Given the fact that reflux is normal in most infants, determining which patients should be treated surgically requires careful consideration and keen judgment, researchers warned.
The majority of patients receiving surgical antireflux procedures are 6 months old or younger (52.7%), and the hazard for progression to such a procedure decreased significantly as patients got older, according to Jarod McAteer, MD, MPH, of Seattle Children's Hospital in Washington, and colleagues.
However, for every gastroesophageal reflux disease (GERD) incident requiring hospitalization, risk of surgical treatment increased by 10% (95% CI 1.08-1.12), they wrote online in JAMA Surgery.
The authors cautioned that there is no objective criteria to guide diagnosis and treatment of GERD in pediatric populations. However based on their research, optimal GERD management 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," after less invasive therapies fail.
The American Academy of Pediatrics cautioned healthcare professionals to first determine whether a pediatric patient is exhibiting symptoms of gastroesophageal reflux or if that reflux is considered GERD before attempting a course of treatment.
Another study showed parents are more likely to request a drug treatment for infant's reflux, even if the pediatrician said that drugs would not be effective.
McAteer and colleagues conducted a retrospective cohort study of 141,190 hospitalized GERD patients, including 11,621 who underwent antireflux procedures, from 2002 to 2010 and whose patient data were contained in the Pediatric Health Information System. The authors looked to identify factors associated with surgical treatment for reflux in pediatric GERD patients.
Patient variables included sex, age at admission, Medicaid status, and length of hospital stay. Age was grouped by younger than 2 months, 2 to 6 months, 7 months to 4 years, and 5 to 17 years, which "represent break points in the evolution of physiologic regurgitation in children."
Additionally, they gathered data on comorbidities present at any time the patient was hospitalized, including neurodevelopmental delay, chromosomal anomalies, cardiopulmonary disorders, asthma, Barret esophagus, esophageal atresia, tracheoesophageal fistula, congenital diaphragmatic hernia, hiatal hernia, abnormality of intestinal fixation, cerebral palsy, and seizure disorders.
Patients who received antireflux procedures had a mean length of stay of 36.3 days, which was nearly three times that of those hospitalized for GERD without additional surgical intervention (12.5 days).
Compared with those who did not undergo antireflux procedures, receipt of surgery was associated with a greater likelihood of aspiration pneumonia (11.4% versus 2.4%), failure to thrive (59.7% versus 28%), neurodevelopmental delay (51.7% versus 20.2%), cardiopulmonary disorders (42% versus 21.9%), seizure disorder (32.2% versus 11.9%), asthma (21.6% versus 16.5%), and cerebral palsy (19.5% versus 5.7%).
More patients receiving a surgical procedure underwent a diagnostic procedure than those who did not.
Younger patients had a longer length of stay on average than older ones (70.5 days for those younger than 2 months versus 15.6 days for those ages 5 to 17 years).
Hazard ratios for undergoing antireflux procedures decreased significantly among those ages 7 months to 4 years (HR 0.63, 95% CI 0.54-0.74) and 5 years to 17 years (HR 0.43, 95% CI 0.36-0.51) compared with those younger than 2 months. There was no significant difference between those younger than 2 months and those ages 2 to 6 months.
Daily regurgitation is common to roughly three-quarters of 2-month-olds and half of 6-month-olds, "but this normal reflux resolves spontaneously in most infants by the end of the first year of life," they wrote, cautioning that the burden of identifying surgery-worthy cases of reflux rests on the shoulders of pediatricians and surgeons.
"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," they concluded.
They also cautioned that the study was limited by miscoding and misclassification, absent confounders, and focus on inpatient hospital stays.
The authors declared no conflicts of interest.
- Reviewed by Zalman S. Agus, MD Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania