Approach Considerations
Most cases of Sandifer syndrome resolve with time and development, within the first 24 months. Initial interventions should be directed at the following lifestyle changes:
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Modification of or attention to feeding habits
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Adjustment of feeds (whether breast milk or formula)
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Exclusionary diets
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Positioning
Typical medications directed at gastroesophageal reflux disease (GERD) include acid suppressants (H2 receptor antagonists, proton pump inhibitors), buffers (antacids), and prokinetic agents. These medications are used to treat GERD in older children and adults. There are very limited data about their usefulness in infants under age 12 months. Those studies that have been done show mixed results with respect to the efficacy of these pharmacologic interventions versus their recognized adverse effects and cost. [16, 17, 18, 19, 20, 21]
Medical Care
Sandifer syndrome generally does not require treatment and typically resolves in the first 12-24 months of life. During this period, nutrition is gradually less dependent on volumes of fluid, and the lower esophageal sphincter function improves unless the spasms result from gastroesophageal disease that is severe enough to interfere with growth and feeding. In the latter case, therapy should be directed toward the specific cause (see Pediatric Gastroesophageal Reflux for more detail). The American Gastroenterological Association has issued guidelines for the management of GERD. [22]
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-electroencephalography monitoring or additional evaluation for possible GERD may be of value (eg, pH probe/multichannel intraluminal impedance study).
Often, parent education and explanation regarding the nature of the spasms are all that is required in the treatment of Sandifer syndrome. If the patient has pathologic gastroesophageal reflux or complications from gastroesophageal reflux such as cough, poor growth, or guaiac-positive stools, then consideration of milk protein allergy or intervention for GERD may be indicated.
Surgical Care
In patients with severe, confirmed gastroesophageal disease that is unresponsive to medical therapy and conservative interventions and that interferes with growth and development, some evidence suggests that fundoplication may alleviate symptoms. [3] See the image below.
Diagram illustrating the Nissen fundoplication. Note how the stomach is wrapped around the esophagus (360º wrap).
Consultations
Primary care pediatricians should consider and be able to recognize the symptoms of Sandifer syndrome. In the absence of other concerning findings on the history or physical examination, it is appropriate for the primary care pediatrician to initiate dietary and other lifestyle interventions.
In cases that are refractory to conservative interventions or that raise suspicion of other possible gastrointestinal 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.
Diet
Dietary interventions typically include sequential trials of the following:
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Feeding modifications, such as smaller volume, more frequent feeding, and avoiding overfeeding.
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Use of thickened feeds, including rice or oat cereals or other types of thickeners (see Pediatric Gastroesophageal Reflux for more detail).
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Use of extensively hydrolyzed protein- or amino-acid–based formula with or without thickening.
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For breast-fed infants, modification of maternal diet to exclude cow's milk and eggs. [8]
Other lifestyle interventions include avoidance of second-hand tobacco smoke exposure, maintaining the infant in a semi-upright position for 30 minutes after feeding, and avoiding seated or supine positioning during the immediate period after feeding. [8, 20, 21, 23]
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Diagram illustrating the Nissen fundoplication. Note how the stomach is wrapped around the esophagus (360º wrap).
