Esophageal pH monitoring abnormalities and gastroesophageal reflux diseasein infants with intestinal malrotation

Hypothesis: Infants with rotational abnormalities of the midgut mesentery a re at high risk for gastroesophageal reflux disease (GERD) and for sudden i nfant death (SID) from GERD. Design: A survey of the prevalence of GERD and the risk factor for SID from GERD in a case series of infants treated for congenital anomalies that inc lude intestinal malrotation. Eighty-one (89%) of the infants studied for GE RD had a mean follow-up of 23.2 months (median, 12 months). Setting: Patients treated in 2 tertiary care centers consisting of a childr en's hospital and a university medical center. Patients: Two hundred eighty-six consecutive infants were treated for conge nital anomalies from September 1, 1985, through May 31, 1998. The patients selected for study were 91 infants who had 18- to 24-hour esophageal pH mon itoring performed and no prior operation on the stomach or esophagus. The s tudied infants had intestinal malrotation either alone (n = 55) or associat ed with a repaired abdominal wall defect (n = 23) or congenital diaphragmat ic hernia (n = 13). Of the 91 infants, 34 were asymptomatic at the time of esophageal pH monitoring. Interventions: Eighteen- to 24-hour esophageal pH monitoring was used to de termine the presence of GERD (abnormal pH score >2 hours postcibal) and the risk factor for SID from GERD (type I or III reflux pattern in combination with a prolonged mean duration of sleep reflux). Main Outcome Measures: The prevalence of GERD and the risk factor for SID f rom GERD. The follow-up of GERD was reported as a combination of clinical o utcome and subsequent extended esophageal pH monitoring. Results: Of the 91 infants studied, 80 (88%) had GERD and 26 (29%) had the risk factor for SID from GERD. Of 55 infants with intestinal malrotation al one, 52 (95%) had GERD, and 20 (36%) had the risk factor for SID from GERD. Although GERD was found in 19 (83%) of 23 patients with repaired abdominal wall defects, the prevalence of the risk factor for SID from GERD was sign ificantly lower (13% [3 patients]; P = .03) than in patients with intestina l malrotation alone. The prevalence of GERD in infants with repaired congen ital diaphragmatic hernia was significantly lower (69% [9/13]; P = .02) tha n in infants with intestinal malrotation alone but not for the prevalence o f the risk factor for SID from GERD (23% [3/13]; P = .19). Both symptomatic and asymptomatic patients had similar prevalences of GERD (91% [52/57] vs 82% [28/34]; P = .17) and for the risk factor for SID from GERD (31% [18/57 ] vs 24% [8/34]; P = .28). On followup, the prognosis for GERD in infants w ith intestinal malrotation was better in the infants who were asymptomatic than in those who were symptomatic at the initial extended esophageal pH mo nitoring. Conclusions: The prevalence of GERD in infants with intestinal malrotation is high, and the prevalence of the risk factor for SID from GERD is a signi ficant concern. The prevalence of GERD is lower in infants with congenital diaphragmatic hernia. Infants with repaired abdominal wall defects have a l ower prevalence of the risk factor for SID from GERD. We recommend careful evaluation and follow-up of infants with intestinal malrotation for problem s, such as SID, from GERD.