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Sandifer Syndrome Treatment & Management

  • Author: Pegeen Eslami, MD; Chief Editor: Carmen Cuffari, MD  more...
 
Updated: Nov 11, 2015
 

Approach Considerations

Most cases of Sandifer syndrome resolve with time and development, within the first 24 months.  Initial interventions should be directed at "lifestyle" changes--modification or attention to feeding habits, adjustment of feeds (whether breast milk or formula), exclusionary diets, positioning.

Typical medications directed at GERD include acid suppressants (H2 receptor antagonists, proton pump inhibitors), buffers (antacids), prokinetic. These medications are used to treat GERD in older children and adults.  There is very limited data about their usefulness in infants < 12 months.   Those studies which have been done show mixed results with respect to the efficacy of these pharmacologic interventions versus their recognized adverse effects and cost.   ([13, 14, 15, 16, 17, 18]

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Medical Care

Sandifer syndrome does not require treatment and typically resolves in the first 12-24 months of life, as nutrition is gradually less dependent on volumes of fluid, and the LES function improves unless the spasms are the result of gastroesophageal disease which is significant enough to interfere with growth and feeding. In the latter case, therapy should be directed towards the specific cause (see Gastroesophageal Reflux). The American Gastroenterological Association has issued guidelines for the management of gastroesophageal reflux disease (GERD).[19]

  • The primary aim of medical care is to identify Sandifer syndrome.
    • This can be accomplished most often by soliciting a careful history of the times of day the spasms occur and their association with feeding.
    • If recognizing the complex is difficult, then video-EEG monitoring or more evaluation of possible GERD may be of value (pH probe/MII).
  • Often, parent education and explanation regarding the nature of the spasms are all that is required in treatment of this condition. If the patient does have pathologic gastroesophageal reflux or complications from gastroesophageal reflux such as cough, poor growth, guaiac positive stools then consideration of milk protein allergy and /or intervention for gastroesophageal reflux disease may be indicated.
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Surgical Care

See the list below:

  • In those cases with severe, confirmed gastroesophageal disease unresponsive to medical therapy and conservative interventions, and which is interfering with growth and development, some evidence suggests that fundoplication may alleviate symptoms. [5] See the image below.
    Diagram illustrating the Nissen fundoplication. No Diagram illustrating the Nissen fundoplication. Note how the stomach is wrapped around the esophagus (360º wrap).
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Consultations

See the list below:

  • Primary care pediatricians should consider and be able to recognize the symptoms of Sandifer syndrome
  • In the absence of other concerning findings on history or physical it is appropriate for the primary care pediatrician to initiate interventions discussed below.
  • With refractory cases or where there is a concern about either the lack of response to conservative interventions, or other possible GI pathology, referral to a pediatric gastroenterologist is appropriate
  • If any doubt surrounds the nature of the seizurelike activity or if the child has underlying neurologic impairment, a consultation with a pediatric neurologist may be beneficial.
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Diet

See the list below:

Dietary interventions typically include sequential trials of the following: 

  • Trial of feeding modifications such as smaller volume, more frequent feeds, avoiding overfeeding
  • Trials of thickened feeds (including rice or oat cereals, or other types of thickeners (see gastroesophageal reflux articles for detailed discussion))
  • Trials of extensively hydrolyzed protein or amino-acid -based formula +/- thickening
  • For breast fed babies, modification of maternal diet to exclude cow's milk and egg [12]

Other lifestyle inventions including avoidance of second-hand tobacco smoke exposures, maintaining infant in semi-upright position for 30 minutes after feed, avoiding seated or supine positioning during the immediate period after feeds [12, 17, 18, 20]

 

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Contributor Information and Disclosures
Author

Pegeen Eslami, MD Associate Professor of Pediatrics, Division of Pediatric Emergency Medicine, UMass Memorial Medical Center

Pegeen Eslami, MD is a member of the following medical societies: Academic Pediatric Association, American Academy of Pediatrics, American College of Emergency Physicians, Massachusetts Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Raj D Sheth, MD Chief, Division of Pediatric Neurology, Nemours Children's Clinic; Professor of Neurology, Mayo College of Medicine; Professor of Pediatrics, University of Florida College of Medicine

Raj D Sheth, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Pediatrics, American Epilepsy Society, American Neurological Association, Child Neurology Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

David A Piccoli, MD Chief of Pediatric Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia; Professor, University of Pennsylvania School of Medicine

David A Piccoli, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Disclosure: Nothing to disclose.

Chief Editor

Carmen Cuffari, MD Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine

Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, Royal College of Physicians and Surgeons of Canada

Disclosure: Received honoraria from Prometheus Laboratories for speaking and teaching; Received honoraria from Abbott Nutritionals for speaking and teaching.

Additional Contributors

Jorge H Vargas, MD Professor of Pediatrics and Clinical Professor of Pediatric Gastroenterology, University of California, Los Angeles, David Geffen School of Medicine; Consulting Physician, Department of Pediatrics, University of California at Los Angeles Health System

Jorge H Vargas, MD is a member of the following medical societies: American Liver Foundation, Latin American Society of Pediatric Gastroenterology, Hepatology & Nutrition, American Society for Gastrointestinal Endoscopy, American Society for Parenteral and Enteral Nutrition, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Disclosure: Nothing to disclose.

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Diagram illustrating the Nissen fundoplication. Note how the stomach is wrapped around the esophagus (360º wrap).
 
 
 
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