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Article |

Variations Between Hospitals in Antireflux Procedures in Children FREE

Adam B. Goldin, MD, MPH; Michelle Garrison, PhD; Dimitri Christakis, MD, MPH
[+] Author Affiliations

Author Affiliations: Department of General and Thoracic Surgery, Seattle Children's Hospital (Dr Goldin); Child Health Institute, University of Washington (Dr Garrison); and the Center for Child Health, Behavior, and Development, Seattle Children's Hospital Research Institute, Seattle, Washington (Drs Garrison and Christakis).


Arch Pediatr Adolesc Med. 2009;163(7):658-663. doi:10.1001/archpediatrics.2009.103.
Text Size: A A A
Published online

ABSTRACT

Objective  To examine the differences and trends in pediatric antireflux procedures (ARPs) across individual pediatric hospitals over time.

Design  Retrospective cohort study.

Setting  Administrative database containing inpatient records with discharge dates between January 1, 2001, and March 31, 2006.

Participants  Hospitalized pediatric patients younger than 18 years with primary procedure codes for ARP, appendectomy, pyloromyotomy, and gastrostomy tube placement. The comparisons with admissions for these common procedures were used to identify changes in the incidence of ARP per hospital per year.

Main Outcome Measures  The ratio of ARPs to appendectomies, pyloromyotomies, gastrostomies, and all 3 procedures combined, in each hospital by year.

Results  During our study period 13 691 ARPs, 41 441 nonincidental appendectomies, 14 895 pyloromyotomies, and 23 527 gastrostomy tube placements were identified. The average number of ARPs per appendectomy, pyloromyotomy, and gastrostomy tube placement declined annually across free-standing pediatric institutions. When these annual changes are examined within each hospital individually, however, it appears that such changes are not occurring equally, in that some hospitals are performing significantly greater and some significantly fewer ARPs relative to these common procedures.

Conclusions  The number of ARPs being performed in 36 free-standing children's hospitals is decreasing each year relative to several operations commonly performed at these institutions. Despite this overall annual decrease, there is tremendous variation between individual hospitals in how frequently ARPs are being performed relative to these procedures.

Figures in this Article

Gastroesophageal reflux disease (GERD), the pathologic and symptomatic reflux of gastric content into the esophagus, affects about 7% of infants in the first year of life.1,2 The indication for referral for surgical therapy for GERD is most commonly a failure to respond to medical management, though some are also referred based on their medical comorbidities for prophylactic procedures, given the perceived natural history and risks associated with these underlying problems.3

Antireflux procedures (ARPs) are common in children and are being performed with increasing frequency.3,4 Many studies described excellent outcomes after ARP, with greater than 90% resolution of symptoms and improved quality of life.5,6 Given the prevalence of GERD and the reported success of ARP, it is not surprising that, historically, it has been described as one of the most common surgical procedures performed. A recent study examining national trends in the use of ARP, however, concluded that the indications for ARPs have “evolved during the laparoscopic era,” in that fewer operations are performed on neurologically impaired children or on children after infancy.7 A recent study used the Nationwide Inpatient Sample coupled with census data to identify national population-based trends with respect to ARP. Citing a study that demonstrated variation between individual hospitals and national trends, the authors also stated that they were not able to address how local variations in the use of ARP may affect infants and children.8

While on the macrolevel it is extremely helpful to identify the national trend in the rate of ARPs, it raises many questions. Among them is whether this trend is universal or if it is specific to a region, hospital, group practice, or even to an individual surgeon. While a moderate amount of variation in practice patterns between local groups or individuals is expected, large variations might suggest either similarly large variation in the indications for the operation or in the preoperative assessment and decision making. This is important, in that to identify valid measures of outcomes of an intervention like ARP beyond universal measures such as death or length of stay, we must first identify the indications. For example, if children have an ARP for aspiration pneumonia, it would be ideal to identify a cessation of events of aspiration pneumonia after the operation. A recent article demonstrated that when evaluating ARPs by more specific disease-related outcomes such as rate of hospitalizations for GERD-related diagnoses like aspiration pneumonia, some children were hospitalized more frequently after compared with before.9

No published articles to date describe clustered or regional prevalence of regurgitation or GERD and, similarly, no data suggest clustered or regional severity of disease. Given the lack of demonstrable clustering of the presence or severity of GERD across the United States, if the indications for ARP are standard, one would expect that ARPs would be performed equally often in pediatric hospitals nationwide. Our hypothesis, therefore, is that a critical evaluation of the incidence of ARPs should not exhibit regional or clustered patterns. The aim of this study is to examine differences in the annual rate of pediatric antireflux operations across individual pediatric hospitals over time.

METHODS

We performed a retrospective examination of pediatric hospital discharge data relevant to antireflux operations. Issues explored included differences across hospitals and trends over time. Hospital-level denominator data were not feasible given the absence of clearly defined catchment areas for admissions to free-standing children's hospitals. As a result, we used comparisons with admissions for other relatively common gastrointestinal surgical procedures as a proxy, assuming that the referral patterns and incidence of these comparison operative procedures should remain relatively stable within institutions over time. For example, as the incidence of appendicitis in children would be expected to stay relatively constant over the study period, a decrease in the ratio of antireflux operations to appendectomy procedures within a hospital would suggest a drop in the frequency of antireflux operations.

DATA SOURCE

We used the Pediatric Health Information System (PHIS) database developed by the Child Health Corporation of America that includes demographic, diagnostic, and charge data from 36 freestanding, noncompeting children's hospitals.10 These hospitals include private as well as University pediatric tertiary referral centers. The PHIS includes diagnosis and procedure codes using the International Classification of Diseases, Ninth Revision, Clinical Modification(ICD-9-CM) format. In a secondary post hoc analysis, we also examined the incidence of antireflux operations in the Healthcare Cost and Utilization Project Kid's Inpatient Database (HCUP KID) for the year 2000. The sole purpose of this post hoc analysis was to estimate the overall proportion of pediatric antireflux operations performed in the United States that are included in the PHIS database.

PATIENTS

Our study included pediatric patients younger than 18 years with discharge dates between January 1, 2001, and March 31, 2006. The primary sample included all patients with procedure codes for ARP (ICD-9 procedure codes 44.66-44.67). Comparison samples were drawn for patients meeting the same age and date criteria, with procedure codes for appendectomy, pyloromyotomy, and gastrostomy; individual patients may be represented in more than 1 category, although this was rare. Unique patient identifiers were used, however, to ensure that an individual patient only counted toward a category for the first admission, even if subsequent admissions occurred with the same procedure code.

VARIABLES OF INTEREST

Other variables examined included demographic characteristics (age, sex, Medicaid status), hospital stay characteristics (year of discharge, length of stay, intensive care unit use, laparoscopic procedures), and relevant comorbid conditions.

STATISTICAL ANALYSIS

The distribution of collected variables was described across each of the operative categories. The ratio of antireflux operations to each of appendectomy, pyloromyotomy, and gastrostomy procedures were then calculated by year at the hospital level. As only one-fourth of the data were available for 2006, ratios were only calculated for the years 2001 through 2005. The distribution of ratios across hospitals was then examined, calculating the median, range, and interquartile range.

To test for changes in the procedures over time within the hospitals, a series of linear regression analyses were performed with hospital as a fixed effect. The unit of analysis for these regressions was a given year of data within an individual hospital, and the coefficient for the discharge year was examined. Again, only data for the years 2001 through 2005 were included for these analyses, as the outcome of interest was the total number of antireflux operations for the year. Four regression models were tested, controlling for (1) the number of appendectomy procedures during the year for each hospital, (2) the same for pyloromyotomy and (3) gastrostomy, and (4) including the annual figures for all 3 procedures. These analyses allowed us to estimate the annual change in the number of antireflux procedures across hospitals.

In a secondary post hoc analysis, we used the KID data with population-based sample weights to estimate the total proportion of pediatric admissions for each procedure that were captured within the PHIS database, with the aim of adding context to the overall findings. Unique patient identifiers were not available within the public-use KID data files, however, so repeat admissions of the same child within a category could not be excluded.

This study was approved by the institutional review board at the Children's Hospital and Regional Medical Center in Seattle, Washington.

RESULTS

During our study period, 13 691 ARPs, 41 441 nonincidental appendectomies, 14 895 pyloromyotomies, and 23 527 gastrostomy tube placements were identified. More than half of the patients undergoing each operation were male (Table 1). Of the patients undergoing an ARP, 48% had at least 1 hospital day in the intensive care unit during their hospitalization. Thirty-nine percent of the ARP population had a diagnostic code consistent with a neurologic condition or developmental delay, 33% had a diagnosis of aspiration pneumonia, and more than half had failure to thrive. Barrett esophagus was associated with 0.1% of patients. Of note, though only 11% of patients were identified as having had an operation performed laparoscopically, an ICD-9 code specific to this approach was only introduced in late 2004. In the years following for which we have data in PHIS, 44% of cases were performed laparoscopically.

Table Graphic Jump LocationTable 1. Summary of the Study Populationa

Between 2001 and 2005, the average number of ARPs per appendectomy, pyloromyotomy, and gastrostomy tube placement declined annually across free-standing pediatric institutions (Table 2). For example, the 2001 ratio of ARP to appendectomy was 0.36, declining to 0.26 in 2005. This change is indicative of either a decrease in the number of ARPs, an increase in the number of appendectomies, or a combination of both. Similarly, the ratio for pyloromytomy declined from 0.96 to 0.76, and that of gastrostomy tube placement from 0.67 to 0.47. The repetition of the decline across ratio categories suggests that a true decrease in ARP rates was taking place. When we visually examine the frequency of ARP per appendectomy, pyloromyotomy, and gastrostomy placement by individual hospitals, we identify considerable interhospital variability in these ratios (Figure 1). Each dot on these graphs represents an individual hospital within PHIS. We do not observe a strong correlation between the numbers of ARPs performed per year per hospital relative to the other control procedures.

Place holder to copy figure label and caption
Figure 1.

Ratios of antireflux operations vs other gastrointestinal procedures by hospitals. ARP indicates antireflux procedure.

Graphic Jump Location
Table Graphic Jump LocationTable 2. Ratios of Antireflux Operations vs Other Gastrointestinal Procedures Across Hospitals

The regression analyses demonstrated that the frequency with which ARPs are being performed in freestanding pediatric hospitals is significantly decreasing over time relative to appendectomies, pyloromyotomies, and gastrostomy placement (Table 3). Within each hospital, an average of 2.9 fewer ARPs are being performed each year relative to the number of appendectomies (P < .01), and more than 4 fewer relative to the number of pyloromyotomies and gastrostomy tube placements each (P < .001). When these annual changes are examined within each hospital individually, however, it appears that such changes are not occurring equally everywhere (Figure 2). At one extreme, one of the hospitals is performing over 40 fewer ARPs per year relative to the number of appendectomies, pyloromyotomies, and gastrostomy tube placements per year, whereas at the other extreme, one of the hospitals is performing over 10 more ARPs relative to these common procedures.

Place holder to copy figure label and caption
Figure 2.

The annual change in the number of antireflux operations in each hospital after controlling for appendectomy, pyloromyotomy, and gastrostomy tube placement.

Graphic Jump Location
Table Graphic Jump LocationTable 3. Regression Analysis of the Change in the Number of ARPs Performed Across Pediatric Hospitals per Year Relative to 3 Other Commonly Performed Operations in Infants and Children

In a post hoc analysis, we used the KID data to estimate the proportion of pediatric admissions for these procedures nationwide that were captured by the PHIS database. As the KID database is not available for every year, the closest comparison was between the 2000 KID data and the 2001 PHIS data. Assuming no significant change over the single year, we can estimate that the PHIS database captured 37% of all Nissens, 8% of all appendectomies, 13% of laparoscopic appendectomies, 24% of pyloromyotomies, and 36% of gastrostomies placed in patients younger than 18 years in the United States.

COMMENT

The number of ARPs being performed in 36 free-standing children's hospitals is decreasing each year relative to several commonly performed operations performed at these same institutions. Despite this overall annual decrease, there is tremendous variation between individual hospitals in how frequently ARPs are being performed relative to these procedures. These findings compel us to question our a priori assumptions that either (1) the prevalence and severity of GERD or (2) the indications for ARP are consistent across populations and between hospitals.

Prior studies have addressed the prevalence of childhood regurgitation and GERD across populations.1113 Though no environmental factors have been clearly identified as responsible for the development of GERD, there may indeed be cultural, environmental, or ethnic factors that influence the natural history and geographic distribution of this disease.14,15 Most of the hospitals contributing to the PHIS database, however, are large referral centers that draw from diverse ethnic and socioeconomic populations, and it is therefore unlikely that the variability observed in our data are entirely due to significant differences in each hospital's population. In fact, we looked at variables that might be associated with hospital-level characteristics that might explain the observed variation such as census region, population size of each hospital's metropolitan area, and bed size of the hospital. Neither region nor population were correlated with the outcome, and the association with bed size was not statistically significant (P = .08, with hospitals with >350 beds more likely to exhibit a decrease). We think it is more likely that the indications for ARP vary significantly between pediatric hospitals. As ARPs are major operations that can be associated with significant benefits as well as significant complications, these are important findings in that inconsistent indications may translate into 2 possible adverse scenarios—one in which children with unremitting GERD that would benefit from this intervention are not receiving it, and another in which children undergo these operations despite having the potential benefits outweighed by the risks.

There is much indirect evidence to support this concern. Recent studies have questioned the excellent outcomes of ARP in infants and children.9,1620 Gastroesophageal reflux disease is poorly understood in the pediatric population, and often a diagnosis made clinically by reporting of subjective symptoms rather than objective evidence.1 Additionally, the symptoms leading to the diagnosis can vary significantly with age and underlying medical conditions.21 Though several articles have linked objective studies with the reported symptoms, use of these studies preoperatively is neither universal nor standardized, as it is in adults.22 In fact, a publication reviewing more than 7000 ARPs performed in 7 major hospitals over 20 years demonstrates that the most frequent objective measure of reflux used preoperatively was upper gastrointestinal series, and was performed in 68% of the population. The next most commonly used study was a pH probe, used in 54% of patients.5 In terms of the clarity of the link between subjective symptoms and objective measures of GERD in children, another recent study demonstrated that only 52% of children evaluated for symptoms suggestive of GERD had a positive pH test, which has been considered the diagnostic gold standard.23

Though many articles have been written describing the excellent outcomes after these operations, most are based on subjective measures of outcome, and few use objective measures to evaluate their efficacy.5,6,2427 This becomes especially problematic in light of the recent publication by Lee et al.20 The authors found that not only are patients hospitalized with equal frequency before and after an ARP but, more importantly, many patients who were previously without specific symptoms ended up hospitalized with that symptom postoperatively. For example, these authors found that only 3 of the 24 patients who were hospitalized with aspiration pneumonia before ARP were hospitalized after ARP with this same diagnosis. They found, however, that an additional 20 patients that had never been hospitalized for aspiration pneumonia were hospitalized for this diagnosis after their ARP. The next obvious questions in light of the marginal association between symptoms and GERD and objective studies and GERD is, what are the indications for these procedures and what measures of outcome should we use to evaluate their efficacy? Should we aim to relieve the specific GERD-related symptom for which an individual was referred, should we aim to relieve any GERD-related symptom including the one for which the patient was referred, should we focus on normalizing objective measures of GERD such as pH probe results, or should it be a combination of these things?

There are several limitations to this study. First, we use an administrative database that does not capture all of the possible clinical data. As a result, we are using this information to identify disparity in clinical practices across hospitals, to suggest the need for a more standardized approach, and to use these associations to design better prospective studies. Second, the hospitals in this database are large referral centers, and we cannot account for possible changes in referral patterns over the years of this study. We attempted to account for this possibility by using patients who had 3 different procedures (appendectomy, pylorolyotomy, and gastrostomy tube placement) as reference populations.

Despite these limitations, this article has some important implications. The significant disparity in the use of ARPs across free-standing children's hospitals in this country relative to other common procedures raises the question of whether too many or too few operations are being performed. There is little doubt that infants and children benefit from both medical and surgical interventions for GERD. It is a disease that is driven clinically by symptoms that are variable and diverse, such as pain, aspiration, acute life-threatening events, apnea, and failure to thrive, each of which is often poorly specific to GERD, and each of which is not clearly associated with a positive objective study. If the variability between hospitals is due to variability in the indications, then our next task is to clarify the indications for ARPs. We need to clarify the association between symptoms and the disease. We need to identify which objective studies will confirm the presence of GERD, and the relationship between specific symptoms and each of these objective studies. We need to develop disease-specific and population-specific measures of not only the quality of life of patients, but also measures of the impact of GERD on the patient and family (S. C. Acierno, et al, unpublished data, December 2008). Only then will we be able to identify measures of outcomes appropriate and specific to this population. This should be done by identifying a cohort of patients referred for GERD-related symptoms, and prospectively following up this group through a diagnostic and therapeutic algorithm that will carefully record underlying medical conditions, presenting symptoms, objective results, and the interactions between these variables that might predict the optimal interventions.

ARTICLE INFORMATION

Correspondence: Adam Goldin, MD, MPH, Pediatric General and Thoracic Surgery, Children's Hospital and Regional Medical Center, M/S W-7729, PO Box 5371, Seattle, WA 98105-0371 (adam.goldin@seattlechildrens.org).

Accepted for Publication: November 3, 2008.

Author Contributions:Study concept and design: Goldin, Garrison, and Christakis. Acquisition of data: Goldin, Garrison, and Christakis. Analysis and interpretation of data: Goldin, Garrison, and Christakis. Drafting of the manuscript: Goldin. Critical revision of the manuscript for important intellectual content: Goldin, Garrison, and Christakis. Statistical analysis: Goldin, Garrison, and Christakis. Obtained funding: Goldin and Christakis. Administrative, technical, and material support: Goldin and Garrison. Study supervision: Garrison and Christakis.

Financial Disclosure: None reported.

REFERENCES

Rudolph  CDMazur  LJLiptak  GS  et al. North American Society for Pediatric Gastroenterology and Nutrition, Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr 2001;32 ((suppl 2)) S1- S31
PubMed Link to Article
Orenstein  SRShalaby  TMKelsey  SFFrankel  E Natural history of infant reflux esophagitis: symptoms and morphometric histology during one year without pharmacotherapy. Am J Gastroenterol 2006;101 (3) 628- 640
PubMed Link to Article
Fonkalsrud  EWAment  ME Gastroesophageal reflux in childhood. Curr Probl Surg 1996;33 (1) 1- 70
PubMed Link to Article
Turnage  RHOldham  KTCoran  AGBlane  CE Late results of fundoplication for gastroesophageal reflux in infants and children. Surgery 1989;105 (4) 457- 464
PubMed
Fonkalsrud  EWAshcraft  KWCoran  AG  et al.  Surgical treatment of gastroesophageal reflux in children: a combined hospital study of 7467 patients. Pediatrics 1998;101 (3 pt 1) 419- 422
PubMed Link to Article
Kazerooni  NLVanCamp  JHirschl  RBDrongowski  RACoran  AG Fundoplication in 160 children under 2 years of age. J Pediatr Surg 1994;29 (5) 677- 681
PubMed Link to Article
Lasser  MSLiao  JGBurd  RS National trends in the use of antireflux procedures for children. Pediatrics 2006;118 (5) 1828- 1835
PubMed Link to Article
Safadi  BYKown  MWren  S Utilization of laparoscopic antireflux surgery at a single Veterans Affairs facility compared with the Veterans Affairs national trend. Am J Surg 2003;186 (5) 505- 508
PubMed Link to Article
Goldin  ABSawin  RSeidel  KDFlum  DR Do antireflux operations decrease the rate of reflux-related hospitalizations in children? Pediatrics 2006;118 (6) 2326- 2333
PubMed Link to Article
 Owner Hospitals. Child Health Corporation of America Web site. http://www.chca.com/owner_hospitals/index.html. Accessed October 2008
Martin  AJPratt  NKennedy  JD  et al.  Natural history and familial relationships of infant spilling to 9 years of age. Pediatrics 2002;109 (6) 1061- 1067
PubMed Link to Article
Nelson  SPChen  EHSyniar  GMChristoffel  KKPediatric Practice Research Group, Prevalence of symptoms of gastroesophageal reflux during infancy: a pediatric practice-based survey. Arch Pediatr Adolesc Med 1997;151 (6) 569- 572
PubMed Link to Article
Nelson  SPChen  EHSyniar  GMChristoffel  KKPediatric Practice Research Group, One-year follow-up of symptoms of gastroesophageal reflux during infancy. Pediatrics 1998;102 (6) E67
PubMed Link to Article
Osatakul  S The natural course of infantile reflux regurgitation: a non-Western perspective. Pediatrics 2005;115 (4) 1110- 1111
PubMed Link to Article
Osatakul  SSriplung  HPuetpaiboon  AJunjana  COChamnongpakdi  S Prevalence and natural course of gastroesophageal reflux symptoms: a 1-year cohort study in Thai infants. J Pediatr Gastroenterol Nutr 2002;34 (1) 63- 67
PubMed Link to Article
Hassall  E Antireflux surgery in children: time for a harder look. Pediatrics 1998;101 (3 pt 1) 467- 468
PubMed Link to Article
Hassall  E Decisions in diagnosing and managing chronic gastroesophageal reflux disease in children. J Pediatr 2005;146 (3) ((suppl)) S3- S12
PubMed Link to Article
Hassall  E Outcomes of fundoplication: causes for concern, newer options. Arch Dis Child 2005;90 (10) 1047- 1052
PubMed Link to Article
Poets  CF Gastroesophageal reflux: a critical review of its role in preterm infants. Pediatrics 2004;113 (2) e128- e132
PubMed Link to Article
Lee  SLShabatian  HHsu  JWApplebaum  HHaigh  PI Hospital admissions for respiratory symptoms and failure to thrive before and after Nissen fundoplication. J Pediatr Surg 2008;43 (1) 59- 65
PubMed Link to Article
Carson  JATunell  WPSmith  EI Pediatric gastroesophageal reflux: age-specific indications for operation. Am J Surg 1980;140 (6) 768- 771
PubMed Link to Article
Horgan  SPellegrini  CA Surgical treatment of gastroesophageal reflux disease. Surg Clin North Am 1997;77 (5) 1063- 1082
PubMed Link to Article
Semeniuk  JKaczmarski  M 24-hour esophageal pH-monitoring in children suspected of gastroesophageal reflux disease: analysis of intraesophageal pH monitoring values recorded in distal and proximal channel at diagnosis. World J Gastroenterol 2007;13 (38) 5108- 5115
PubMed
Bensoussan  ALYazbeck  SCarceller-Blanchard  A Results and complications of Toupet partial posterior wrap: 10 years' experience. J Pediatr Surg 1994;29 (9) 1215- 1217
PubMed Link to Article
Bliss  DHirschl  ROldham  K  et al.  Efficacy of anterior gastric fundoplication in the treatment of gastroesophageal reflux in infants and children. J Pediatr Surg 1994;29 (8) 1071- 1075
PubMed Link to Article
Fonkalsrud  EWBustorff-Silva  JPerez  CAQuintero  RMartin  LAtkinson  JB Antireflux surgery in children under 3 months of age. J Pediatr Surg 1999;34 (4) 527- 531
PubMed Link to Article
Norrashidah  AWHenry  RL Fundoplication in children with gastro-oesophageal reflux disease. J Paediatr Child Health 2002;38 (2) 156- 159
PubMed Link to Article

Figures

Place holder to copy figure label and caption
Figure 1.

Ratios of antireflux operations vs other gastrointestinal procedures by hospitals. ARP indicates antireflux procedure.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

The annual change in the number of antireflux operations in each hospital after controlling for appendectomy, pyloromyotomy, and gastrostomy tube placement.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Summary of the Study Populationa
Table Graphic Jump LocationTable 2. Ratios of Antireflux Operations vs Other Gastrointestinal Procedures Across Hospitals
Table Graphic Jump LocationTable 3. Regression Analysis of the Change in the Number of ARPs Performed Across Pediatric Hospitals per Year Relative to 3 Other Commonly Performed Operations in Infants and Children

References

Rudolph  CDMazur  LJLiptak  GS  et al. North American Society for Pediatric Gastroenterology and Nutrition, Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr 2001;32 ((suppl 2)) S1- S31
PubMed Link to Article
Orenstein  SRShalaby  TMKelsey  SFFrankel  E Natural history of infant reflux esophagitis: symptoms and morphometric histology during one year without pharmacotherapy. Am J Gastroenterol 2006;101 (3) 628- 640
PubMed Link to Article
Fonkalsrud  EWAment  ME Gastroesophageal reflux in childhood. Curr Probl Surg 1996;33 (1) 1- 70
PubMed Link to Article
Turnage  RHOldham  KTCoran  AGBlane  CE Late results of fundoplication for gastroesophageal reflux in infants and children. Surgery 1989;105 (4) 457- 464
PubMed
Fonkalsrud  EWAshcraft  KWCoran  AG  et al.  Surgical treatment of gastroesophageal reflux in children: a combined hospital study of 7467 patients. Pediatrics 1998;101 (3 pt 1) 419- 422
PubMed Link to Article
Kazerooni  NLVanCamp  JHirschl  RBDrongowski  RACoran  AG Fundoplication in 160 children under 2 years of age. J Pediatr Surg 1994;29 (5) 677- 681
PubMed Link to Article
Lasser  MSLiao  JGBurd  RS National trends in the use of antireflux procedures for children. Pediatrics 2006;118 (5) 1828- 1835
PubMed Link to Article
Safadi  BYKown  MWren  S Utilization of laparoscopic antireflux surgery at a single Veterans Affairs facility compared with the Veterans Affairs national trend. Am J Surg 2003;186 (5) 505- 508
PubMed Link to Article
Goldin  ABSawin  RSeidel  KDFlum  DR Do antireflux operations decrease the rate of reflux-related hospitalizations in children? Pediatrics 2006;118 (6) 2326- 2333
PubMed Link to Article
 Owner Hospitals. Child Health Corporation of America Web site. http://www.chca.com/owner_hospitals/index.html. Accessed October 2008
Martin  AJPratt  NKennedy  JD  et al.  Natural history and familial relationships of infant spilling to 9 years of age. Pediatrics 2002;109 (6) 1061- 1067
PubMed Link to Article
Nelson  SPChen  EHSyniar  GMChristoffel  KKPediatric Practice Research Group, Prevalence of symptoms of gastroesophageal reflux during infancy: a pediatric practice-based survey. Arch Pediatr Adolesc Med 1997;151 (6) 569- 572
PubMed Link to Article
Nelson  SPChen  EHSyniar  GMChristoffel  KKPediatric Practice Research Group, One-year follow-up of symptoms of gastroesophageal reflux during infancy. Pediatrics 1998;102 (6) E67
PubMed Link to Article
Osatakul  S The natural course of infantile reflux regurgitation: a non-Western perspective. Pediatrics 2005;115 (4) 1110- 1111
PubMed Link to Article
Osatakul  SSriplung  HPuetpaiboon  AJunjana  COChamnongpakdi  S Prevalence and natural course of gastroesophageal reflux symptoms: a 1-year cohort study in Thai infants. J Pediatr Gastroenterol Nutr 2002;34 (1) 63- 67
PubMed Link to Article
Hassall  E Antireflux surgery in children: time for a harder look. Pediatrics 1998;101 (3 pt 1) 467- 468
PubMed Link to Article
Hassall  E Decisions in diagnosing and managing chronic gastroesophageal reflux disease in children. J Pediatr 2005;146 (3) ((suppl)) S3- S12
PubMed Link to Article
Hassall  E Outcomes of fundoplication: causes for concern, newer options. Arch Dis Child 2005;90 (10) 1047- 1052
PubMed Link to Article
Poets  CF Gastroesophageal reflux: a critical review of its role in preterm infants. Pediatrics 2004;113 (2) e128- e132
PubMed Link to Article
Lee  SLShabatian  HHsu  JWApplebaum  HHaigh  PI Hospital admissions for respiratory symptoms and failure to thrive before and after Nissen fundoplication. J Pediatr Surg 2008;43 (1) 59- 65
PubMed Link to Article
Carson  JATunell  WPSmith  EI Pediatric gastroesophageal reflux: age-specific indications for operation. Am J Surg 1980;140 (6) 768- 771
PubMed Link to Article
Horgan  SPellegrini  CA Surgical treatment of gastroesophageal reflux disease. Surg Clin North Am 1997;77 (5) 1063- 1082
PubMed Link to Article
Semeniuk  JKaczmarski  M 24-hour esophageal pH-monitoring in children suspected of gastroesophageal reflux disease: analysis of intraesophageal pH monitoring values recorded in distal and proximal channel at diagnosis. World J Gastroenterol 2007;13 (38) 5108- 5115
PubMed
Bensoussan  ALYazbeck  SCarceller-Blanchard  A Results and complications of Toupet partial posterior wrap: 10 years' experience. J Pediatr Surg 1994;29 (9) 1215- 1217
PubMed Link to Article
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