What is the appropriate management and treatment for shuddering?

Management of Shuddering Attacks in Children

Shuddering attacks are benign, self-limited episodes that require no medical treatment or antiepileptic medications—only parental reassurance and clinical observation. 1

Clinical Recognition and Diagnosis

Shuddering attacks present as brief, involuntary shivering movements of the head, shoulders, and upper extremities lasting 4-5 seconds, occurring multiple times daily without loss of consciousness or postictal state. 1, 2

Key Diagnostic Features:

• Onset typically between 4-6 months and 2 years of age 3, 4
• Episodes last only seconds (typically 4-5 seconds) and occur during normal activities 1, 2
• Consciousness is completely preserved throughout the episode 1, 2
• Increased frequency often noted at mealtimes or during stimulating activities 1, 3
• Normal neurologic examination between episodes 1

Distinguishing from Seizures:

• Video-EEG monitoring shows no epileptiform discharges during attacks 2, 4
• The tremor frequency on EMG contamination during EEG may resemble essential tremor patterns 5, 2
• No postictal confusion, sleepiness, or behavioral changes occur 1

Diagnostic Workup

A single video-EEG recording is sufficient to confirm the diagnosis and exclude epilepsy—no further neuroimaging or laboratory testing is indicated in children with typical presentations and normal neurologic examinations. 1, 4

When to Obtain Video-EEG:

• When the clinical history alone cannot definitively distinguish shuddering attacks from epileptic seizures 2, 4
• When parental anxiety requires objective documentation to provide reassurance 4
• The referring diagnosis is frequently epilepsy (58% in one series), making EEG useful to prevent unnecessary antiepileptic treatment 4

Investigations to Avoid:

• Brain MRI is not routinely indicated unless focal neurologic deficits are present 1, 5
• Metabolic workup and genetic testing are unnecessary 1
• Repeated EEG monitoring adds no value once the diagnosis is established 4

Management Approach

No pharmacologic intervention is warranted—shuddering attacks neither warrant nor respond to antiepileptic medications. 1

Parental Counseling:

• Reassure parents that this is a benign phenomenon distinct from epilepsy 1, 4
• Explain that attacks will spontaneously decrease in frequency and completely remit by 3-7 years of age (mean 5.6 years) 4
• Emphasize that no developmental delays or neurologic sequelae occur 1
• Advise parents that no activity restrictions are necessary 1

Follow-Up Strategy:

• Clinical observation only—no routine neurologic follow-up is required 1
• Reassess if episodes change character, duration increases beyond seconds, or consciousness becomes impaired 2
• Monitor for complete resolution by early childhood (typically by age 5-7 years) 4

Associated Conditions and Triggers

While shuddering attacks are typically isolated, consider evaluating for gastroesophageal reflux if feeding-related symptoms are prominent. 3

Potential Triggers:

• Teething may coincide with onset or exacerbate frequency (78.9% in one series had symptom onset during teething periods) 3
• Eating, breastfeeding, and stimulating play activities commonly trigger episodes 3

Relationship to Essential Tremor:

Despite earlier speculation, shuddering attacks show no association with essential tremor—neither affected children nor their families develop essential tremor during long-term follow-up (mean 6.3 years). 4

Common Pitfalls to Avoid

• Do not initiate antiepileptic medications—shuddering attacks are not epileptic and will not respond to these drugs 1
• Do not pursue extensive neuroimaging or metabolic workups in children with typical presentations 1
• Recognize that the diagnosis is frequently missed by referring physicians (never suspected in one series), leading to unnecessary investigations 4
• Avoid labeling these children with epilepsy, as this creates unnecessary anxiety and may lead to inappropriate treatment 4