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Is It Daydreaming Or Seizures?

I had a child recently come in for an ADHD evaluation who was actually having seizures. The parents thought that their child was just not focusing in class and having trouble paying attention. The teacher thought the child was always “daydreaming.” In fact, the poor child was actually having dozens of seizures a day. This child’s story is not that uncommon. This special kind of seizure disorder is called absence seizures.

What is an absence seizure?

An absence seizure is an abnormal brain activity. Absence seizures are different that typical seizures because they don’t present with classic shaking. Instead, when the seizure happens, the child appears to completely zone out or stare into space. The seizure will start and stop abruptly and often is quite short, typically lasting only a few seconds. During the seizure, the child cannot be called to attention out of it. The person having the seizure is not aware of the seizure, cannot make it stop, and will not do other activities (e.g., talking) while seizing. In the olden days, absence seizures were referred to as petit mal (in case you’ve ever heard the term).

Technically speaking, there are two types of absence seizures:

  1. Simple absence seizures: When the seizing person just stares into space, usually sub 10 seconds.
  2. Complex absence seizures: When the seizing person has some sort of movement along with staring into space (e.g., blinking, chewing, lip smacking, hand gestures), usually sub 20 seconds.

Who does it affect?

Absence seizures are more common in children ages 4-14 years, although it can happen at any age.

How is it diagnosed?

Absence seizures can go undiagnosed for a long time because they are so brief and often don’t have associated unusual movements. Often times in kids, it isn’t until a child starts having trouble in school and is labeled a “daydreamer” that absence seizures are even recognized. The test for diagnosing seizures is an EEG (electroencephalogram). During an EEG, electrodes are attached to the head to check the brains electrical activity. When the brain is seizing, the electrical activity (brain waves) are abnormal. It is worth noting that getting the person with absence seizures to hyperventilate will often induce an absence seizure.

How do I tell daydreaming from seizures?

  1. Daydreaming
    1. Happens when your child is bored.
    2. Can be interrupted (if you call your child’s name while daydreaming, they can stop and look up).
    3. Will keep going until someone or something gets the child’s attention (can go on for 10 mins until the teacher calls on the child).
    4. Comes on slowly and builds (the child’s mind will start to wander and then gradually get more involved in the daydream).
  2. Seizure
    1. Happens anytime (even during physical activity or in the middle of talking).
    2. Comes on suddenly, without warning.
    3. Can’t be interrupted (calling the child’s name or waving a hand in front of the child’s face won’t “snap” the child out of it).
    4. Ends quickly (within 20 seconds).

How are absence seizures treated?

Treatment is often tricky. If the seizures are very infrequent and not causes problems, then the treatment may be to do nothing. However, the mainstay of treatment is seizure medications. These medications, while effective have some well known side effects, so discussion with your doctor is appropriate before starting your child on them.

Is there hope?

There is great hope for absence seizures. Reportedly, 70% of kids with absence seizures will stop having them by the time they are 18 years-old. So for most kids, this is not a life sentence.

It’s Kindergarten Physical Time

It’s springtime, and that means time to register your kids for the upcoming school year. If you have a child that will be in kindergarten come this fall, you’ll need to schedule a Kindergarten Physical. Every state’s requirements are a little different. In Utah, there is a physical form, immunization form, and medication form (if applicable) for your physician to fill out. The physical form allows the school to know if there are any major medical problems they should know about or limitations in a child’s physical abilities (e.g., ability to participate fully in gym). It also has a vision screen as part of the form. The immunization form ensures that a child is up-to-date on shots. Depending on what state you live in, you may or may not be able to opt out of immunizations if you want your child to go to a public/state funded school. The medication form is for school personnel to be able to administer medications (either regularly scheduled or on an emergency basis) to your child. This is particularly necessary for children who have conditions like asthma, serious peanut allergies, seizures, etc.

What to expect during your visit?

Your pediatrician should talk with your child, and in so doing, assess his or her kindergarten readiness. Can your child carry on a conversation? Can your child follow directions? Is your child academically ready (e.g., know letters, count)? There should also be a number of questions relating to your child’s overall health (e.g., diet, sleep, exercise). The visit should include a complete head-to-toe examination (including a vision screen). There should also be a component of what is termed “anticipatory guidance.” This is the helpful teaching your doctor should do with you and your child (e.g., education on media time, car seats, healthy eating, appropriate development). Finally, if your child didn’t get them the year previous (kindergarten shots can be given any time after the age of 4), the visit will end with the vaccinations. As a side note, many offices will also do a blood test at the kindergarten physical to see if your child is anemic. This can be done as a finger poke or a full blood draw. It may be worth knowing ahead of time if your pediatrician’s office does this, so you can prep your child.

Knowing what to expect can make a huge difference in helping the visit go smoother. I can usually tell when a parent has taken the time to walk through with the child what to expect at the visit. The child isn’t bothered by being asked to wear a gown, open his/her mouth, have a light shown in the ears, etc. The only potential backfire is knowledge of the shots. Sometimes knowing that the visit is going to end in shots will cause a child to be more afraid (I get it, shots hurt). While I am a big believer in being honest and upfront with children, if your child is going to freak out for the hours before the visit and all during the visit, you may want to hold on telling him or her about the shots until moments before they happen. You know your child best and will know best how to handle knowledge about that component of the visit.

I love the Kindergarten physical visits in my schedule each day. It’s a great age, the kids are all so different, and it’s fun to see them growing up.

Febrile Seizures: Is Your Child At Risk?

A febrile seizure is a seizure that happens when a child has a fever. Febrile seizures happen in 3-5% of children, and usually occur between the ages of 6 months to 6 years. Children who have had 1 febrile seizure have a 20-30% risk of having another. Most febrile seizures happen as a result of viruses (like what causes a common cold).

How do I know if my child is having a febrile seizure?

Febrile seizures cause involuntary twitching, shaking, or stiffening of the body. It usually involves the whole body (not a partial seizure that causes just a part of the body, like an arm to shake). During the seizure, the child’s eyes will often roll back, or to the side, and the child is unresponsive to you calling. Your child’s breathing may be unusual, and the skin can change color (darker or paler). While the seizure will seem like it goes on forever when it is happening, febrile seizures are typically very short, less than a minute. Rarely, they can last more than 15 mins. Usually the child recovers fairly quickly (a few mins) after the seizure.

What to do when it happens.

  1. Get your child into a safe position. Lay him down on the floor so he doesn’t fall or hit his head on anything hard or sharp.
  2. Position your child’s head to the side, so he doesn’t choke on any saliva or potential vomit.
  3. Look at the time. Two minutes can feel like an hour when your child is seizing. It is important you know how long it lasts.
  4. Record it. Everyone has a phone on them nowadays. Record the seizure. It helps tremendously for your pediatrician to be able to see what happened.
  5. Call your child’s name and put your hand on your child to see if you can stop it. In a true febrile seizure, your child will not respond to your calling and the shaking will not stop with your touch. These two simple moves help distinguish seizures from other causes of shaking.
  6. Seek medical care if it is the first time. This will help confirm the diagnosis and may help determine the cause of the fever.

The long-term consequences.

This is the good news. While it will scare you to death to watch your small child have a febrile seizure, there are almost no long-term consequences in an otherwise healthy child. Febrile seizures are not life threatening and do not cause brain damage or nervous system problems. Most kids “outgrow” them as they get to be school-aged.

Can I prevent them?

Did you know that everyone has a seizure threshold? For most people, the value is so high (maybe 105-108 degrees) that you can’t naturally get there, even if you’re sick. For whatever reason, some small children have what seems to be a lower threshold. In those children, it seems logical to prevent the seizure, by preventing the fever from getting too high. As a general rule, most docs will tell you to treat fevers in kids with febrile seizures more aggressively (Tylenol, Motrin, cool baths, etc.). With that said, there was a study in 2009 in the Archives of Pediatrics and Adolescent Medicine that revealed no difference in recurrence rates of febrile seizures in those treated with fevers from those not treated. As for me, even though I know it may not make a difference, if it were my kid, I’d probably still treat the fevers. As a parent, if there is anything I can do to help prevent it, I’m all over it. If nothing else, it will help my kid feel better (from whatever is causing the fever in the first place).

A Question About Shaking Movements In Infants

Thanks J.R.F. of New York for your question about shaking movements in infants.

Babies (and children) who reportedly have shaking movements always catch my attention. The challenge is that there is an endless list of potential causes. Many movements that babies make are normal. Normal movements include a quivering chin, a startle reflex, and a trembling hand. Anytime shaking comes up though, so does the possibility of a seizure. (Keep in mind, all that shakes is NOT a seizure).

What is a seizure?

A seizure is an abrupt change in physical movement caused by an abnormal electrical firing in the brain. Seizures can involve the whole body (e.g., generalized tonic-clonic, grand mal) or a specific part of the body (e.g., focal seizure). There is further classification based on whether there is loss of consciousness, presence of fever, or shaking vs. just starring.

How do I tell if shaking is a seizure?

There are a couple of little tricks that can help you determine if the movement is a seizure. If the movement always happens only in certain circumstances (e.g., when you turn your baby’s head a certain way or change her diaper), then it is NOT a seizure. If you can easily make the movement stop (by distracting the child or gently touching the shaking limb), then it is NOT a seizure. If the movement is symmetric (same in all affected limbs), bilateral (both sides of the body), or rhythmic (same speed and intensity) that is more suggestive of a seizure.

If it’s not seizures, what else could it be?

Common causes of shaking, that can be mistaken for seizures include: fainting, breath-holding spells, myoclonus (body and facial twitching), and sleep disorders (e.g., night terrors, cataplexy, sleep walking). What the shaking looks like and the circumstances surrounding the shaking are the best indicators of the cause. Is the child awake, asleep, fevering, chilled, well, sick, etc? There are more rare causes of shaking (and frankly more concerning) including problems with the brain, muscular disorders, metabolic disorders, etc.

It’s a good sign if:

Generally speaking, it is a good sign if your child is growing normally, developing normally (appropriate milestones, etc.), and appears healthy. When shaking is due to one of the “bad causes,” babies/children most often start to show other signs of problems.

Should I see a doctor?

Because of the risk of something “bad,” I think most cases of shaking should be seen by your pediatrician. The likelihood of your child having one of the shaking episodes in the office is slim though, so I highly recommend videotaping the episode if at all possible so your doctor can see it.