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Your Pediatric Neurologist Questions, Answered

In this edition of Ask the Doctor, you asked INTEGRIS physician Jennifer Norman, M.D., your child brain and nervous system questions. Dr. Jennifer Norman is a board certified pediatric neurologist. She attended the University of Oklahoma and then went on to the University of Oklahoma College of Medicine. It was during a medical school elective in subspecialty pediatrics that she first realized that she could combine her fascination with the inner workings of the nervous system and her love of pediatric medicine. She went on to complete her Pediatrics training at OU Medical Center Children’s Hospital before moving to Houston to complete her subspecialty training with Baylor College of Medicine, at the prestigious Texas Children’s Hospital. She is thrilled to be back in her home state and providing neurological care to the children of Oklahoma.

1. What are the main reasons someone would see a pediatric neurologist?

A pediatric neurologist can assist in diagnosis and treatment of most conditions that affect the brain, spinal cord, nerves and muscles. Common conditions that I see are epilepsy, headache, concussion, Tourettes syndrome, tic disorders, developmental delays and muscular dystrophy.

2. Any thoughts on pediatric bipolar disorder? Our son is almost 11 and was diagnosed at age 7. We have consulted two neurologists on top of all his primary doctors. No one has been able to treat the mania. His MRI and EEG were normal. The medication he’s on seems to work for a few months then we have to change it up and start over. Are there any new tests or imaging we could check into to help our child?

Although pediatric bipolar disorder is certainly a disease of the brain, it is something typically managed by psychiatry as opposed to neurology. The main role of neurology in this scenario is to rule out any neurological conditions that can mimic bipolar disorder, such as a brain tumor, epilepsy, or metabolic disorder (for example Wilson’s disease). If these conditions have been excluded, then this helps to confirm the psychiatrist’s assessment of bipolar, which remains a clinical diagnosis – meaning that no specific tests or imaging are likely to be helpful.

3. Have you had many patients with “laughing seizures?” I think my 3-year-old has had several over the past two years. I think they are gelastic seizures, but have not been diagnosed. The first episode was two years ago, unprovoked. Then yesterday I woke up to her having them. She was ill and was running high fever. They stopped after I got her cooled down some with a shower. I took her to the emergency department, but they said everything they could see was normal. What kind of diagnostics (outside of EEG or MRI) go into a diagnosis of these types of seizures? What are they potential treatments that are effective? I am worried since these seem to be so sporadic that she will go undiagnosed and untreated for a long time. I am worried they will progress to more severe or longer-lasting absent, or tonic/clonic, or focal seizures and will begin to affect her development and cognition. I guess I am really just looking for some reassurance as a mother because as an RN I know just enough to worry more than is probably necessary.

Gelastic (or “laughing seizures”) are a very rare seizure type, most commonly associated with a non-malignant brain tumor called a ‘hypothalamic  hamaratoma.’ This brain abnormality is easily seen on conventional MRI scanning and is therefore the first test of choice in evaluating these kind of seizures. They can also be seen in some other severe epilepsy syndromes, but are very rare in otherwise typically developing children. Most parents readily identify these seizures due to the inappropriate bursts of laughter that typically sounds very different from the child’s typical laugh. They usually last for 30 seconds to a minute and then stop on their own. Again, it is quite rare for gelastic seizures to be the only manifestation of epilepsy and they usually happen quite frequently when they occur. The best tests for diagnosis are an MRI and EEG. Any parent with concerns about this rare seizure type in their child should definitely consult with a child neurologist.

4. I have a 9-year-old daughter who began to develop tics around the age of 5, although not severe and not several at once. She would have one for a few months, it would go away, but then another would begin. She hasn't had any tics in several months and I'm hoping they've gone away forever. I never took her to the doctor because they were very mild and not disruptive in school. I read that bringing them to attention made them worse. She knew she had them and they did get more intense if I mentioned it. Could you tell me why it was happening? And if they return should I wait it out again or take her to the doctor?

Tics are very common in children and will often wax and wane in intensity over time. It is most common for the tics to “rotate,” meaning that they will have one for a while and then a different one takes over. Tics can be motor (repetitive movements) or vocal (repetitive sounds). The vocal tics do not have to be words – in fact, they are usually not. It is more common to have repetitive sniffing, throat clearing, or squeaking type sounds. Tics are often worse in times of stress or illness. It can be good stress (excitement) or bad stress (anxiety). They can also worsen with sleep deprivation or illness. However, oftentimes they seem to come ‘out of the blue’ with no clear trigger at all. As long as the tics are not causing pain and are not interfering with day-to-day activities, no intervention is necessary. If the tics become bothersome, there are some medications to help. I would recommend a consultation with your child’s physician if they do start to interfere with activities.

5. My 11-year-old daughter’s hands shake when she is doing fine motor tasks like tying her shoes, using a pen or trying to pick up something small. It’s not related to being nervous -- when we point it out she just says she can’t help it. What could be the cause and should we be worried about a bigger underlying issue?

In most cases this kind of tremor is associated with a condition called, ‘benign essential tremor’. This is a very slowly progressive, lifelong condition but is not life threatening or dangerous. This condition tends to run in families but can start at different ages in different family members. However, there are a few more rare conditions that con manifest as tremors in children, therefore a screening neurological examination is recommended.

6. My son occasionally gets migraine headaches. He has to lie down for a few hours and it’s very painful for him. Is there anything we can try to prevent migraines? Any reason why a child so young would be getting migraines?

You did not mention the age of your son, but migraines can start as early as 18-24 months. Possibly even earlier, but children do not typically have the language before then to describe what is going on with their bodies. Healthy living habits are important when trying to prevent migraines (good sleep, exercise and diet). Avoiding foods high in sugar and avoiding caffeine can help. Migraines tend to run in families, but persistent severe headaches, regardless of the child’s age, should always be brought to the attention of the child’s physician.

7. My daughter complains of tingly hands a lot. She says her fingertips feel really tingly sometimes – they don’t hurt, but she says the feeling will last for a few minutes and then go away. Is this a sign of a nervous system problem? She has no other pain or numbness issues.

In rare cases, tingling of the hands or feet can be a sign of underlying nerve inflammation or nerve damage. However, in the case of a nerve problem, the symptoms are typically persistent – either present all the time or lasting hours at a time. Brief periods (a few minutes) of altered sensation are typically not related to a neurologic issue.

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