Published online December 29, 2008
PEDIATRICS Vol. 123 No. 1 January 2009, pp. 338-345 (doi:10.1542/peds.2007-1740)

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ARTICLE

Impact of Fundoplication Versus Gastrojejunal Feeding Tubes on Mortality and in Preventing Aspiration Pneumonia in Young Children With Neurologic Impairment Who Have Gastroesophageal Reflux Disease

Rajendu Srivastava, MD, FRCP(C), MPH^a, Earl C. Downey, MD^a, Molly O'Gorman, MD^a, Peter Feola, MD^b, Matthew Samore, MD^a, Richard Holubkov, PhD^a, Michael Mundorff, MBA/MHSA^b, Brent C. James, MD, MStat^b, Peter Rosenbaum, MD, FRCP(C)^c, Paul C. Young, MD^a, Jonathan M. Dean, MD^a

^a University of Utah Health Sciences Center, Salt Lake City, Utah
^b Intermountain Healthcare Inc, Salt Lake City, Utah
^c McMaster University, Hamilton, Ontario, Canada

OBJECTIVE. Aspiration pneumonia is the most common cause of death in children with neurologic impairment who have gastroesophageal reflux disease. Fundoplications and gastrojejunal feeding tubes are frequently employed to prevent aspiration pneumonia in this population. Which of these approaches is more effective in preventing aspiration pneumonia and/or improving survival is unknown. The objective of this study was to compare outcomes for children with neurologic impairment and gastroesophageal reflux disease after either a first fundoplication or a first gastrojejunal feeding tube.

PATIENTS AND METHODS. This was a retrospective, observational cohort study of children with neurologic impairment who had either a fundoplication or gastrojejunal feeding tube between January 1997 and December 2005 at a tertiary care children's hospital. Main outcome measures were postprocedure aspiration pneumonia–free survival and mortality. Propensity analyses were used to control for bias in treatment assignment and prognostic imbalances.

RESULTS. Of the 366 children with neurologic impairment and gastroesophageal reflux disease, 43 had a first gastrojejunal feeding tube and 323 underwent a first fundoplication. Median length of follow-up was 3.4 years. Children who received a first fundoplication had similar rates of aspiration pneumonia and mortality after the procedure compared with those who had a first gastrojejunal feeding tube, when adjusting for the treatment assignment using propensity scores.

CONCLUSIONS. Aspiration pneumonia and mortality are not uncommon events after either a first fundoplication or a first gastrojejunal feeding tube for the management of gastroesophageal reflux disease in children with neurologic impairment. Neither treatment option is clearly superior in preventing the subsequent aspiration pneumonia or improving overall survival for these children. This complex clinical scenario needs to be studied in a prospective, multicenter, randomized control trial to evaluate definitively whether 1 of these 2 management options is more beneficial.

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Key Words: children • neurologic impairment • gastroesophageal reflux disease • aspiration pneumonia • fundoplication

Abbreviations: AP—aspiration pneumonia • GERD—gastroesophageal reflux disease • GJT—gastrojejunal feeding tubes • RCT—randomized, controlled trial • PCMC—Primary Children's Medical Center • ICD-9-CM—International Classification of Diseases, Ninth Revision, Clinical Modification • CCC—complex chronic condition • HR—hazard ratio • CI—confidence interval

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Accepted May 1, 2008.

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				R. Srivastava, J. G Berry, M. Hall, E. C Downey, M. O'Gorman, J M. Dean, and D. C Barnhart Reflux related hospital admissions after fundoplication in children with neurological impairment: retrospective cohort study BMJ, November 18, 2009; 339(nov18_2): b4411 - b4411. [Abstract] [Full Text] [PDF]