Infant Back Arching

Dear Lisa,

Infant born at 25.5 weeks (weight 2 lbs 1 oz). Now 7 months of age. Recently began arching back, holding head back and stiffening arms. Has a shunt, has had hernia repairs, has had surgery on muscle between stomach and esophagus (can't burp or spit up), has feeding button (now eats most formula from bottle). Acid reflux? Food Allergies? Other suggestions????

“Concerned Family”

Dear “Concerned Family”,

It sounds like you and your baby have been through a lot over the last 7 months. Certainly back arching can be a sign of Gastroesophageal reflux disease(GERD). Infants with Sandifer syndrome demonstrate these symptoms. Sandifer syndrome is a condition that is found in some infants with GERD. The symptoms include spasms of the head, neck as well as back arching in response to refluxed abdominal contents. (1,2) An infant with this condition arches her back and turns her head to the side in order to lengthen the esophagus, increase lower esophageal sphincter pressure and avoid aspiration. (1,3)

Infants who had anti-reflux surgery such as the one you described should not have symptoms of reflux. The purpose of this type of surgery, also known as Fundoplication, is to treat GERD symptoms. Of the several different Fundoplication techniques, the Nissen Fundoplication, is the one most commonly performed.(4) During this type of surgery the fundus or the top part of the stomach is wrapped 360 degrees around the base of the esophagus or food tube. After a child eats, the stomach distends and the increased pressure around the wrap should prevent reflux.(5)

The outcome of anti-reflux surgery is usually favorable, but the duration of efficacy or the length of time that the results last is limited. The need for repeat surgery is common. (6) There have been some reports of high rates of failure associated with this surgery. (7) In children who have had Fundoplication surgery, 3- 18.9% of them need re-operation. (8)

An evaluation by your Gastroenterologist and Surgeon that performed you child’s surgery will be able to tell you if the procedure is effectively controlling her GERD symptoms. Testing, such as 24 hour intraesophageal pH monitoring may need to be performed in order to determine if your daughter’s present symptoms are due to GER. A pH probe determines the percentage of total time that the esophagus is exposed to a pH lower than 4. This is the most valid measure of gastric acid reflux and is considered the gold standard in the diagnosis of GER.(9)

Reflux is not the only condition that can cause a child to have head and neck spasms and back arching. GERD symptoms and seizure activity are very similar in their presentation and one of these conditions can easily be mistaken for the other. (10) Seizure activity can present in many different ways. A partial focal seizure can present with unusual body movements. Simple partial seizures can present as something as discrete as hand twitching. (11) An absence seizure presents as a staring spell in which a child gazes into space and can be mistaken for daydreaming.

The symptoms of these types of seizures are much different from what most people consider to be a seizure. Most people are familiar with myoclonic generalized seizures which involve the rapid jerking of the whole body and its extremities. Something as subtle as back arching, abnormal positioning of the head and stiffening of the extremities could be signs of seizure activity in an infant and should be further investigated.

Other potential causes for this type of infant activity include cardiac events or dystonia. (11) A dystonia is a movement disorder with many causes. It presents as a sustained muscle contraction that may cause twisting or repetitive movements. (11) Dystonia can be caused by a side effect to a medication. Certain medications such as Phenothiazines and Metoclopramide (an anti-emetic drug) can cause dystonia. (1) Phenothiazine derivatives can be found in some cough medications.

Your daughter’s symptoms need to be evaluated by a Health Care Professional in order to determine the cause. You can take a video recording of the event so that your Pediatrician can visualize the symptoms that you are describing. A symptom diary should be kept noting the time, duration, relation to activity and eating, eliciting factors and surrounding environment. This information can aid your daughter’s Physician in determining the cause of her symptoms.

If your are interested in reading other Pediatric Advice stories covering this topic:

Gastroesophageal Reflux

I wish you and your daughter well.

References:
(1)Schwartz M, Charney E, Curry T, Ludwig S. Pediatric Primary Care. A Problem Oriented Approach. 2nd Ed. Littleton, Mass:Year Book Medical Publishers, Inc. 1990:353,344.
(2)Edmunds A. Gastroesophageal Reflux Disease in the Pediatric Patient. Therapeutic Spotlight. 2005. August:4-13.
(3)Gorrotxategi P, Reguilon MJ, Arana J. Gastroesophageal reflux in association with the Sandifer syndrome. Eur J Pediatr Surg.1995.5:203-205.
(4)Suwandhi E, Ton M, Schwarz S. Gastroesophageal Reflux in Infancy and Children. Pediatric Annals. 2006.35(4):259-266.
(5)Behrman R, Kliegman R. Nelson Essentials of Pediatrics. Philadelphia ,PA: W.B.Saunders Company. 1990:393.
(6)Waring JP, Fieler MJ, Hunter JG. Childhood Gastroesophageal reflux symptoms in adult patients. J Pediatr Gastroenterol Nutr. 2002.; 35:334-338.
(7)Hassall E. Wrap session: is the Nissen slipping? Can medical treatment replace surgery for severe Gastroesophageal reflux disease in children? Am J Gastroenterol 1995;90
(8):1212-1220. (8) North American Society for Pediatric Gastroenterology and Nutrition. Guidelines for evaluation and treatment of Gastroesophageal reflux in infants and children. J Pediatr Gastroenterol Nutr. 2001.32(suppl 2).
(9)Rudolph CD, Mazur LJ, Liptak GS. North American Society for Pediatric Gastroenterology and Nutrition. Guidelines for evaluation and treatment of Gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr. 2001;32(Supple 2):S1-31.
(10) Jackson P, Vessey J. Primary Care of the Child with a Chronic Condition. St. Louis, Missouri: Mosby –Yearbook, Inc. 1992:278.
(11) Wolf S, Engel McGoldrick P. Recognition and Management of Pediatric Seizures. Pediatric Annals. 2006. 35(5):332-344.

Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice Website