ALTE and gastro-oesophageal reflux.

reflux McGovern and Smith have embarked on the welcome development of an evidence based algorithm for the investigation of infants presenting with an apparent life threatening event (ALTE). Unfortunately, they do not distinguish between coincidence and causality. Recurrent vomiting occurs in over 60% of 4 month old babies, and it is therefore unsurprising that gastro-oesophageal reflux is commonly found in infants presenting with ALTEs. The aim of their study was to determine the diagnoses reported after the first evaluation of an ALTE, but the paper’s title then somewhat misleadingly refers to ‘‘causes’’ of ALTE. Despite the fact that in six of the eight studies analysed, patients did not routinely undergo pH monitoring, one of the most common diagnoses made was ‘‘gastrooesophageal reflux disease’’ (GORD). This begs the question as to whether most if not all of the children merely had physiological gastro-oesophageal reflux (GOR), wrongly defined as GORD, simply because of the ALTE under investigation—an unwarranted assumption of causality. Moreover, they fail to point out that the milk scans and contrast studies used in some of their cited studies have unacceptably low sensitivity and specificity in the diagnosis of non-physiological GOR. Their suggested plan of investigation acknowledges that in around 50% of infants experiencing an ALTE, a careful history and examination will point to an underlying diagnosis. Conversely, in the absence of other symptoms (for example, vomiting) they imply it may be important to identify and treat occult reflux by recommending investigating for GOR. Demonstration of a significant temporal relation between lower oesophageal acidification and apnoea is crucial in establishing a causal hypothesis linking the two. However, when Arad-Cohen et al explored the relation between GOR and apnoea in infants with a history of ALTE during polygraphic recording, only 19% of 741 brief apnoeas were coupled with GOR, and of these, apnoea preceded rather than followed GOR in the vast majority. The concept of an ‘‘ALTE–sudden infant death’’ spectrum in which GOR plays an important role is no longer widely accepted. We argue that there is no need to perform tests for GOR unless there is a suggestive clinical history such as vomiting during or after feeds, poor weight gain, feed refusal, etc. Under these circumstances pH monitoring (whatever its limitations) remains the investigation of choice. A reliance principally on contrast studies and clinical history is likely to mean that physiological ‘‘GOR’’ will be diagnosed as ‘‘GORD’’. This may lead not only to unnecessary treatment, but also focus attention away from serious disorders including factitious illness. We regard pH monitoring in children who have experienced an ALTE but have no clinical pointers to GORD as being of little value, and contend that there is no evidence base for such an approach.