• Respiratory disorders. Some parents may be alarmed about epilepsy, but it may help to describe a typical breath-holding spell for them. In general, it’s not epilepsy if a trigger (such as pain or frustration) causes the child to suddenly freeze, stop crying, and/or pass out. Such children may be so upset they just cannot move, but they are not having a seizure.
• Behavioral and sleep disorders. Night terrors are relatively common, and should be distinguished from seizures that occur at night and really frighten a child. Some children repeatedly bang their heads against the bed, but this behavior does not point to epilepsy.
Sleep walking, sleep apnea, and nightmares also can be mistaken for seizures. Ask parents about any excessive daytime sleepiness to raise your suspicion of sleep disorders, including apnea. Also consider confusional arousals as well as periodic limb movement disorder during sleep, both of which might require assessment by a sleep specialist.
• Psychiatric and mental disorders. Consider fugue state, panic attacks, and schizophrenia in your differential. Children can experience hallucinations as part of seizures or from psychiatric disorders.
Mannerisms and/or nonresponsiveness in your autistic patients can appear like seizures.
Münchausen syndrome by proxy is another condition to keep in mind. In rare cases, parents will provide a fabricated history and describe spells that did not happen. A parent who is dead set against supplying a video of a future event might raise your suspicion for this rare but important condition.
• Perceptual disturbances. Dizziness or vertigo can be described as part of a seizure, but these symptoms are general and can be associated with many other disorders.
• Episodic features of medical disorders. Hypoglycemia is sometimes confused for epilepsy if a child becomes sweaty, confused, or disoriented, and/or loses consciousness. Contractures associated with hypocalcemia also can mimic epilepsy.
In addition, paroxysmal changes can result from cardiac arrhythmias or long QT syndrome. Some congenital heart conditions (such as tetralogy of Fallot) cause events in which children pass out or turn blue. Another consideration is hydrocephaly, which can cause a sudden increase in intracranial pressure that causes fainting.
A very, very common condition – even for us – is gastroesophageal reflux or Sandifer’s syndrome. These infants may stiffen or arch in response to the reflux pain, which can look just like a tonic seizure. Pediatricians can do a great service in reassuring parents that their child has reflux, not epilepsy.
Dr. Bourgeois is the director of the division of epilepsy and clinical neurophysiology and the William G. Lennox Chair in pediatric epilepsy at Children’s Hospital Boston. He is also professor of neurology at Harvard Medical School, also in Boston. Dr. Bourgeois is a consultant for Upsher-Smith Laboratories and a principal investigator on a multicenter study sponsored by Ovation/Lundbeck Pharmaceuticals.