Videotaping of episodes is helpful to distinguish shuddering attack movements from tonic or myoclonic seizures. 7 Other theories propose that shuddering attacks are seizures with deep-seated epileptiform discharges not detected on EEG, or that they are paroxysmal autonomic events similar to sneezing or yawning. Vitamin D deficiency has been suggested as a cause of benign shivers and tremors in newborns, 12 but only 1 report of shuddering attacks in children has included a biochemical investigation and found a borderline level of vitamin D. 3 However, only 3 children with shuddering attacks also had a history of tics, 1 and none had motor or vocal tics upon follow-up. 6 Another suggested explanation is that shuddering attacks are a variant of motor tics, both exclusively occurring in wakefulness and precipitated by excitement or frustration. 11 Several patients had a history of imminent preterm delivery, suggesting a possible relationship with intrauterine stress. 6 However, this condition tends to have spasmic rather than tremulous movements and generally remits by 2 years of age. One report suggested that shuddering attacks could be a variant of benign myoclonus of early infancy, which can present with similar movements and can also be triggered by eating and excitement. 6 However, a study of 39 children younger than 18 years of age with essential tremor found no personal or family history of shuddering attacks, 10 and other reports found no family history of essential tremor. The original report hypothesized that they are the immature brain’s expression of essential tremor, 1 and the presentation of shuddering attacks can be similar to postural essential tremor. The pathophysiology of shuddering attacks is unknown. 3, 6 There is no report of shuddering attacks occurring during sleep. 4 Triggers of attacks include excitement, 2, 3 eating, 4, 6 and frustration with not being able to perform a task. 2, 6 They occur spontaneously and are not elicited by voluntary movement, 2 although a 15-month-old boy had episodes associated with pressing Lego bricks together and had head movements when drying his hair. 2, 7, 9 Attacks have paroxysmal onset during normal activities, such as when sitting in a chair or when having a diaper change. 2Ĭhildren remain fully conscious throughout and after an episode, distinguishing shuddering attacks from seizures. 6 Shuddering attacks differ from common shivering in their longer duration, greater frequency, and posturing of the arms. 2, 5- 7 Frequency of attacks varies widely but can be as often as hundreds of times per day, 1, 8 and episodes can occur in clusters of longer intervals. 6 Events typically last from a few to 15 seconds. 1, 2, 5, 6 Facial expression can change during an attack, including staring, 2, 4, 6 eye deviation, lip tightening, and teeth clenching. doi:10.4103%2F0972-2327.Shuddering attacks typically present as stiffening, tonic posturing, and rapid shivering movements of the head and upper extremities, at times involving the trunk. Guidelines for management of essential tremor. Prevalence of tic disorders: a systematic review and meta-analysis. Knight T, Steeves T, Day L, Lowerison M, Jette N, Pringsheim T. Tourette syndrome and tic disorders: a decade of progress. Swain JE, Scahill L, Lombroso PJ, King RA, Leckman JF. National Institute of Neurological Disorders and Stroke.
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