Monday, June 10, 2019

Non-Epileptic Paroxysmal Attacks in Children


Non-epileptic paroxysmal episodes in children are very common and are commonly misdiagnosed as epilepsy in many cases. This false positive diagnosis of epilepsy in children leads to unnecessary investigations, increased parental anxiety, and “treatment failure”. This particular blog focuses on some of the common non-epileptic phenomena seen in children which can be easily picked up by pediatricians to avoid unnecessary investigations, long term medication use and false diagnosis of epilepsy.



        Sandifer Syndrome:
Gastroesophageal reflux disease (GERD) is a very common diagnosis seen in infants particularly under 6 months of age. Severe gastroesophageal reflux can lead to prolonged episodes of crying in babies, with severe “back-arching” and in some cases babies can present with acute life-threatening events because of apnea. These are/can be easily misdiagnosed as epileptiform disorder, and dystonic movement disorder. In severe form of GERD (Sandifer Syndrome), babies cry incessantly, severe back arch for a prolonged period of times with head and neck extension and rarely become apneic. A high index of suspicion for GERD should be kept in these babies, as usually the development is completely normal, and episodes can be at times associated with the feeding times.

   Benign neonatal sleep myoclonus:
This particular non-epileptic phenomenon is seen in new born infants and can present up to few weeks of age, with quite significant episodes of sudden jerking of one or more limbs, but confined entirely in sleep. The baby is usually not distressed or woken up from these episodes, and usually do not involve the face. Although, the history is reasonably clear that these episodes during sleep, an EEG to capture some of these episodes maybe necessary to ensure that there are no ictal phenomena. Generally, no treatment is required in this condition and in a few months’ time these episodes cease.

Shuddering attacks:
Shuddering attacks are also very common, but usually under diagnosed or misdiagnosed episodes seen in normal infants as a part of their behavior. The usual story is that when the infants get very excited, which precipitates these episodes, they have involuntary shivering of the upper body, and sometimes most of the torso. This condition is not harmful or epileptic in nature. As the child matures, these episodes abate on their own without any intervention. A video of the paroxysmal episode can be very helpful in diagnosing this condition, as the shuddering attacks occur commonly at home and not usually in the outpatient clinic!

  Tic disorder:
Tics is a very common movement disorder seen in older children around the age of 5 to 6 years, when they present with repeated movements of different parts of the body, commonly involving the face with eye blinking, “screwing the eyes tight”, neck movements, and in severe cases upper and lower limb movements. These movements occur compulsively and sometimes can be associated with “vocal noises” as well called as vocal tics. The most common period or times when these episodes occur is usually in the afternoons once the children come back from school. The children are able to “supress” these movements in the school to avoid any unnecessary attention from other children (sometimes bullying), and as soon as they arrive home, they have a “release phenomena” with ample tics in the afternoon. Classically, tics get better when the children are relaxed e.g. during holidays and they get worse when they are nervous.

In the author’s opinion, a detailed history along with the video if possible is paramount to make the correct diagnosis. An EEG is usually unnecessary investigation. Author usually advises the parents to ignore these movements, because when the children are made aware of the tics, the child gets nervous and has more Tics.  As the children mature, the frequency and intensity of Tics decrease and very commonly tics stop during or before adolescence. Very rarely, if the tics are quite annoying to the child then a clinical psychologist is needed to carry out “tic reversal therapy” which can be very beneficial. On rare occasions medications are also used to supress the tics if they cause any hindrance to the day-to-day activities of the child.

  Benign myoclonus of infancy:
This is a very important non-epileptic paroxysmal phenomena which is commonly confused with infantile spasms as it resembles this particular type of epilepsy which presents in a similar age group. The benign myoclonus of infancy usually starts between the age of 1 month and 1 year and typically the child presents with sudden “jerking” movements occurring randomly during the course of the day. The infant is developmentally normal with normal milestones.
An EEG is usually required to ensure that the child does not have a EEG abnormality which can point towards the diagnosis of infantile spasm. A video of is also very important for a pediatric neurologist to delineate whether the condition is benign myoclonus of early infancy or indeed infantile spasms. Needless to say, the children with this condition do not need treatment and as they “grow out” of these episodes by second year of life.


For any informal queries, please contact the author at aman.sohal@neuropedia.ae