NRP/543 Week 5: Pediatric Neurological Concern, sample paper

Not Daydreaming After All: Recognizing Childhood Absence Epilepsy in an Eight-Year-Old Whose Teacher Noticed the Pauses, and Choosing the First Drug From a Three-Arm Trial

[Student Name]

University of Phoenix

NRP/543: Management of Pediatric and Adolescent Populations

Week 5 Assignment

[Instructor Name]

[Date]

The child and family are composites written for a model paper. Diagnosis and treatment would be coordinated with pediatric neurology.

Emma, an eight-year-old girl, comes with her mother after her third-grade teacher wrote a note: Emma "zones out" many times a day, sometimes stopping mid-sentence and then continuing as if nothing happened. Her reading scores have dropped. Her mother had noticed that Emma sometimes does not answer when called and thought she was ignoring her. Emma is otherwise healthy, developing normally, with no history of febrile seizures or head injury. Her maternal uncle had "seizures as a kid" that he outgrew. This paper describes how I evaluated these episodes and what treatment was chosen.

Staring Spells: A Differential

Staring spells in school-age children have several causes. Daydreaming occurs when bored, can be interrupted by touch or voice and does not interrupt ongoing activity abruptly. Inattention from attention-deficit hyperactivity disorder is constant rather than episodic. Focal seizures with impaired awareness last longer, often a minute or more, with automatisms and confusion afterward. Absence seizures are brief, a few seconds to about 20 seconds, start and stop suddenly, may include eyelid fluttering or lip smacking and are followed by immediate return to normal activity. They can occur dozens or hundreds of times a day.

Classification

The International League Against Epilepsy classifies seizures by onset, generalized, focal or unknown, and by awareness and motor features (Fisher et al., 2017). Absence seizures are generalized-onset, nonmotor seizures, with typical absence seizures showing a characteristic pattern on EEG. Childhood absence epilepsy is an epilepsy syndrome with typical absence seizures beginning in school-age children who are otherwise developing normally.

A Bedside Test

Hyperventilation provokes absence seizures in most children with the condition. I ask Emma to blow on a pinwheel continuously for three minutes, counting aloud. At about 90 seconds, she stops counting and blowing, stares with her eyelids fluttering for about 10 seconds and does not respond when I say her name. Then she resumes counting, unaware that she stopped. Her mother, watching, says, "That's what the teacher means."

Three minutes with a pinwheel showed in the exam room what the teacher had seen for weeks and no one had named.

Confirming the Diagnosis

The next step is an EEG, which in childhood absence epilepsy typically shows generalized 3-Hz spike-and-wave discharges, often provoked by hyperventilation. I arrange an urgent EEG and referral to pediatric neurology. Brain imaging is not routinely needed for typical childhood absence epilepsy with a normal neurological examination.

Examination

Emma's neurological examination is normal: normal cranial nerves, strength, coordination, reflexes and gait. Her growth and development are appropriate, and she has no skin findings suggesting a neurocutaneous syndrome.

Choosing the First Drug

The Childhood Absence Epilepsy Trial randomly assigned 453 children with newly diagnosed childhood absence epilepsy to ethosuximide, valproic acid or lamotrigine. After 16 weeks, freedom from treatment failure was 53% with ethosuximide and 58% with valproic acid, both higher than 29% with lamotrigine, and ethosuximide was associated with fewer adverse attentional effects than valproic acid (Glauser et al., 2010). The American Academy of Neurology guideline recommends that ethosuximide or valproic acid be considered before lamotrigine for childhood absence epilepsy unless adverse effects are a concern (Kanner et al., 2018).

For Emma, ethosuximide is the logical first choice: it is as effective as valproic acid, causes fewer attention problems, which matter for a child whose schoolwork is already affected, and avoids valproic acid's other risks, including weight gain, liver toxicity and harm in future pregnancy. The neurologist will start and titrate it; my role is to support the family and monitor for side effects, which include stomach upset, fatigue and, rarely, blood count changes or rash.

Why Treat

Untreated absence seizures interrupt learning dozens of times a day, and some children with absence seizures develop generalized tonic-clonic seizures. Emma's falling reading scores likely reflect missed moments of instruction.

School Plan

With her mother's permission, I write to Emma's teacher explaining absence seizures and asking her to note the time and frequency of episodes, which will help judge treatment response. Because seizures interrupt instruction, Emma may benefit from repeated instructions and checking her understanding until seizures are controlled. A formal school plan can be developed if needed.

Safety

Because awareness is lost briefly, safety precautions matter. Emma should swim only with close supervision and bathe with a caregiver nearby until seizures are controlled. She can ride a bicycle with a helmet in safe areas.

Why Not Valproic Acid or Lamotrigine

Valproic acid was as effective as ethosuximide in the trial, but it caused more attention problems and carries risks of weight gain, liver injury, pancreatitis and, for a girl who may later become pregnant, birth defects. Lamotrigine was better tolerated but failed far more often, with freedom from failure in fewer than a third of children at 16 weeks (Glauser et al., 2010). For a child whose main difficulty is already attention in class, a drug that adds attentional side effects is a poor trade.

What Monitoring Will Show

The goal of treatment is no seizures, not fewer seizures, since even brief absences interrupt learning. The neurologist may repeat an EEG with hyperventilation to confirm control, and the teacher's log will show whether episodes have stopped in class. If ethosuximide fails at a full dose or is not tolerated, valproic acid would be the usual next option.

Emma's Own Understanding

I explained to Emma, in words suited to an eight-year-old, that her brain sometimes takes very short breaks she does not notice and that medicine can help stop them so she does not miss parts of lessons. Children who understand their condition often cooperate better with medicine and with telling adults about side effects.

Prognosis

I explain to her mother that many children with childhood absence epilepsy outgrow it by adolescence, as her uncle may have, although some do not, and that the neurologist will guide how long treatment continues.

Family Questions

Her mother asks whether Emma caused this by screen time or stress. I explain that childhood absence epilepsy has a genetic basis, is not caused by anything she or Emma did and is common and treatable.

Documentation

The note records the teacher's report, the hyperventilation test with the duration and features of the event, the normal neurological examination and the referral, giving the neurologist a clear starting point.

Follow-Up

I will see Emma after her neurology visit to review the diagnosis, medication and any side effects, and ask the teacher for an update after four weeks of treatment.

Conclusion

Emma's frequent, brief, abrupt staring spells, reproduced by hyperventilation in the office, fit typical absence seizures, which an EEG will confirm. Ethosuximide, supported by a three-arm randomized trial and the neurology guideline, is the preferred first drug because it controls seizures as well as valproic acid with fewer attention effects. School and safety plans complete the care of a condition that was hiding in plain sight as daydreaming.

References

Fisher, R. S., Cross, J. H., French, J. A., Higurashi, N., Hirsch, E., Jansen, F. E., Lagae, L., Moshé, S. L., Peltola, J., Roulet Perez, E., Scheffer, I. E., & Zuberi, S. M. (2017). Operational classification of seizure types by the International League Against Epilepsy: Position paper of the ILAE Commission for Classification and Terminology. Epilepsia, 58(4), 522-530. https://doi.org/10.1111/epi.13670

Glauser, T. A., Cnaan, A., Shinnar, S., Hirtz, D. G., Dlugos, D., Masur, D., Clark, P. O., Capparelli, E. V., & Adamson, P. C. (2010). Ethosuximide, valproic acid, and lamotrigine in childhood absence epilepsy. New England Journal of Medicine, 362(9), 790-799. https://doi.org/10.1056/NEJMoa0902014

Kanner, A. M., Ashman, E., Gloss, D., Harden, C., Bourgeois, B., Bautista, J. F., Abou-Khalil, B., Burakgazi-Dalkilic, E., Llanas Park, E., Stern, J., Hirtz, D., Nespeca, M., Gidal, B., Faught, E., & French, J. (2018). Practice guideline update summary: Efficacy and tolerability of the new antiepileptic drugs I: Treatment of new-onset epilepsy. Neurology, 91(2), 74-81. https://doi.org/10.1212/WNL.0000000000005755