para>PPIs not approved for children <1 year. No improvement in GERD-associated symptoms in infants with PPI use versus placebo (7)[A]. Idiosyncratic reactions develop in 12 " 14% of children (nausea, diarrhea, constipation, and headaches) (7)[B]. First-line treatment for children <1 year is histamine-2 receptor antagonists (H2RA) (7)[C].
Ranitidine: 4 to 10 mg/kg/day divided BID ( ≥16 years use adult dose of 150 mg BID)
Famotidine: 1 mg/kg/day divided BID ( ≥12 years use adult dose 20 to 40 mg BID)
Nizatidine: 5 to 10 mg/kg/day divided BID ( ≥12 years use adult dose 150 mg BID)
ISSUES FOR REFERRAL
- Gastroenterology: for diagnostic procedures to confirm GERD
- Neurology: prolonged tonic " clonic movements, mental status changes during episodes, postictal state, or apnea
- Surgery: GERD with Sandifer syndrome that is refractory to medication therapy
ADDITIONAL THERAPIES
- Prokinetic agents: Cisapride, metoclopramide, or erythromycin may help in refractory GERD with Sandifer syndrome if delayed gastric emptying is present (9).
- Nasojejunal or IV feedings may be helpful in refractory cases (10).
- If eosinophilic esophagitis from cow 's milk protein allergy is present, amino-acid-based-formula may contribute to resolution of symptoms (5).
SURGERY/OTHER PROCEDURES
Nissen fundoplication can be curative for GERD and associated Sandifer syndrome.
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
If symptoms do not resolve with treatment of GERD, refer to a neurologist for video-EEG to look for seizures (11).
PROGNOSIS
Sandifer syndrome resolves once the GERD is treated.
REFERENCES
11 Lehwald N, Krausch M, Franke C, et al. Sandifer syndrome " a multidisciplinary diagnostic and therapeutic challenge. Eur J Pediatr Surg. 2007;17(3):203 " 206.22 Nowak M, Strzelczyk A, Oertel WH, et al. A female adult with Sandifer 's syndrome and hiatal hernia misdiagnosed as epilepsy with focal seizures. Epilepsy Behav. 2012;24(1):141 " 142.33 Kabaku
N, Kurt A. Sandifer syndrome: a continuing problem of misdiagnosis. Pediatr Int. 2006;48(6):622 " 625.44 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). J Pediatr Gastroenterol Nutr. 2009;49(4):498 " 547.55 Bamji N, Berezin S, Bostwick H, et al. Treatment of Sandifer syndrome with an amino-acid-based formula. AJP Rep. 2015;5(1):e51 " e52.66 Frankel EA, Shalaby TM, Orenstein SR. Sandifer syndrome posturing: relation to abdominal wall contractions, gastroesophageal reflux, and fundoplication. Dig Dis Sci. 2006;51(4):635 " 640.77 Sullivan JS, Sundaram SS. Gastroesophageal reflux. Pediatr Rev. 2012;33(6):243 " 253.88 Czinn SJ, Blanchard S. Gastroesophageal reflux disease in neonates and infants: when and how to treat. Paediatr Drugs. 2013;15(1):19 " 27.99 Michail S. Gastroesophageal reflux. Pediatr Rev. 2007;28(3):101 " 110.1010 Kirkham FJ, Haywood P, Kashyape P, et al. Movement disorder emergencies in childhood. Eur J Paediatr Neurol. 2011;15(5):390 " 404.1111 Hahn JS, Sanger T. Neonatal movement disorders. NeoReviews. 2004;5(8):e321 " e326.
CODES
ICD10
M43.6 Torticollis
ICD9
723.5 Torticollis, unspecified
SNOMED
Sandifer syndrome
CLINICAL PEARLS
- Sandifer syndrome is underrecognized and often misdiagnosed as epilepsy.
- History is the most important aspect of diagnosing Sandifer syndrome.