Reflux surgery challenged for smallest children

Nov 12 2013

By Lynda Williams, Senior medwireNews Reporter

US physicians have raised concerns over the diagnosis and treatment of gastroesophageal reflux disease (GERD) in small children, especially among infants for whom regurgitation is normal and likely to resolve with conservative treatment.

The team found that 8.2% of 141,190 US children with a GERD diagnosis underwent antireflux procedures (ARPs) between 2002 and 2010, 52.7% of whom were aged 6 months or younger. Patients who did not undergo ARP had a similar age and gender distribution to those who did.

“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,” write Jarod McAteer (Seattle Children’s Hospital, Washington) and colleagues in JAMA Surgery.

“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.”

Indeed, the researchers found no standardized work-up for the diagnosis, with 65.0% of patients in the ARP group undergoing upper gastrointestinal (GI) tract fluoroscopy, 17.1% a gastric emptying study, and 14.0% upper GI endoscopy. Just 1.3% and 0.2% underwent 24-hour esophageal pH measurement and esophageal manometry, respectively.

“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,” the authors comment.

Multivariate analysis showed that, in comparison to children aged less than 2 months, the likelihood of undergoing ARP was significantly lower in children aged 7 months to 4 years and in those aged 5 to 17 years (hazard ratio [HR]=0.63 and 0.43, respectively).

ARP was significantly predicted by diagnoses of hiatal hernia (HR=4.69), failure to thrive (HR=2.67), and neurodevelopmental delay (HR=2.42). Congenital diaphragmatic hernia (HR=1.79), cardiopulmonary disorders (HR=1.56), cerebral palsy (HR=1.44), internal fixation anomaly (HR=1.59), and chromosomal abnormality (HR=1.34) also increased the risk for ARP.

In addition, the likelihood for ARP significantly increased with each additional hospital stay for GERD (HR=1.10) or aspiration pneumonia (HR=1.17).

“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,” the researchers conclude.

“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.”

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