McGovern and Smith¹ 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,² 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 “gastro-oesophageal 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 …