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Primary Steps for Primary Care: Staring Spells

Boy staring blankly

Staring spells are a common complaint in pediatrics, often first noted by parents or teachers who then prompt evaluation. While absence seizures are certainly on the differential, staring can be many other things and careful history and evaluation is needed to guide evaluation and management.

What is the differential of staring spells?

Often times, staring events in children represent transient inattention or daydreaming, where the child will "zone" out for a brief period of time (seconds up to minutes). Many times children are engaged in other activities and will not respond to parents or teachers, creating concern. Both absence and focal onset seizures can present as isolated staring, as well.

How can a parent or provider differentiate seizures from inattention or daydreaming?

First, we try to determine if the child is truly unresponsive. Parents often try to get their child's attention when they stare by calling the child's name or waving their hands in front of them; however, to truly gauge response, we recommend that parents engage their child with more vigorous stimulation. Common examples are tickling them under the arm or at the collarbone – two forms of stimuli that a child just daydreaming rarely ignores. If the child still does not respond to tactile stimulation, then the next question to ask is whether the staring is an abrupt pause of activity or pause of speech mid-sentence, as this is more concerning for seizure, than simply noting the child is staring out the window. Next, ask if there are any associated signs, such as rhythmic eyebrow movement, blinking, eye rolling, eye deviation or automatisms, such as chewing or picking at clothing, which might suggest seizures.

If there is concern for seizure, how do you differentiate absence seizures from focal seizures?

Absence seizures are typically brief (5-15 second) events of sudden pause during activities or during conversation, followed by the child resuming their normal activity without a post-ictal period. The child may not have recollection of the event; however, older children are often aware of their "pauses or lost time." Focal seizures more commonly last 30 seconds or longer and can be associated with a post-ictal period of sleepiness or similar symptoms. Absence seizures often occur numerous times in a day, whereas focal seizures may be more sporadic.

What is the initial workup if the events sound like seizures?

The provider can provoke absence seizures by hyperventilating the child in clinic (assuming no contraindication, such as asthma) by asking them to take slow deep breaths over 3 minutes. If the child has a pause, testing their response by asking them to recall a phrase spoken during the pause of activity can be used. Next, a routine EEG performed in an outpatient clinic setting is valuable. The study can help diagnose absence seizures because during hyperventilation, the interictal EEG often shows generalized 3Hz spike waves or other generalized abnormalities. If the EEG is normal, the diagnosis of absence seizure is unlikely and the events may be due to inattention, behavioral situations or just daydreaming. However, focal onset seizures may have normal EEGs. If the EEG has focal abnormalities, such as focal spike wave discharges or slowing, an MRI may be warranted. MRI is often not necessary with absence seizures.

When should a patient be referred to neurology?

Children with absence seizures captured on EEG and children with spells suspicious for seizure with abnormalities on EEG should be referred for further evaluation and treatment. Children with normal EEGs, but with events suspicious for seizure also warrant further evaluation, as long-term EEG monitoring may be necessary to better characterize the events. Cook Children's neurologists are available to evaluate staring spells by calling 682-885-2500 to schedule an appointment.

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Contributing author:

Cynthia Keator, MD

Cynthia Keator, MD

Medical Director, Epilepsy Monitoring Unit
Jane and John Justin Neuroscience Center

Meet Dr. Keator


Cook Children's Neurology team

Great outcomes begin with great input. Having a medical system where every department, doctor, and care team member works together means that your child can have quick access to testing, diagnosis and treatment, and that means better outcomes now and in the future.

Contact the Jane and John Justin Neuroscience Center at Cook Children's to refer a patient: 682-885-2500.