Pediatric neurologist Mary Jeno, MD, starts by laying out useful parameters for navigating the nuances of odd motions – from eye fluttering to shuddering to hip thrusting – that worried parents report seeing in their babies, young children and teenagers. She discusses keys to distinguishing benign abnormalities from urgent and serious ones, offering tips on history taking as well as numerous educational resources for both providers and families. Spoiler tip: Ask the parents for a video!
So the tactic is gonna be on abnormal movements that we see. I'm gonna try and go through a few different ways of looking at this. So, the one thing I think that is helpful is to go at different ages. So I like to start with cases for you guys and then walk through different age group populations. So we'll start with the newborn and infant, then we'll move into early childhood, and then we'll move into later childhood. Adolescence. Sometimes I think the early childhood movements can be a little bit trickier, so I spent a little extra time on those and getting some videos, um, and then getting into early childhood and childhood and adolescence, sometimes it's easier to talk through those cases separately. Like I said, if you guys have any questions, please just let me know. Hopefully this is helpful. Um, I don't have any disclosures for you other than to say I am a huge Iowa Hawkeye fan. That's where I did my residency and training, uh, with pediatric neurology. So there is a lot of subtle Iowa tidbits and fun facts in here. And yes, I did watch the WNBA draft, and yes, Caitlin Clark is now going to Indiana Fever, so I am now an Indiana Fever fan as well. So one thing I think that I take away from every referral that I get and every time I talk to a PCP, you know, when I'm on call is it's, it's all about the history, right? When you guys are talking to families and the family says, well, they're not walking, or, well, their friends are talking and they're not talking yet and we don't know why. It all has to do with just the different parts of the history that claimed that specific child. And so, I really want, I'm gonna get at the history of these different cases and how that impacts the way that I think about them as a diagnosis, and then how I think about them in terms of my workup and treatment. So the first thing we're gonna do is we're gonna start with infancy, and we're gonna start with the case, and then we'll move into a little bit more about um this specific case and then things that it could look like and the descriptions that are different between all of these different cases. So the first patient I have for you, um, I feel like I could pull this case out of any particular week of the year. This is something that we see a lot as a referral and something that I think is very common. So it's a 2 month old baby comes into your clinic and the chief complaint is abnormal movement. So the family has been home with the baby. It's their first baby. There's no significant birth history, was born at term, 40 weeks gestation. Mom was healthy, had great prenatal care. I know this never happens, but bear with me. Had great prenatal care, normal ultrasounds, everything looked perfect and has been developmentally normal, moving its head around, lifting its head up in tummy time. Parents being the perfect parents are doing tummy time 5 minutes a day, 3 times a day. Um, and since the second week of life, there's been this repetitive stretching jerking while sleeping. So, looking at this history, there's a lot of things that come to mind when I think abnormal movement in a in a young baby and infant, and there's kind of three ways I like to look at things. I like to look at things from the history, I like to look at things from timing, and I like to look at them from the semiology. So what did it look like? So from the history standpoint, I like to think, OK, when did these symptoms begin? When did this jerking begin? They said there's a stretching jerking. OK. Since 2 weeks of life, was there any particular thing that happened at that 2 weeks of lifetime frame? Since it began, has it increased or decreased? So it started at 2 weeks, was it happening once at night? Was it happening 5 times at night? Does it cluster together? That again leads to something else that we think about. Um, or does it just the one time? Is it, you know, one time and then it's done and it doesn't happen again, and then they see it the next day? What is the kind of time frame look like in that history? And then more on timing. When does it occur? Is it only while they're falling asleep? When they're waking up in that wake to sleep transition, only during sleep when they're awake in certain positions with feeds? And then how long does it last? So not only does it cluster again, or do they see it a couple times here, a couple times there, but does it last for extended periods of time, or is it a one second kind of flip in time that changes? And then finally, semiology, which I think is one of the most important things and the thing that, especially when, you know, you refer to neurology that we really try and get down in in the weeds on, is where does it occur? Is it one limb, trunk, what happens to the rest of the body? Is there loss of awareness? Does the baby stare off? Is it interruptible? So are the parents able to stop the movement? All of those sorts of things, I think play a lot into semiology. And I say all this knowing that in a primary care doctor's office, you guys have 15 minutes to do this well child to check while the other sibling is sneezing and coughing in the corner. And so I'm trying to make this as tailored and focused so that you're able to take away just little significant snippets that help us kind of narrow down when we're worried or when we should be concerned about a, about a baby or about a case. So talking about some things that can look like seizures or neurologic concerns based on that 2 month old 2 month old's history, trying to remember how old the baby was. So the first thing I think about is benign sleep myoclonus. So benign sleep myoclonus is something we see often. This is often a referral. It's very, very common. Usually it starts shortly after birth. So it's one of those things that parents will say, well, we noticed it, you know, from the first week of life or right away. And probably in the back of your head there's always that that history of could this be 5th week fit or 5th day fits or the seizures that start right after birth, but there's some very specific things that happen only in sleep myoclonus that don't happen with things like seizures. Number one, it tends to improve as they get older. So this is a baby that parents will say they've been doing all these movements, and it's, it's happening all the time, and, you know, maybe we've seen it a little bit less this week than we saw it last week. The timing of these, these are only during sleep. So benign sleep myoclonus, the baby will be sleeping, and it can happen during the as they're falling asleep in those early sleep stages too, especially since baby sleep stages are very different than adult sleep stages and teenager sleep stages. But it's when they're doing that falling asleep thing, and then when the parents wake them up cause they're panicking and they shake the bassinet, they stop. Now, sleep on clonus can be kind of tricky because it can be rhythmic. It can also be sporadic, so you can see it in one limb, you can see it in two limbs, you can see it in multiple at the same time. It can be coordinated, so it can be kind of sneaky that way, and it can happen multiple, multiple times. So parents who will, you know, these new parents will sit there and stare at their child. And they watched them and they watched them sleep and then they noticed, oh, the right leg twitched and it twitched a lot, and then the left leg twitched, and then both legs twitched, then the arms twitched, and then they woke the child up and scared the child half to death and, and then the patient stopped. So a good example of this, I'm gonna show you guys a video, let me know. If you can see it. Yeah, that looks good. OK, perfect. So this is a great example of benign sleep myoclonus. Is this little just twitching, sort of rhythmic, kind of, and you can see a little bit to that leg is going, there's like one arm and then the other arm, and they're going together, and then the baby kind of moves around a little bit and it kind of stops it, and it seems to calm down. So that I think is a really good example of what that can look like. OK. Next is Sandofer syndrome. So Sandofer syndrome, um, is something that you are all actually probably more familiar with than I am because I, I see this one a little bit less, but I still think it's an important one to think about. I see it, you know, if I'm seeing a baby every few days, this is one I see maybe every other month. So it's not as common, but it's still one I like to think about, especially in those babies that have a hard time with feeding. So they're not always neurodevelopmentally normal, which can make this challenging as well. So this can happen anytime in that first year, um, tends to be a little bit on that younger side, um, especially like I said in those babies that maybe have a harder time with feeds they're slow feeders, they need feeds that are thickened, those sorts of things, but it's really feeding dependent so parents will put the. Baby in the high chair, they'll give the baby the bottle or they'll, you know, have them sitting up, give them the bottle, and then within 30 minutes they lay them down to do tummy time or lay them down on their back so they can roll over and they get this back arching posturing apnic type of picture. The classic one is the baby that's arched back and their head is back and their arms are extended and flexed, and it almost looks like tonic posturing in a baby, especially because when this happens, they can also have the apnea episodes where they, they kind of look like they're holding their breath or they're turning blue and you get that stiffening of their arms. There can even be little twitches and jerks, so it can be very confusing. I think the big thing with this one and the, the part that I try to highlight is really the feeding correlation. So this one, we like to see that association with feeding. Again, kids that have difficulty with tolerating their feeds and then the posturing that they get is very unique because back arching is not a common semiology of seizures in this age. So I think those are kind of the big takeaways from this one. Now back to our 2 month old, could it be shuddering attacks? This is another thing that I think we get referrals for a lot. Um, it's a very benign finding in infancy, but it can last for a while. There are shuddering attacks that are a little less benign, and I'll talk about that on the next slide, but these can be part of just normal development. And what I'd like to tell parents is that babies' nervous systems are very immature, which is why they're uncoordinated, why they twitch, why they tremor, why they're just kind of shaky in general. And why they're not very good at tap dancing when they're born. They just don't have it all put together yet. And so it's one of those things that I see associated with an immature nervous system. We see these several times a day, but it really with this one tends to be with excitement. So we don't see this during sleep, we see this more when parents pick them up and rock them or cuddle them, when they're eating or taking a bottle, when there's a shocking noise or a loud noise, um, kind of all those sort of stimulus type environments can cause these. And it's a low amplitude tremor. So one of the big takeaways today for all of our movements is that any of our seizures, or most of our seizures tend to be large. Let me think about this. Large amplitude low velocity as opposed to high velocity low amplitude. So the tremor is that high amplitude low velocity high velocity low amplitude, excuse me, which is more reassuring against seizure or epilepsy. They can also during these kind of stare off briefly, almost like they're surprised or shocked. So this is another one that I was able to find a little cute video for, um, because we all like to see cute babies and let's see here. Here's a great example for you of a shuddering attack. I characterize it by stiffening of both lids. And so the baby kind of looked up and did this little shudder and then went back. And I think that's a very, a very good example of what it can look like. The hand stiffening doesn't have to happen. That's kind of unique to this child. It can, but it doesn't have to. It's just kind of more of a surprise. Some babies will kind of open their hands as if they're surprised by it. OK. Now, the less benign hyperkalplexia is something that I think can also be kind of frightening and is one of those things that looks like a shuddering attack, but is much more significant. So this is something that again is apparent shortly after birth. It's really in that very initial time frame, and babies are described as very stiff. So you touch them and as soon as they're stimulated, they go into almost a tonic posturing. Oh, you can tap them and they'll have this exaggerated startle where they throw their arms out and they have that startle reflex, but it almost seems like it doesn't stop right away. While they're awake, they'll get referrals for hypertonicity for being stiff. So parents have a hard time changing diapers, they seem like they can't relax or calm down, and part of that is this constant, um, stimulation type reflex that they have, and then during sleep they have myoclonus. Now, Yes, you can have benign sleep myoclonus. Yes, you can have benign startles, but all this together is where we start getting a little suspicious. Those tonic spasms they have when they're awake and when they're stimulated with the reflex can actually cause apnea. And so these children, unfortunately can go on to develop significant brain injury associated with hyperkyflexia. Um, and there are some genes associated with this as well, so it can run in families. This is one of those things that I think are, it's, it's very uncommon, but when you see it, it's dramatic. So it tends to be a little bit more obvious than some of our other um more common. Uh, reflex pictures. So here's another little video for you, and I think this is a good example. The other thing about these babies is that they tend to not be doing well. They tend to have a lot of apnea issues, they tend to have a lot of respiratory issues. And so you'll see they touch this baby, and they just touch it, and then then it goes into the startle that doesn't seem to stop. And you can see the baby's hips are flexed up and kind of continues to have that increased tone, almost has that exaggerated back um arch to it as well, and it just, it continues to have that significant startle. Now, while none of us like to be hit on the head, I think we would all do a little bit better than what we would expect to see with that, where you just have that continual startle, shaking type response. So that is very significant and that warrants further workup for several things, um, but the biggest thing is those kids tend to be doing very poorly to begin with. Now the thing I think that we get referred for a lot and probably the most common thing that we see um in terms of true neurologic impact is infantile spasms. Now this is one of our Probably only true neurologic emergencies. Of course, stroke and things like that are, are a neurologic emergency, but this, when we're talking about seizures and epilepsy is something that if you see it, I wanna see the patient within the day. So usually I say if this is something you're seeing in clinic, the baby needs to go to the ER for because time is very important with these sorts of patients. So infantile spasms, they can develop um really I see the most common from that 6 to kind of 1011 months of age, but they can go down to around 3 months of age. Um, I think the earliest I saw was 10 weeks at one point in time, uh, but that was not a developmentally normal child. So these kids tend to not be developmentally normal if they, especially if they're starting early. We think about these when we think about our children with significant HIE, they're at a high risk for infantile spasms. So babies that were in the NICU had that neuro injury and then go home. We often caution these families and watch these children very, very closely for spasms. If spasms are going on for a while, parents will tell you that they may have some regression or loss of skills. So if you see a 6 or 7 month old come into your clinic and, you know, they've been sitting up but they haven't really done much else, they're not really rolling very well, and parents mention, oh, you know, Especially at bath time and, you know, kind of at night, and then in the morning after feeds on the mat, she does these things where she kind of extends her arms and legs and, and we see it a few times a day and it seems to be getting more frequent. That would be a big red flag for something like infantile spasms. The timing of these is a little bit different. So timing tends to be during drowsy and arousal periods. So parents will see it when they're waking up, feeding their first bottle in the morning, after meals, bath times at the end of the day. Um, there tends to be periods of the day, especially around those nap hours, early wake and sleep hours, that we see these peak. Not as much during sleep. So unlike the benign sleep myoclonus, this is more something we see when they're awake. Um, babies for the semiology, there's 3 different types. So there's a flexor, extensor, or mixed. So the flexor flexor is everything coming in. So the arms come in, the head drops down, and the neck comes in, and then the legs will flex up. Similarly, extensor means everything extends back out, including head and neck, or you can have a mixed. When they did some studies on it, I believe the mixed was the most common finding where you have like flexion of the arms and extension of the neck or vice versa, but you can have kind of an interesting pattern of those three. During this, there will be a stop in whatever they're doing, so it'll be a brief motor arrest while they do the movement. And then there tends to be irritability. So oftentimes babies will cry or become upset or difficult to console when this happens. They may appear shocked when it's first happening, and then they kind of flip. The movements can be repetitive, and so it's this synchronous, so the whole body kind of does the movement, and then it tends to cluster. So parents will see it a few times in a row. It can be, it'll happen, and then a few seconds go by and it happens again, and a few seconds go by and it happens again, and that's kind of the history we get for these. Again, it really over time you'll start to see developmental changes, and that's when we start getting into more of that West syndrome, uh, picture when you have invital spasm, hips rhythmia on EEG and developmental regression that would then qualify for something like that. Um, there's lots of different videos out there, so I always have to be a little careful what I find on YouTube with these because not everything is, of course, infantile spasms, but this, I believe, was one I found that I liked. And sometimes they can even start as subtly as eye rolling, but that's not always ones that will pick up on right away. But you can see that baby, he's holding onto his shirt with the one hand, but the other hand really comes out, and there you go. So you have kind of that extension of both of the arms. The hard part with laying down is you may not see always that head or neck flexion. So it's this repetitive synchronous. Almost starting like events, and so it tends to look kind of dramatic, and parents will notice it because it doesn't look like what other kids do, especially in this repetitive nature. OK. And then the last thing I like to mention to end on maybe a more positive note, is breath holding spells. So again, this is something that I think you guys are probably much better experts on than I am myself, but this is one of those things that we see early on. So 6 months, and then it can persist into early childhood. There are some older kids that will continue to do this. This tends to be a little bit less than that very early neonatal period. So if I ever hear something about this, like when we're thinking bruy, Or, um, you know, in a, a 3 month old, I don't put it into this basket. Um, typically this is a response to a mild injury, and again, timing and that triggering event is the big thing here where they fall, they hit their head, they scream, scream, scream, scream, scream, and then they hold their breath. One of the really the things that's really difficult with these is that especially the pallid breath holding spells can look a lot like a seizure because they'll hold their breath, they become limp. They turn pale, and then they can even get a little bit of increased tone. So instead of being floppy, parents will say, well, they got stiff and then they twitched. And so that sounds a lot like a seizure, but the preceding event in this case is the thing that triggers it off to suggest that this is more of a pallid breath holding spell. Now what I will say about all of these things, and again in relation to, uh, of course, your limited time in clinic and limited ability to gather all this history, well, I get an hour with my new patients, is that if it's ever a concern and you ever don't know, we are always more than happy to see these patients because I would always rather be safe. The, the big thing for takeaway is what is the associated timing, when is the history, and does it make sense for the age that you're seeing the patient in, and then what did it look like and just describing it, which is so, so helpful when it comes to seeing these patients for follow-up or seeing them as new patients myself. This one I did also find a very cute video of. Um, And I believe this was a cyanotic breath holding spell if I'm not mistaken. I think some of the pallid ones can be hard to find reliable videos of. Um, but just scream, scream, scream, scream, scream, scream, scream, and then seems to hold, I think at some point the baby will hold its breath and then become floppy. And of course for all new parents, something like this is very scary. Um, uh, there's the floppy and then unresponsive, and babies can become stiff, they can hold posture, so there's a lot of different ways they can present. This poor baby. Really was having a tough time. Poor guy. So I think, again, just getting those histories, they all look so different and and it's of course easy to say, but then when you're looking back you can say, OK, you know, this was a 12 month old when this first happened and it happened once, or it's repetitive and it happens only at night, and those things can be really helpful. So I'm thinking back to our original case on this 12 month old, she complained abnormal movement, arms and legs jerking repetitively only while sleeping, developmentally normal baby, um. What I would say just based on history alone and this very simple history, this is most likely gonna be sleep myoclonus. Um, the baby, maybe the movements stop when the when the parents wake the baby up, they haven't noticed anything else, it hasn't changed or progressed. It's gotten a little bit better even since it's happened, since they first began to notice it. You see them back in 6 months and it's gone. So this is one of those things that I would continue to follow and just make sure it hasn't progressed. The other thing I always ask parents is that if they're able to, videos are incredibly helpful. Um, in the spirit of talking a lot about babies, because I think it's one of the tricky things. I have 2 more cases in the baby time frame. So this is a 4 month old, uh, born at 37 weeks gestation due to uh low fetal movements, so was having mom was having a stress test, baby wasn't moving as well. Um, they were taken out via C-section, had low apgars, we'll say 4 and 5, initial gas was 7, they were hospitalized and were found to have moderate HIE. The motor skills were delayed. Um, initially baby was really floppy in the NICU and then started becoming stiff, and it was stiff kind of in all extremities, maybe one side a little bit more than the other, but they've been working with physical therapy and occupational therapy. Mom is really excited cause baby has started lifting her head, but over the last 2 to 3 weeks, parents have been noticing this kind of unusual movement, especially when the baby's in the bath at the end of the day and on the play mat. And parents, because they were asked to describe this very helpful history, which is that the eyes roll up briefly. The hands extend outward outward. They don't know exactly what the legs do because that's a lot to look at all at the same time, but they do notice the neck flexes up and back, and then this happens 2 to 3 times per minute, and then will stop. After the movements, the baby seems irritable, um, you know, thinking about feeds and if this is related, they do say that the baby does really well receiving feeds via an NG tube, but this doesn't seem related to the timing of the events. So in this case, based on history, I would send the baby to the ER and say that sounds like infantile spasms. Again, I think things that are really important to do with this one is knowing that it's not a neuro neurodevelopmentally normal child. So it's not neurodevelopmentally normal. The episodes cluster, the timing of them, they happen during the evening hours when the baby is calm, during nap time times when the baby is on the floor. It's not related to feeds, the baby is very annoyed after, and then the description of the events is very helpful, where the arms extend out, the eyes briefly roll up, and the neck flexes back. There's not a lot of other things that fit quite as well with that description as opposed to something like an infantile spasm. And then my last case for the infant time frame is there is a 4 week old baby with fossiness born at term 4 weeks gestation. Um, this baby. Had a really difficult pregnancy. Um, there was a lot of drug exposures, presumed opiates, benzos, and methamphetamine, but that's all we know cause that's all that came back on the urine toxicology. was brought to the NICU, did OK, discharged after two days when it wasn't noted to be having withdrawal symptoms to foster family. But my foster mom notices that this baby is just very difficult to calm. She's had a lot of foster kids. She has a lot of kids due to drug use. She takes them in, and on exam, you notice that this baby is kind of got the shaking increased tone. Timing and semiology, the baby is fussy all day long. There's tremor-like movements. They appear to have an increased startle. It's not constant and it's not all the time, but they just seem really upset. They don't necessarily have high tone. They can be sleeping and they'll be calm and relaxed, and they don't have any movements at night. The tremors that they have while awake are these high velocity, low amplitude tremors, and when you put your hands on them, you can suppress it. So this case isn't one that I necessarily talked about, but this would fit more with the infant withdrawal and neonatal abstinence. And so those kids, I think we see them quite a bit kind of in our communities and then just, you know, as as mothers struggle to kind of control drug use during pregnancy. And I, again, along with those immature nervous systems, I like to give these babies a lot of time. So what I like to say for these is that You know, I'll follow them. I continue to follow them. I monitor how frequent the movements are happening and make sure they're not increasing in frequency, but I'll see them at 3 months and then at 6 months. As time goes on, I like to see that the movements decrease. If the movements are continuing to increase in frequency, Then I worry something else might be going on. But for something like this, it would fit. On that note, this is something I didn't get the chance to talk about. There are hundreds of other things that can happen to babies that I didn't get the chance to reference. That can be just very normal baby movements, but these are a couple of things that I think we see often and I see a lot of referrals, so I wanted to make sure that I was able to touch base on those with you. The next thing we'll do, um, kind of getting a little bit out of that baby area is move into early childhood. So this is case number 4. So, 2 year old boy comes into clinic and parents have noticed this eye fluttering movement. Speaking of eyes and eye rolling, again, age really plays into this. Timing happens throughout the day. They don't notice it during this during the day, this 2 year old sleeping, um, as all good parents, we just stare at our children while they sleep, um, at least I do. And it does seem to happen often when this 2 year old is watching TV or eating dinner. So when the family is sitting down and they're staring at him, they really notice this eye fluttering. The eyes flutter, both will flutter at the same time, and they don't really notice anything else in the body that happens at the same time. So now I want to talk a little bit about some weird movements that kids do with their eyes when they're in this early childhood stage. Again, there are many, many, many types of things that can happen in the, in the childhood years, but this is just trying to get at some of those bigger things that I see often. All right, so spasms Newton. So this is one that is relatively common, meaning that I see it, but I think general pediatricians see it a lot less than I do. Um, this can happen early, this can actually happen in infancy, and it can go into early childhood. So, this has 3 parts to it. Although I will say torticollis is not always present. I just tend to see it, I think more in kids with torticollis. So they'll get this little bit of head tilt, they'll nod their head, and then their eyes do this very fast rotational movement. And this is very random, and it occurs when they're awake, and then it stops when they're sleeping. It lasts for about 5 to 30 seconds at a time. I will say it can go outside of those ranges quite a bit. But parents will say they'll notice these little twitches in the kid's eye, and I think more what they notice is this head nodding and tilting before they notice this horizontal oscillation. The other thing about this particular movement is that it is not always synchronized. So this sort of gaze can be very disconjugate. Um, so you may see like the left eye goes, but not the right, or that sort of thing. And then at the same time you get the head shaking. Now, the nodding that you see with this is actually compensatory, same with that head tilt, for the nystagmus. So the child is trying to offset the fact that their eyes are doing this little eye jerking and twitching. Oftentimes this is um I know I did not pull this one up ahead of time, so give me just a second, guys. Um, often this is Something that ophthalmology will help um evaluate for in clinic. And so if it's not something that I see when the parents come to see me in clinic right away, I'll send them to ophthalmology to have it evaluated. And then I usually also ask them to try and take a video of the patient doing it. Again, videos are probably one of the most helpful things that we see when parents come in, uh, to clinic. Now this particular clinic I'm gonna show you the video from is excellent. Um, it's the Utah Clinic Ophthalmology Clinic, and they have a bunch of videos up and I think all of their videos are fabulous. Um. We'll see if it'll, if it'll load for us. If not, I'll, I'll put it on in the background. So I believe at some point here, They're going to, uh, yeah, we'll go to this part. They kind of zoom in and you see that little eye twitching shaking. It's just that very fine horizontal, very quick nystagmus type movement. And the baby is not doing a lot of head nodding here, but that's kind of the those eye twitches are what we're looking for. So again, that can be a very hard movement to detect, and sometimes parents will see those other things first. Then we also have something called a very long name, but paroxysmal tonic upward gaze. So tonic up gaze is something that also occurs randomly. So what kids will do is they'll be staring at their parents, they'll kind of be talking, and then they get these episodes where their eyes go up. And they'll look back at them. There's no impairment of consciousness. There's nothing else that tends to happen during these. They can happen independently. They can also happen with some alteration where the kid will seem to be a little like toxic for just a minute or two, and then they'll continue. It really only happens during wake periods, and so parents will say, you know, my mom called, said that this child rolls their eyes all the time, and I noticed that they roll their eyes too, and my daycare provider mentioned it. And then you'll see them in clinic in 3 weeks and it'll be gone. So it's one of those things that will come up randomly and then will slowly go away with age as well. Again, it doesn't impair consciousness at all. It's a quick update and then the patient will look back. It's one of those random things that again, depending on if it's always looking to one side or the other side, sometimes we'll look a little bit more into it, but oftentimes it's just an up and then back. They can also have a little bit of fluttering with it at the same time. Getting a little bit further along. I didn't, I will say I did not put a lot of videos in after this point because things started getting a little um more variable, and I think YouTube becomes a little less reliable as we go. Uh, so parasomnias, these are things that can mimic seizures quite a bit. So it sounds very simple, but not necessarily. So I think the big one I wanna hit on is confusion or arousals. So history, this is often in that 2 year age range and above, more common in that early childhood around 5 or 6. It's really in that first part of the night. So stage 3 sleep or non-REM sleep is when we really see this, and stage 3 sleep tends to be the 1st 3rd of the night. So while nightmares happen in the second half of the night, um, parasomnias happen in the 1st 3rd of the night, and confusion arousals, I think, are the one that looks a little bit more like seizures. So they're toddlers, they go away as kids get older, so unlike nightmares and other things that can be persistent, they tend to get better as the kids get older, kind of gone by around 13. But they'll kind of sit up in bed, and they'll cry, and they'll start saying nonsensical words and seem distressed, and then no matter what parents try to do, they can't get them to calm down. So unlike a night terror where they're screaming out or panicking, they just kind of wake up and seem confused. The thing about this that's a little bit different than seizure or things that we're concerned for seizure, is that Um, there's no, they tend not to be flushed or sweating, they don't throw up. Um, they may not have any of those stereotypical motor behaviors that we typically see with seizure. These can last up to half an hour, which would also be very unusual for a seizure, and then the child will just go back to bed. These don't have any sort of EEG changes, it's just one of those weird things that kids can do. Another thing that we see in this age, and then I see a lot referral for is motor ticks. So motor ticks are exceptionally common. Oftentimes I see kids in, you know, they start coming in around 5 or 6, but when I ask parents back, I'll say, did they do a lot of blinking when they were younger? And parents are like, oh yeah, we always thought there was just, you know, we got their eyes checked a few times when they were 1 or 2. And I'll say, OK, that might have actually been the onset. And so this is something I can see as young as 2 years old, where kids will be staring at the TV and they'll eye flick, the eye flick up, and then they'll go back to what they're doing, or they'll flutter their eyelids, or they scrunch their nose, or they roll their eye, and they roll it and roll it and roll it, or they raise an eyebrow, or they close their eyes and they scrunch their face up. Lots and lots of different types. Um, it tends to be worse when kids are bored and it's better when they're focused. So kids playing baseball games won't have them as often as kids that are sitting at the dinner table when parents really notice it. It can occur anytime during the day and you can have hundreds a day. It can also occur during sleep, so ticks can occur during sleep, but they're not, they're not only allowed to happen during the day. The big thing about ticks is that they tend to fluctuate. So some days they'll be gone or seemingly be significantly better, some days or weeks will be significantly worse, and you get this kind of frequent pattern of fluctuating of both symptoms, frequency, and severity. And then as time goes on, they tend to get different types. They're brief, sudden, rapid, they can be repetitive and stereotyped. Consciousness is never impaired. So ticks, when they're happening, never impaired consciousness. Difference between ticks and Tourette's is just simply if they've had motor and vocal tics for longer than a year or not, that's, that's the big takeaway from that standpoint. Then the last thing that I think a lot of things can look like, which is the absound seizure. So, unfortunately for kids, this is one of those ones that can be really difficult to diagnose and can again happen hundreds of times a day without us really knowing. Um, kids will sometimes be told they have ADHD and so parents will take them in and the teacher says, you know, they, they're missing pieces of time, they're staring off, they're not responsive, they don't listen to their name being called, they're missing assignments, they're missing information, and it turns out it may actually be an absence seizure. Average age is 6, you can see it younger. You can also see it older, but then we're getting into different sort of diagnoses. Um, childhood absence is really the one that we're talking about right now in this age group. The big thing with absence is that there's a significant impairment in consciousness. And so what I ask parents all the time when they say my kids' eyelids flutter, I say, if you touch them, do they respond? So parents will say, oh, I called their voice and they don't respond. I don't respond when my husband calls my voice either. Did you touch them? Did you physically try to interrupt it? Did you clap in front of their face? Did they blink when you clapped? All of those sorts of things are very, very helpful. The other thing with absence seizures is I can often provoke them in clinic by hyperventilating a patient, which is not always enjoyable for parents, and they don't always like me watch, they don't always like watching me hyperventilate their child, but that's one thing that can, that can really bring them out. So getting back to our case, so we had this 2 year old boy, parents know as eye fluttering movements, could be many things, right? They see it during the day, not when the child's sleeping, um, and it does seem to happen more when he's bored, eating dinner, watching TV, and then they're like, well, it's probably worse when he's really stressed, so going to school in the morning, they tend to see it. Both eyes will flutter, there's no loss of consciousness, and it just happens for a second at a time, and then it can repeat. So based on history like this, I would say that this is a simple motor tick, and I would talk to them about what we do about that, which is clonidine, guanfacine, and then as he gets older, we can consider also therapy intervention with habit reversal. Most of the time, I'm gonna be honest, I don't treat with medication at all, unless it's impairing their day to day social skills or school. And that gets us into childhood. Maria, do we have any questions? I'm trying to wrap it up. I know I'm talking a little bit longer than I thought I would. No, you're good. Yeah Uh, so I, the Gomer blog is just a great reference for everybody, but I thought this was pretty funny. OK. So going in, we now have one last uh case, and this is a 14 year old presents with new spells. She is developmentally normal, no past medical history. Everything's been OK. She's been following with you guys in clinic for 14 years, you know the family, they're great. And then you start to ask her a little bit more about those questions that teenagers love getting, like, how are you feeling? And she says that she recently had a fight with her friend, she's failing her math class, she forgot to turn in a couple of assignments, and she's panicking. She's a straight A student. She's planning on being a doctor when she grows up. She's idolized you her whole life. And the timing of these was really sudden and occurring daily. So then getting into semiology a little bit. She woke up at night Uh, she cried out and she began to thrust her hips and shoulders in this kind of non-rhythmic pattern. Now what I will say is frontal lobe seizures can be very sneaky, and they can happen at night and happen with weird patterns. So I, this is something we get referred for a lot. The episode lasted 30 to 40 minutes. She went to the ED and it got better with Ativan. They gave her 0.1 per kilo of Ativan because they knew their epilepsy dosing. The next day she had more than 40 episodes, despite getting the treatment of Ativan and the ED, and they were varied in pattern. Most, if not all, the episodes had a couple of things that were stereotyped, including her eyes would be closed, she would hyperventilate, and then she would have this movement of her hips and shoulders with arm twitching. She was only responsive to deep pressure with a sternal rub. So big things I think for for this particular case, I just have 3 big ones to take away. Um, syncope, this is something I see a lot um as referrals in clinic. Um, oftentimes syncope is infrequent. So if a patient's having 40 episodes of syncope a day, there's a significant issue going on. Oftentimes also with our adolescents, we see something preceding. They got hit, they pinched their finger in a door, they saw blood, or they stood up too quickly, right? And they haven't drank water in the last 26 hours, and they felt lightheaded and dizzy, and then they started hearing the ringing in their ears, their vision went black, and they fell over. One thing that's a little bit tricky about syncope is that you can have an episode that looks like a seizure, so you can fall to the floor and you can become a little stiff and twitchy. That can happen. It's a little less common than the total limpness and loss of tone in the body, but again, those preceding symptoms of the pallor, lightheadedness, shade falling over the eyes, ringing in the ears, sweaty clamminess, those are the big things that kind of differentiate it from a seizure. Functional neurologic disorder or FND. I see this. Often in our adolescent population. Again, it's that sudden onset that seems to be triggered by something. So there's often underlying anxiety, depression, mental health, PTSD, stressors in school or at home. And the semiology is very varied. So there's many, many, many, many types of functional. I've seen movement disorders, seizure disorders, headaches, tics, all kinds of things that that can be functional. And specifically in terms of seizure, trunk involvement is kind of different for this, and tends to be present, which is not often something that we see in a true seizure, and their eyes tend to be closed. The episodes are often not rhythmic, and they can be interruptible with significant external pressure applied, such as a sternal rub. And I'm just trying to wrap up here, and the last thing is um epilepsy. So JME, juvenile myoclonic epilepsy, is the big one in this age group. We see it after the age of 10. Um, oftentimes what happens is kids will come into clinic after their first generalized tonic-clonic seizure. They had one at home cause they were up all night studying and or doing other things they shouldn't have been doing. And they come into clinic and they bit their tongue. They were incontinent. It was a true generalized tonic clonic seizure, family's panicking. And then I ask them, you know, what else is, have you ever dropped things in the morning? They say, oh yeah, I dropped my phone. I get like a jerk in my arm once a day I can't control. So they get these episodes of myoclonus that can go unnoticed for a long time because it's just, you know, a jerk of one arm or a jerk of another, and then when they come into clinic, it's because they had a full seizure. These kids can also have absence seizures, and so with these, I also like to make sure that there's no history of ADHD and evaluate for that. Going back to our case, our 14 year old girl with these new spells, her EEG was normal, and we discussed functional diagnosis with her because again, she had that trunk involvement, full body shaking, eyes were closed, not, not typical semiology every time, not repetitive semiology. I wanted to include for you guys some resources. So these are things I refer for patients all the time. So, FND Hope and neurosymptoms.org. I think it's FNDHOP, is it .org or .com? I think it's .org. So these, these two websites I use all the time for functional. Um, I also think they're great resources for providers. They have a lot of information about what they can look like and how to help manage these patients. Epilepsy website is a fabulous website. So for parents who saw a neurologist, neurologists like you have epilepsy, go on and be free. This is a great place for them to find resources such as seizure first aid, action plans, all of that sort of thing. The Child Neurology Foundation has a disorder directory. So if you have a patient that comes in with tuber sclerosis complex or any of those sorts of things, it's a resource for both providers and for patients on expectations and outcomes. And then the Tourette website is also a great one. But at the end of the day, if you're not sure, just refer. We're always happy to see these patients. The biggest thing to take away is just timing and semiology. And if they can, please have them get videos because that's the most helpful thing.
