Gastroesophageal reflux after repair of atrioventricular septal defect in infants with trisomy 21: A comparison of medical and surgical therapy

Background: Gastroesophageal reflux and dysmotility are common in children with trisomy 21. Children with trisomy 21 and congenital heart disease are at increased risk for complications of gastroesophageal reflux even after r epair of their cardiac abnormalities. The optimal management of reflux in t hese patients is not known. Methods: The authors studied 24 consecutive infants (5.3 +/- 3.1 months) wi th trisomy 21 and atrioventricular septal defect who had symptoms or signs of gastroesophageal reflux and a positive esophageal pH study finding early after repair of their cardiac anomaly. Ten patients were given standardize d medical therapy with upright positioning during and after feedings, thick ening of feedings, metoclopramide, and an Hz-receptor antagonist. The other 14 underwent primary surgical management consisting of Nissen fundoplicati on through a minilaparotomy. Results: All 10 medically treated patients required readmission within 2 we eks for complications related to reflux, including aspiration or pneumonia (n = 6), persistent failure to thrive (n = 2), and frequent apneic episodes (n = 2). No surgically treated patients had reflux-related complications r equiring readmission. The total duration of hospitalization in the medicall y treated patients, including the initial hospitalization and the rehospita lization, was significantly longer than in patients who underwent fundoplic ation (35.8 +/- 9.8 v 10.4 +/- 2.2 days, P <.001). At follow-up (24 to 56 m onths), all patients were alive except for 1 medically treated patient who died of aspiration pneumonia 28 days after readmission. Two medically treat ed patients required a Nissen, and 3 patients in the surgical group underwe nt redo fundoplication, all within 1 year. Three other patients in the medi cally treated group required a total of 8 hospitalizations for complication s of reflux. No patient in either group required placement of a gastrostomy tube. Weight percentile for age was higher in surgical than medical patien ts. Conclusions: Infants with trisomy 21 and atrioventricular septal defect who undergo fundoplication are less likely to experience major complications o f reflux early after cardiac surgery than those treated with a medical regi men of upright posture, thickened feedings, metoclopramide, and H-2-recepto r blockade. J Pediatr Surg 34:1359-1363. Copyright (C) 1999 by W.B. Saunder s Company.