Larry Hand
November 06, 2013
Full Story: http://www.medscape.com/viewarticle/813930
Infants younger than 2 months who are hospitalized more than once with gastroesophageal reflux disease (GERD) are significantly more likely to undergo antireflux procedures (ARPs) than children aged 7 months or older, according to an article published online November 6 in JAMA Surgery.
Children with multiple disorders, regardless of age, are also more likely to undergo ARPs, and most ARPs in general are performed without a standard workup in advance, the researchers report.
Jarod McAteer, MD, MPH, from the Division of Pediatric General and Thoracic Surgery, Seattle Children’s Hospital, Washington, and colleagues conducted a retrospective cohort study of inpatient records in the Pediatric Information System database, an administrative depository for 41 US children’s hospitals.
The researchers identified 141,190 patients younger than 18 years with a GERD-related hospitalization between January 1, 2000, and December 31, 2010. They excluded from their analysis 3749 patients who had an elective ARP within 48 hours of a first hospitalization.
Of the remaining patients, 11,621 (8.2%) underwent ARP during the study period, and 129,569 did not. Almost 53% of all patients who underwent ARP were aged 6 months or younger.
When the researchers calculated the proportional hazard of undergoing an ARP, using age less than 2 months as the reference and controlling for covariates, they found the risk was similar for patients aged 2 to 6 months, but decreased significantly for children aged 7 months to 4 years (hazard ratio [HR], 0.63; 95% confidence interval [CI], 0.54 – 0.74) and 5 to 17 years (HR 0.43; 95% CI, 0.36 – 0.51).
Moreover, of all patients who underwent ARP, 65.0% did not have a uniform workup in advance.
“[O]ur 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,” the researchers conclude. “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.”
Longer Stays
Hospital stays for those who underwent ARPs were significantly longer than for those who did not, ranging from 70.5 days for the youngest patients to 15.6 days for patients aged 5 to 17 years. In addition, hazard of progression to ARP increased 17% with each consecutive hospital stay for GERD.
Comorbidities most associated with increased hazard of progression to ARP were hiatal hernia (HR, 4.69; 95% CI, 3.98 – 5.52), failure to thrive (HR, 2.67; 95% CI, 2.35 – 3.03), and neurodevelopmental delay (HR, 2.42; 95% CI, 2.17 – 2.70).
“Given that an ARP remains one of the most common operations performed by pediatric surgeons, I am perplexed that a standard workup and clear indications for such procedures in children do not exist as they do in adults,” writes Steven Lee, MD, from the Division of Pediatric Surgery at Harbor-University of California, Los Angeles, Medical Center in Torrance, in an accompanying commentary.
A limitation of the study is reliance on an administrative database subject to miscoding and misclassification, the researchers note. Dr. Lee agrees strongly, “Although the authors recognize the ongoing controversy in the management of GERD in infants and children, the data reported in this study are derived from an administrative database that simply does not provide enough details to make any significant conclusions.”
The authors and the commentator have disclosed no relevant financial relationships.
JAMA Surg. Published online November 6, 2013.