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Original Investigation |

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

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.
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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.

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Study Selection Flowchart

ARP indicates antireflux procedure; GERD, gastroesophageal reflux disease.

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