The mother had been telling her pediatrician for several years that her son, now eight, would often “zone out.” He had a predilection for doing this countless times a day, often for no more than a few seconds each time. It might happen while he was watching TV, or sitting at the dining room table, or doing his homework. “He acts like he’s a million miles away,” she had told the doctor. “He seems to be there and then, suddenly, he’s not. He drifts away. But, it doesn’t seem like normal daydreaming.”
“He’ll outgrow it,” said the pediatrician. The boy’s teacher at school had also noticed it. “We see this all the time,” she told the mother. “It’s classic ADHD and you should consider medicating him.”
Instead of taking the advice of either the doctor or educator, the woman chose to take her child to the office of Dr. Dina Kornblau, a pediatric neurologist at SBH Health System, for a more definitive explanation. After asking the mother several questions, Dr. Kornblau had a much different take.
“I asked her what happens if you stand between him and the TV when he’s spacing out, or when you snap your fingers or clap your hands to get his attention,” says Dr. Kornblau. “When she said he still doesn’t respond, I had a good idea what we were dealing with.”
Dr. Kornblau sat the child in a secure place in her exam room and got him to hyperventilate. The abnormally fast rate of breathing soon put him into a state his mother recognized all too well. “That’s what he does,” she said, as the boy stared into space for several seconds.
The child was diagnosed with absence seizure (or petit mal), which was later confirmed by an EEG. This is a common childhood malady caused by brief abnormal electrical activity in the brain. Most children will eventually outgrow it. Dr. Kornblau prescribed Ethosuximide (Zarontin) which soon controlled the seizure and eliminated his episodes of “zoning out.”
Many of the children referred to Dr. Kornblau suffer from seizures and headaches. “Seizures are very common,” she says. “The most common in childhood are febrile seizures, which occur in as many as five percent of children. These are usually children between the ages of six months and six years, who are neurologically and developmentally normal, and have generalized convulsions that are associated with fever. They are normal before and normal after (the seizure).”
Dr. Kornblau typically becomes involved when the child is younger or older than this, or the seizures are recurring or longer in duration. These children are at greater risk of developing epilepsy.
Epilepsy, which can start at any age, affects an estimated 450,000 American children under the age of 17. In some cases, it can be well controlled by medication and will be outgrown. More severe cases of epilepsy may not respond well to medication and may require surgery (removing the area of the brain that is electrically abnormal and causes the seizures); vagal nerve stimulation, which involves implantation of a device that stimulates the vagus nerve with electrical impulses; or diet (e.g. the Ketogenic Diet, a severe, very low carb, high fat diet).
“The treatment depends on the child and the kind of seizures they have,” says Dr. Kornblau. “If they have been through a few medications that don’t work and their MRI is abnormal and it shows a specific lesion, then surgery is likely to be considered in order to remove the lesion. If the MRI is normal and there is no specific area of malformation, then diet might be considered. There are certain types of seizures that are more likely to be affected by diet.”
Seizures, she says, are divided into two main categories: generalized (which affects both sides of the brain) and partial onset (or focal, affecting a certain part of the brain). “With generalized seizures, you have a loss of consciousness,” she says. You may fall to the ground, get stiff, then convulse. This is what most people think of as a seizure.” But generalized seizures include the more subtle absence seizure (when the child is not conscious but does not fall or convulse) as well as tonic-clonic (grand mal) seizures.
Partial seizures depend on the part of the brain affected. It may affect the child’s vision or muscles in a certain part of the body and they may lose consciousness. There may or may not be a change in awareness. “The child may know his arm is shaking, but he can’t stop it; or the child may be unaware what is happening,” says Dr. Kornblau. “I have had patients who were previously diagnosed with psychiatric disease. But, no, they don’t have psychiatric disease. They are having partial seizures with a change in their level of awareness.”
Dr. Kornblau says it is particularly gratifying to explain to a parent that there is a reason for their child’s behavior and that it can be successfully treated. “In many cases, these are signs that have been missed for so long,” she says. “Parents are very relieved to hear there’s a reason for what’s happening and that we’re going to be able to help them.”
In seeing a child with persistent headaches, Dr. Kornblau’s first concern is dividing the condition into one of two main types: primary, where symptoms are consistent with migraines and muscle tension headaches; and secondary, where something else may be going on (e.g. a tumor, hydrocephalus, vasculitis, and idiopathic intracranial hypertension).
“The vast majority of the time it’s primary, most commonly among teenage girls,” says Dr. Kornblau. Yet, migraines can start as young as five years old, and frequently occur within families.
“Certain things can often trigger headaches,” she says. “It could be not sleeping enough or too much. Too much caffeine can be a trigger, as can being hungry. Stress can be a factor. I send patients home with a headache diary so they can keep track of what is happening, how often they are having headaches, and what precipitated the headache, so we can then figure it out from there.”
For example, a headache that a child feels primarily on school days may be related to the stress they feel about going to school or because they are skipping breakfast or not sleeping enough, just as headaches that occur among children with a propensity for eating a lot of chocolate or cheese can be related to their diet.
“There is the mindfulness of being aware of your headache and what’s triggering it that is so important,” she says. “You need to figure out why you have a headache today and not yesterday. Did you sleep less? Eat differently? Experience certain stressors?”
High achievers, she says, are more prone to headaches. “The straight-A students get more headaches,” she says. Treatments may include counseling, where patients learn techniques that will tamp down on stressors; changes in sleep patterns; changes in diet (such as eliminating foods that are well-known triggers like peanut butter, processed meats, dairy, and foods with monosodium glutamate). Over-the-counter medicines such as ibuprofen and Excedrin (for those 12 and over) as well as prescription triptan medications are commonly used. If headaches remain frequent, then daily preventive medications such as Amitriptyline, Propranolol, Topiramate, and Valproic Acid are often used. Supplements, such as butterbur and magnesium can be helpful as well.
“The most common triggers are skipping breakfast and not drinking enough liquids,” says Dr. Kornblau. “Sometimes just making small changes can make a big difference.”
In addition to pediatric neurology, SBH Health System offers these pediatric specialties:
• Infectious diseases
To make an appointment with an SBH pediatric specialist, call 718-960-6430.