approved by the Seattle Children’s Hospital institutional review board. Informed consent was not required.

Patients

We identified all patients younger than 18 years discharged from January 1, 2002, through December 31, 2010, with a diagnosis of GERD (ICD-9 code 530.11 or 530.81). Medical record numbers were used to identify multiple hospitalizations per patient; the patient’s first hospitalization for GERD during the study period was considered the index hospitalization. Patients with only 1 hospitalization who underwent an ARP within 48 hours of admission were excluded because we believed a priori that they represented an inherently different population with a single admission for elective surgical intervention.

Data Extraction

Our primary outcome was whether the patient ever underwent an ARP (ICD-9 code 44.66 or 44.67) during the index hospitalization or during subsequent admissions captured during the study period. We examined demographic variables, including sex, age at index admission, and Medicaid status. Our primary exposure of interest was patient age, broken down as younger than 2 months, 2 to 6 months, 7 months to 4 years, and 5 to 17 years, because these ages represent break points in the evolution of physiologic regurgitation in children.7 We also extracted total hospital length of stay (LOS). The following comorbidities were examined based on ICD-9 codes: neurodevelopmental delay, chromosomal anomalies, cardiopulmonary disorders, asthma, Barrett esophagus, esophageal atresia/tracheoesophageal fistula, congenital diaphragmatic hernia, hiatal hernia, abnormality of intestinal fixation (eg, malrotation), cerebral palsy, and seizure disorders (Supplement [eTable]). Comorbid conditions were considered present if the diagnosis appeared during any of the patient’s hospital admissions during the study period; aspiration pneumonia and failure to thrive were measured only during the index admission as a proxy for severity because the aim of the analysis was to identify predictors of progression to ARPs that could be assessed at the initial hospitalization. Although diagnostic studies for GERD are often performed on an outpatient basis for patients undergoing elective procedures, we also examined the relevant diagnostic procedures performed during the hospital stay given that our population had repeated hospitalizations and that all patients received their ARP after at least 2 days of hospitalization. We looked specifically at diagnostic procedures that were performed during the index admission and before the ARP if an ARP was performed.

Statistical Analysis

The patient population was described in terms of demographic and clinical characteristics broken down by ARP status and age group. We used χ2 tests to quantify differences across groups. We used a Cox proportional hazards regression model (with the Breslow method of resolving ties) to identify the hazard of progression to an ARP, controlling for the variables described above. This method accounts for the differing periods of follow-up across patients in whom an ARP might be captured. The survival model was adjusted for clustering at the hospital level to take into account the nonindependence of sampling.

We identified 141 190 patients with a GERD hospitalization meeting study criteria after excluding 3749 patients who had only an elective ARP admission (operation within 48 hours of admission) without a preceding GERD hospitalization (Figure). Comparing this excluded population with our study population confirmed our a priori decision. Whereas 64.0% of the ARP arm of our study population was younger than 1 year with a mean LOS of 36.3 days, 80.8% of the excluded population was 1 year or older with a mean LOS of 5.0 days (data not shown). Of all patients meeting inclusion criteria, 11 621 (8.2%) underwent an ARP during the study period.

Place holder to copy figure label and caption
Figure.
Study Selection Flowchart

ARP indicates antireflux procedure; GERD, gastroesophageal reflux disease.

Graphic Jump Location

Overall, 52.7% of the patients in the study population were aged 6 months or younger. The ARP and non-ARP groups were generally similar with regard to sex and age distribution (Table 1). Medicaid insurance was more common among the ARP patients. Mean total hospital LOS for the index admission was also considerably longer for ARP compared with non-ARP patients (36.3 vs 12.5 days). Compared with non-ARP patients, ARP patients were more likely to present with aspiration pneumonia (11.4% vs 2.4%) and failure to thrive (59.7% vs 28.0%). Each of the comorbidities examined was more prevalent among ARP patients, the most common of which were neurodevelopmental delay (51.7% vs 20.2%), cardiopulmonary disorders (42.0% vs 21.9%), seizure disorder (32.2% vs 11.9%), asthma (21.6% vs 16.5%), and cerebral palsy (19.5% vs 5.7%). Diagnostic procedures were also more commonly performed in the ARP group. Upper gastrointestinal (GI) tract fluoroscopy was the most common diagnostic study performed, with 65.0% of ARP patients undergoing a preoperative study. Other diagnostic studies were administered relatively infrequently by comparison.

Table Graphic Jump LocationTable 1.  Patient Characteristics According to ARP Status

Among ARP patients, LOS was significantly longer for younger compared with older patients (70.5 days for patients aged <2 months vs 15.6 days for patients aged 5-17 years) (Table 2). Although failure to thrive was more common among infants, aspiration pneumonia was more common among older children. In general, congenital anomalies (eg, congenital diaphragmatic hernia, esophageal atresia/tracheoesophageal fistula, and malrotation) were more common among infants, whereas neurologic diagnoses (eg, neurodevelopmental delay, cerebral palsy, and seizure disorder) were seen more frequently in older children. Although an upper GI tract endoscopy was more commonly performed in older patients, infants were more likely to receive a preoperative upper GI tract fluoroscopy. Upper GI tract fluoroscopy was the most common study across all age groups. Other diagnostic procedures were performed less commonly and with similar frequency across age groups.

Table Graphic Jump LocationTable 2.  Patient Characteristics According to Age at Index Admission for ARP Cohorta

After controlling for all covariates, the proportional hazard of undergoing an ARP was significantly decreased for children aged 7 months to 4 years (hazard ratio [HR], 0.63 [95% CI, 0.54-0.74]) and 5 to 17 years (0.43 [0.36-0.51]) compared with children younger than 2 months (Table 3). Patients 2 to 6 months of age at the index admission had a hazard similar to the youngest patients (HR, 0.96 [95% CI, 0.87-1.06]). As expected a priori, most of the other covariates included in the model were associated with an increased hazard of progression to ARP, with the largest associations noted for hiatal hernia (HR, 4.69 [95% CI, 3.98-5.52]), failure to thrive (2.67 [2.35-3.03]), and neurodevelopmental delay (2.42 [2.17-2.70]). Each consecutive hospitalization for GERD was associated with a 10% increased hazard of ARP (HR, 1.10 [95% CI, 1.08-1.12]), and each consecutive hospitalization with aspiration pneumonia was associated with a 17% increased hazard of ARP (1.17 [1.12-1.22]).

Table Graphic Jump LocationTable 3.  Adjusted HRs for Progression to ARP According to Demographic and Clinical Covariates

Gastroesophageal reflux disease is a common diagnosis in infants and children, and ARPs remain one of the most common procedure types performed by pediatric general surgeons.8,9 This pathologic entity poses an especially unique challenge in younger children because physiologic regurgitation is common in infancy. Daily regurgitation is noted in about 75% of infants at 2 months of age and 50% at 6 months of age, but this normal reflux resolves spontaneously in most infants by the end of the first year of life.7 Pediatricians and surgeons are charged with the task of determining which cases of regurgitation represent true GERD and which cases of GERD might ultimately warrant surgical therapy. As such, understanding the role of patient age as it relates to current practice in the surgical treatment of GERD is essential in any effort to improve the care of this population of patients. This study is, to our knowledge, the first to examine the independent influence of patient age on the progression to ARP among children hospitalized with GERD. Using a large sample from tertiary pediatric hospitals, our results indicate that among hospitalized children with a diagnosis of GERD, infants younger than 2 months are more likely to receive an ARP than older children are after adjusting for multiple confounding factors.

Ideal management of GERD is a multistep process beginning with an objective diagnosis of pathologic reflux, followed by a trial of validated medical therapy and culminating in an informed decision to offer surgical treatment to appropriate candidates in whom conservative management fails. The degree to which this process occurs in the management of childhood GERD is unclear. Diagnostic criteria in adults are fairly well established because symptoms are generally clear and easily communicated by most patients and because treatment efficacy is easily assessed.10 This approach is more troublesome in children, especially in nonverbal populations (eg, infants and neurologically impaired children). In the past, GERD in children was believed to be adequately diagnosed on the basis of symptoms alone.2 In 2009, however, the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition revised the GERD clinical practice guidelines to be more conservative in their recommendations for diagnosis and treatment.11 Although many authors believe that older children can still receive a diagnosis based on symptoms alone, infants and younger children are generally recommended to undergo objective testing before applying a diagnosis of GERD. Studies have shown that knowledge of diagnostic guidelines by health care providers varies greatly and that infants being treated for GERD often do not meet diagnostic criteria based on objective test results.12,13 The large number of children 6 months and younger in this study in the ARP and non-ARP groups highlights how common this diagnosis is in infants. The number also suggests that physicians may be more likely to apply the diagnosis in this patient group because of diagnostic uncertainty or because other characteristics of these hospitalized infants make it more likely that any regurgitation is perceived as pathologic and indicative of GERD.

Referral for surgical treatment of GERD is generally presumed to be a last resort after failure of medical management, with optimal candidates having undergone specific preoperative evaluations. Indeed, the indications and process are fairly well delineated for adult patients.14 Such guidelines are lacking in children, although several studies1517 have shown the utility of esophageal pH studies specifically in identifying children in whom medical management is likely to fail. As evidenced by this and other studies,1821 upper GI tract fluoroscopy is frequently used in the preoperative workup among children with GERD. Investigations have shown, however, that upper GI tract studies are poor predictors of pathologic reflux. Regardless of the evidence for or against specific objective studies, surveys indicate that physician practice varies widely regarding the application of these tests, and individual provider gestalt still plays a major role in the decision to offer ARP.2224

The results of our study suggest that health care providers are more likely to offer an ARP to infants relative to older children independent of other commonly considered indications for fundoplication in children. The reasons for the difference are unclear but are likely influenced by the high rates of physiologic regurgitation and the diagnostic conundrum in this population, the use of fundoplication as part of a durable feeding plan in infants with failure to thrive, and a greater concern about the potential complications of untreated GERD in younger patients. However, our data show a lack of objective diagnostic studies in all children but especially in infants, a population that certainly warrants greater consideration of confirmatory testing. Similarly, because most cases of infant GERD will resolve with conservative management within 3 to 6 months, our findings of an increased hazard of ARP in the first few months of life suggest that many infants are likely never given an adequate trial of medical management.25 The implications of inappropriate use of ARP in infants are significant, with other studies suggesting that success rates may be lower and recurrence rates higher among these patients.26,27

This study has several limitations. First, the Pediatric Health Information System is an administrative database that is subject to potential miscoding and misclassification. Second, not all potential confounders can be gleaned from this database and controlled for in our model. Third, this analysis focused only on patients with inpatient hospital stays, including those hospitalized specifically for GERD symptoms and those admitted for comorbid conditions. Although not a limitation per se, our choice to focus on a population that has a greater use of inpatient medical resources affects the generalizability of our findings and makes it difficult to apply our findings to older children with isolated GERD in the absence of other significant comorbidities. Last, information on diagnostic studies is limited to inpatient data. In the youngest patients, however, we expect these data should be fairly accurate because many of these patients were likely hospitalized at birth and because the index hospitalization thus captures the period when GERD was diagnosed.

Gastroesophageal reflux disease is a common diagnosis in infants and young children, and the threshold to perform ARPs in these patients appears to be lower. Despite the fact that expert guidelines urge the use of objective studies in the diagnosis of GERD and despite evidence that supports the use of objective studies before performing ARPs, such a standardized evaluation is not common practice. Physiologic regurgitation is common in infants, and even most cases of pathologic reflux respond to conservative measures within the first several months of life. Given what this study shows regarding the current state of practice at tertiary pediatric hospitals, a greater effort is needed to develop and disseminate best-practice standards for the diagnosis and treatment of children, especially infants, with possible GERD. We must clarify the indications for ARP and clarify its use to treat GERD vs its use as an adjunct to a durable long-term feeding plan.

Accepted for Publication: April 5, 2013.

Corresponding Author: Jarod McAteer, MD, MPH, Division of Pediatric General and Thoracic Surgery, Seattle Children’s Hospital, 4800 Sand Point Way NE, Seattle, WA 98145 (jarodmc@uw.edu).

Published Online: November 6, 2013. doi:10.1001/jamasurg.2013.2685.

Author Contributions: Dr McAteer had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: McAteer, Garrison, Goldin.

Acquisition of data: Larison, LaRiviere, Garrison, Goldin.

Analysis and interpretation of data: McAteer, Larison, Garrison, Goldin.

Drafting of the manuscript: McAteer, Larison, Goldin.

Critical revision of the manuscript for important intellectual content: LaRivere, Garrison, Goldin.

Statistical analysis: McAteer, Larison, Goldin.

Administrative, technical, and material support: LaRiviere, Garrison, Goldin.

Study supervision: Goldin.

Conflict of Interest Disclosures: None reported.

Previous Presentation: This paper was presented at the 84th Annual Pacific Coast Surgical Association Meeting; February 17, 2013; Kauai, Hawaii.

Orenstein  SR, Shalaby  TM, Kelsey  SF, Frankel  E.  Natural history of infant reflux esophagitis: symptoms and morphometric histology during one year without pharmacotherapy. Am J Gastroenterol. 2006;101(3):628-640.
PubMed   |  Link to Article
Rudolph  CD, Mazur  LJ, Liptak  GS,  et al; North American Society for Pediatric Gastroenterology and Nutrition.  Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr. 2001;32(suppl 2):S1-S31.
PubMed   |  Link to Article
Fike  FB, Mortellaro  VE, Pettiford  JN, Ostlie  DJ, St Peter  SD.  Diagnosis of gastroesophageal reflux disease in infants. Pediatr Surg Int. 2011;27(8):791-797.
PubMed   |  Link to Article
Carson  JA, Tunell  WP, Smith  EI.  Pediatric gastroesophageal reflux: age-specific indications for operation. Am J Surg. 1980;140(6):768-771.
PubMed   |  Link to Article
Fonkalsrud  EW, Ashcraft  KW, Coran  AG,  et al.  Surgical treatment of gastroesophageal reflux in children: a combined hospital study of 7467 patients. Pediatrics. 1998;101(3, pt 1):419-422.
PubMed   |  Link to Article
Lasser  MS, Liao  JG, Burd  RS.  National trends in the use of antireflux procedures for children. Pediatrics. 2006;118(5):1828-1835.
PubMed   |  Link to Article
Hegar  B, Dewanti  NR, Kadim  M, Alatas  S, Firmansyah  A, Vandenplas  Y.  Natural evolution of regurgitation in healthy infants. Acta Paediatr. 2009;98(7):1189-1193.
PubMed   |  Link to Article
Turnage  RH, Oldham  KT, Coran  AG, Blane  CE.  Late results of fundoplication for gastroesophageal reflux in infants and children. Surgery. 1989;105(4):457-464.
PubMed
Fonkalsrud  EW, Ament  ME.  Gastroesophageal reflux in childhood. Curr Probl Surg. 1996;33(1):1-70.
PubMed   |  Link to Article
Vakil  N, van Zanten  SV, Kahrilas  P, Dent  J, Jones  R; Global Consensus Group.  The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus. Am J Gastroenterol. 2006;101(8):1900-1920, 1943.
Link to Article
Vandenplas  Y, Rudolph  CD, Di Lorenzo  C,  et al; North American Society for Pediatric Gastroenterology, Hepatology and Nutrition; European Society for Pediatric Gastroenterology, Hepatology and Nutrition.  Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroenterol Nutr. 2009;49(4):498-547.
PubMed   |  Link to Article
Khoshoo  V, Edell  D, Thompson  A, Rubin  M.  Are we overprescribing antireflux medications for infants with regurgitation? Pediatrics. 2007;120(5):946-949.
PubMed   |  Link to Article
Diaz  DM, Winter  HS, Colletti  RB,  et al; NASPGHAN/CDHNF Scientific Advisory Board.  Knowledge, attitudes and practice styles of North American pediatricians regarding gastroesophageal reflux disease. J Pediatr Gastroenterol Nutr. 2007;45(1):56-64.
PubMed   |  Link to Article
Stefanidis  D, Hope  WW, Kohn  GP, Reardon  PR, Richardson  WS, Fanelli  RD; SAGES Guidelines Committee.  Guidelines for surgical treatment of gastroesophageal reflux disease. Surg Endosc. 2010;24(11):2647-2669.
PubMed   |  Link to Article
Evans  DF, Haynes  J, Jones  JA, Stower  MJ, Kapila  L.  Ambulatory esophageal pH monitoring in children as an indicator for surgery. J Pediatr Surg. 1986;21(3):221-223.
PubMed   |  Link to Article
Varty  K, Evans  D, Kapila  L.  Paediatric gastro-oesophageal reflux: prognostic indicators from pH monitoring. Gut. 1993;34(11):1478-1481.
PubMed   |  Link to Article
Fike  FB, Pettiford  JN, St Peter  SD, Cocjin  J, Laituri  CA, Ostlie  DJ.  Utility of pH/multichannel intraluminal impedance probe in identifying operative patients in infants with gastroesophageal reflux disease. J Laparoendosc Adv Surg Tech A. 2012;22(5):518-520.
PubMed   |  Link to Article
Al-Khawari  HA, Sinan  TS, Seymour  H.  Diagnosis of gastro-oesophageal reflux in children: comparison between oesophageal pH and barium examinations. Pediatr Radiol. 2002;32(11):765-770.
PubMed   |  Link to Article
Valusek  PA, St Peter  SD, Keckler  SJ,  et al.  Does an upper gastrointestinal study change operative management for gastroesophageal reflux? J Pediatr Surg. 2010;45(6):1169-1172.
PubMed   |  Link to Article
Macharia  EW.  Comparison of upper gastrointestinal contrast studies and pH/impedance tests for the diagnosis of childhood gastro-oesophageal reflux. Pediatr Radiol. 2012;42(8):946-951.
PubMed   |  Link to Article
Cuenca  AG, Reddy  SV, Dickie  B, Kays  DW, Islam  S.  The usefulness of the upper gastrointestinal series in the pediatric patient before anti-reflux procedure or gastrostomy tube placement. J Surg Res. 2011;170(2):247-252.
PubMed   |  Link to Article
Golski  CA, Rome  ES, Martin  RJ,  et al.  Pediatric specialists’ beliefs about gastroesophageal reflux disease in premature infants. Pediatrics. 2010;125(1):96-104.
PubMed   |  Link to Article
LaRiviere  CA, Parimi  C, Huaco  JC, Acierno  SA, Garrison  MM, Goldin  AB.  Variations in preoperative decision making for antireflux procedures in pediatric gastroesophageal reflux disease: a survey of pediatric surgeons. J Pediatr Surg. 2011;46(6):1093-1098.
PubMed   |  Link to Article
Goldin  AB, Garrison  M, Christakis  D.  Variations between hospitals in antireflux procedures in children. Arch Pediatr Adolesc Med. 2009;163(7):658-663.
PubMed   |  Link to Article
Tolia  V, Wuerth  A, Thomas  R.  Gastroesophageal reflux disease: review of presenting symptoms, evaluation, management, and outcome in infants. Dig Dis Sci. 2003;48(9):1723-1729.
PubMed   |  Link to Article
Lee  SL, Shabatian  H, Hsu  JW, Applebaum  H, Haigh  PI.  Hospital admissions for respiratory symptoms and failure to thrive before and after Nissen fundoplication. J PediatrSurg. 2008;43(1):59-65.
Ngerncham  M, Barnhart  DC, Haricharan  RN, Roseman  JM, Georgeson  KE, Harmon  CM.  Risk factors for recurrent gastroesophageal reflux disease after fundoplication in pediatric patients: a case-control study. J Pediatr Surg. 2007;42(9):1478-1485.
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure.
Study Selection Flowchart

ARP indicates antireflux procedure; GERD, gastroesophageal reflux disease.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1.  Patient Characteristics According to ARP Status
Table Graphic Jump LocationTable 2.  Patient Characteristics According to Age at Index Admission for ARP Cohorta
Table Graphic Jump LocationTable 3.  Adjusted HRs for Progression to ARP According to Demographic and Clinical Covariates

References

Orenstein  SR, Shalaby  TM, Kelsey  SF, Frankel  E.  Natural history of infant reflux esophagitis: symptoms and morphometric histology during one year without pharmacotherapy. Am J Gastroenterol. 2006;101(3):628-640.
PubMed   |  Link to Article
Rudolph  CD, Mazur  LJ, Liptak  GS,  et al; North American Society for Pediatric Gastroenterology and Nutrition.  Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr. 2001;32(suppl 2):S1-S31.
PubMed   |  Link to Article
Fike  FB, Mortellaro  VE, Pettiford  JN, Ostlie  DJ, St Peter  SD.  Diagnosis of gastroesophageal reflux disease in infants. Pediatr Surg Int. 2011;27(8):791-797.
PubMed   |  Link to Article
Carson  JA, Tunell  WP, Smith  EI.  Pediatric gastroesophageal reflux: age-specific indications for operation. Am J Surg. 1980;140(6):768-771.
PubMed   |  Link to Article
Fonkalsrud  EW, Ashcraft  KW, Coran  AG,  et al.  Surgical treatment of gastroesophageal reflux in children: a combined hospital study of 7467 patients. Pediatrics. 1998;101(3, pt 1):419-422.
PubMed   |  Link to Article
Lasser  MS, Liao  JG, Burd  RS.  National trends in the use of antireflux procedures for children. Pediatrics. 2006;118(5):1828-1835.
PubMed   |  Link to Article
Hegar  B, Dewanti  NR, Kadim  M, Alatas  S, Firmansyah  A, Vandenplas  Y.  Natural evolution of regurgitation in healthy infants. Acta Paediatr. 2009;98(7):1189-1193.
PubMed   |  Link to Article
Turnage  RH, Oldham  KT, Coran  AG, Blane  CE.  Late results of fundoplication for gastroesophageal reflux in infants and children. Surgery. 1989;105(4):457-464.
PubMed
Fonkalsrud  EW, Ament  ME.  Gastroesophageal reflux in childhood. Curr Probl Surg. 1996;33(1):1-70.
PubMed   |  Link to Article
Vakil  N, van Zanten  SV, Kahrilas  P, Dent  J, Jones  R; Global Consensus Group.  The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus. Am J Gastroenterol. 2006;101(8):1900-1920, 1943.
Link to Article
Vandenplas  Y, Rudolph  CD, Di Lorenzo  C,  et al; North American Society for Pediatric Gastroenterology, Hepatology and Nutrition; European Society for Pediatric Gastroenterology, Hepatology and Nutrition.  Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroenterol Nutr. 2009;49(4):498-547.
PubMed   |  Link to Article
Khoshoo  V, Edell  D, Thompson  A, Rubin  M.  Are we overprescribing antireflux medications for infants with regurgitation? Pediatrics. 2007;120(5):946-949.
PubMed   |  Link to Article
Diaz  DM, Winter  HS, Colletti  RB,  et al; NASPGHAN/CDHNF Scientific Advisory Board.  Knowledge, attitudes and practice styles of North American pediatricians regarding gastroesophageal reflux disease. J Pediatr Gastroenterol Nutr. 2007;45(1):56-64.
PubMed   |  Link to Article
Stefanidis  D, Hope  WW, Kohn  GP, Reardon  PR, Richardson  WS, Fanelli  RD; SAGES Guidelines Committee.  Guidelines for surgical treatment of gastroesophageal reflux disease. Surg Endosc. 2010;24(11):2647-2669.
PubMed   |  Link to Article
Evans  DF, Haynes  J, Jones  JA, Stower  MJ, Kapila  L.  Ambulatory esophageal pH monitoring in children as an indicator for surgery. J Pediatr Surg. 1986;21(3):221-223.
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