To Wrap or Not

Abstract

McAteer and colleagues1 use the Pediatric Health Information System database to evaluate factors associated with progression to antireflux procedures (ARPs) in children hospitalized for gastroesophageal reflux disease (GERD). Theydemonstrated that children younger than 2 months are more likely to undergo ARPs compared with older children. Furthermore, childrenwith additional comorbidites are more likely to undergo ARPs. These findings are not new and are expected within the pediatric surgical community. Buriedwithin this report is the true controversy regarding the management of GERD in children. Physiologic reflux/ regurgitation iscommonin infantsand,giventime,asignificant proportion of childrenwill simply outgrow their reflux symptoms. The authors point out that no uniformworkupwas performedbefore theoperative intervention.Furthermore, the indicationsforARPsvaried.Thus,theauthors logicallymakeaplea for standardization of theworkup and indications for ARPs in children todeterminewhich children reallyneedoperative interventionvs time tooutgrow their symptoms.Unfortunately, thisstudydoesnothingtoaddressthosepleasforstandardmedicalmanagement andworkup before proceedingwith ARPs. Given that an ARP remains one of the most common operationsperformedbypediatric surgeons, I amperplexed that a standard workup and clear indications for such procedures in childrendonot exist as theydo inadults.One reason for this difference is that children with GERD typically present with feeding problems and have additional comorbidities that influence the need for an ARP. It is common to see a newborn with severe cardiac disease and minimal physiologic reserve who cannot tolerate oral feedings. Should only a gastrostomy tube be inserted, with the risk of aspiration and even death given the patient’s fragile state, or should an ARP be performed (despite no clinical evidence of GERD) in addition to the gastrostomy tube? Another common scenario is a newbornwithneurologic compromisewhoonly tolerates continuous feedings via a postpyloric feeding tube.Oral/gavage feedings result inemesiswithoccasional apneaandcyanotic spells. How long should this patient remain in the hospital and be treated medically to determine whether he or she will outgrowthesesymptoms?Should thesurgeonrecommendanARP to facilitate discharge from the hospital and to prevent future complications (eg, aspirationpneumonia)?Areadditional studies required in either patient to make these decisions? As demonstrated above, care of children with GERD is complex and involves many different factors. 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.