Sandifer Syndrome Treatment & Management
- Author: Pegeen Eslami, MD; Chief Editor: Carmen Cuffari, MD more...
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]
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).
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.
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.  See the image below.
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.
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 
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]
Frankel EA, Shalaby TM, Orenstein SR. Sandifer syndrome posturing: relation to abdominal wall contractions, gastroesophageal reflux, and fundoplication. Dig Dis Sci. 2006 Apr. 51(4):635-40. [Medline].
Kirkham FJ, Haywood P, Kashyape P, Borbone J, Lording A, Pryde K, et al. Movement disorder emergencies in childhood. Eur J Paediatr Neurol. 2011 Sep. 15(5):390-404. [Medline].
Obeid M, Mikati MA. Expanding spectrum of paroxysmal events in children: potential mimickers of epilepsy. Pediatr Neurol. 2007 Nov. 37(5):309-16. [Medline].
Kostakis A, Manjunatha NP, Kumar A, Moreland ES. Abnormal head posture in a patient with normal ocular motility: Sandifer syndrome. J Pediatr Ophthalmol Strabismus. 2008 Jan-Feb. 45(1):57-8. [Medline].
Lehwald N, Krausch M, Franke C, Assmann B, Adam R, Knoefel WT. Sandifer syndrome--a multidisciplinary diagnostic and therapeutic challenge. Eur J Pediatr Surg. 2007 Jun. 17(3):203-6. [Medline].
Kabakus N, Kurt A. Sandifer Syndrome: a continuing problem of misdiagnosis. Pediatr Int. 2006 Dec. 48(6):622-5. [Medline].
Shepherd RW, Wren J, Evans S, et al. Gastroesophageal reflux in children. Clinical profile, course and outcome with active therapy in 126 cases. Clin Pediatr (Phila). 1987 Feb. 26(2):55-60. [Medline].
Nalbantoglu B, Metin DM, Nalbantoglu, A. Sandifer's Syndrome: A Misdiagnosed and Mysterious Disorder. Iran Journal of Pediatrics. December 2013. 23 (6):715-716.
Deskin RW. Sandifer syndrome: a cause of torticollis in infancy. Int J Pediatr Otorhinolaryngol. 1995 May. 32(2):183-5. [Medline].
Orenstein SR. Update on gastroesophageal reflux and respiratory disease in children. Can J Gastroenterol. 2000 Feb. 14(2):131-5. [Medline].
Del Giudice E, Staiano A, Capano G, et al. Gastrointestinal manifestations in children with cerebral palsy. Brain Dev. 1999 Jul. 21(5):307-11. [Medline].
Vandenplas Y, Rudolph CD, Di Lorenzo C et al. Pediatric Gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN). Journal of Pediatric Gastroenterology and Nutrition. 2009. 49 (4):498-547.
Ward RM, Kearns GL. Proton Pump Inhibitors in Pediatrics: Mechanism of Action, Pharmacokinetcis, Phamacogenetics, and Pharmacodynamics. Pediatric Drugs. March 2013. 15 (2):119-131.
Tighe M, Afzal NA, Bevan A, Munro A, Beattie RM. Pharmacologic treatment of children with gastroesophageal reflux (Review). The Cochrane Collaboration. 2014. Issue 11:1-83. [Full Text].
van der Pol RJ, Smits MJ, van Wijk MP et al. Efficacy of Proton-Pump Inhibitors in children with gastroesophageal reflux disease: a systematic review. Pediatrics. 2011. 127 (5):925.
Orenstein SR, Hassall E, Furmaga-Jablonska W et al. Multicenter, double-blind, randomized, placebo-controlled trial assessing the efficacy and safety of proton pump inhibitor lansoprazole in infants with symptoms of gastroesophageal reflux disease. Journal of Pediatrics. 2009. 154 (4):514.
Craig WR, Hanlon-Dearmane A, Sinclair C et al. Metoclopramide, thickened feedings and positioning for gastro-esophageal reflux in children under 2 years. Cochrane Database Systematic Reviews. 2004. [Medline].
Horvath A, Dziechciarz P, Szajewska H. The effect of thickened-feed interventions of gastroesophageal reflux in infants: systematic review and meta-analysis of randomized, controlled trials. Pediatrics. 2008. 122 (6):e1268. [Medline].
Kahrilas PJ, Shaheen NJ, Vaezi MF, et al. American Gastroenterological Association Medical Position Statement on the management of gastroesophageal reflux disease. Gastroenterology. 2008 Oct. 135(4):1383-1391, 1391.e1-5. [Medline].
Lightdale JR, Gremse DA, Section on Gastroenterology, Hepatology, and Nutrition. Gastroesophageal reflux: management guidance for the pediatrician. Pediatrics. 2013 May. 131 (5):e1684-95. [Medline].
Chiba N, De Gara CJ, Wilkinson JM, Hunt RH. Speed of healing and symptom relief in grade II to IV gastroesophageal reflux disease: a meta-analysis. Gastroenterology. 1997 Jun. 112 (6):1798-810. [Medline].
Moore DJ, Tao BS, Lines DR, Hirte C, Heddle ML, Davidson GP. Double-blind placebo-controlled trial of omeprazole in irritable infants with gastroesophageal reflux. J Pediatr. 2003 Aug. 143 (2):219-23. [Medline].
Bamji N, Berezin S, Bostwick H, Medow MS. Treatment of Sandifer Syndrome with an Amino-Acid-Based Formula. AJP Rep. 2015 Apr. 5 (1):e51-2. [Medline].
Dias E, Ramachandra C, D'Cruz AJ, Yeshwanth M. An unusual presentation of gastro-oesophageal reflux--Sandifer's syndrome. Trop Doct. 1992 Jul. 22(3):131. [Medline].
Gold BD. Gastroesophageal reflux disease: could intervention in childhood reduce the risk of later complications?. Am J Med. 2004 Sep 6. 117 Suppl 5A:23S-29S. [Medline].
Gorrotxategi P, Reguilon MJ, Arana J. Gastroesophageal reflux in association with the Sandifer syndrome. Eur J Pediatr Surg. 1995 Aug. 5(4):203-5. [Medline].
Mandel H, Tirosh E, Berant M. Sandifer syndrome reconsidered. Acta Paediatr Scand. 1989 Sep. 78(5):797-9. [Medline].
Somjit S, Lee Y, Berkovic SF, Harvey AS. Sandifer syndrome misdiagnosed as refractory partial seizures in an adult. Epileptic Disord. 2004 Mar. 6(1):49-50. [Medline].
Theodoropoulos DS, Flockey RF, Boyce HW Jr. Sandifer's syndrome and gastro-oesophageal reflux disease. J Neurol Neurosurg Psychiatry. 1999 Jun. 66(6):805-6. [Medline].
Werlin SL, D'Souza BJ, Hogan WJ, Dodds WJ, Arndorfer RC. Sandifer syndrome: an unappreciated clinical entity. Dev Med Child Neurol. 1980 Jun. 22(3):374-8. [Medline].
Werlin SL, Dodds WJ, Hogan WJ, Arndorfer RC. Mechanisms of gastroesophageal reflux in children. J Pediatr. 1980 Aug. 97(2):244-9. [Medline].