Sandifer Syndrome

Definition

Paroxysmal abnormal posturing of the head, neck and trunk linked to gastro oesophageal reflux, often with hiatus hernia. It can be mistaken for torticollis or seizures.

Aetiology

  • Gastro oesophageal reflux, with or without hiatus hernia
  • Posturing is thought to ease oesophageal discomfort
  • Neurodisability such as cerebral palsy raises reflux risk

Epidemiology

  • Infants and young children, with a peak under 2 years
  • More frequent in children with neurodisability

Clinical Features

  • Episodic torticollis, neck extension and back arching
  • Episodes related to feeding, lasting minutes
  • Normal neck movement and no sternocleidomastoid mass between episodes
  • Irritability, vomiting, failure to thrive and anaemia
  • Normal neurological examination between episodes
  • Head tilt may alternate sides between episodes

Investigations

  • pH impedance monitoring links episodes to reflux
  • Contrast swallow or endoscopy for hiatus hernia and oesophagitis
  • Video of episodes aids diagnosis
  • EEG excludes seizures
  • Cervical spine radiographs exclude structural causes

Differential Diagnosis

Management

  • Antireflux measures. Feed thickening and positioning
  • Small frequent feeds. Reduce reflux in infants
  • Acid suppression. Proton pump inhibitor or H2 receptor antagonist
  • Fundoplication. Refractory reflux or hiatus hernia

Prognosis

  • Posturing resolves once reflux is controlled
  • Delayed diagnosis leads to needless neurological investigation

References

  1. 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, 17(3), 203-6. PubMed
  2. Mindlina I. Diagnosis and management of Sandifer syndrome in children with intractable neurological symptoms. Eur J Pediatr. 2020, 179(2), 243-250. PubMed

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 19 October 2026.