Essential Tremor in Children
Essential tremor (ET) is often thought of as an adult onset condition. However, it can start any age and in early childhood affecting about 5% of children, predominantly involving the hands. There are two kinds of hand tremor, which are: Kinetic tremor only (i.e. tremor present only when the hands are moving) and Postural tremor only (i.e. tremor is visible when the hands are held outstretched) with some children experiencing both. The hand tremor leads to difficulty holding drinks, eating, writing, coloring, playing a musical instrument and sports.
Very little is known about the treatment of ET in childhood but it is helpful to be open about the condition, to discuss it and to have a common sense open approach. Children will often cope better than adults until school age when often a variety of problems such as writing, school meal times and comments from peers, may cause anxiety and embarrassment.
Recent research indicates that 5 out of every 100 children under the age of 20 has Essential Tremor. That number is staggering, and represents a significant increase in the incidence of ET in children from even ten years ago.
ET inevitably affects the hands in childhood but head tremor is relatively rare, being apparent in about 5% of children that have ET.
Where to start if you have a child with tremors.
First things first, be sure that your child has been diagnosed by a movement disorder neurologist. Many pediatricians and some general neurologists may not be familiar with the diagnosis of movement disorders in children. They may not know the other testing that needs to be done to be sure it is ET and not something else or that it is ET alone, as many children with ET have more than one disorder. If you need help finding a movement disorder neurologist, the best approach is to contact your local teaching hospital in your area and ask for an appointment with a pediatric movement disorder neurologist.
What should you expect from your child’s doctor visit? First, the doctor will want to gather as much information about your child’s tremor as possible. They will ask when you first noticed the tremor, and when it happens most now. Is it when your child is eating or coloring or writing? Is it there all the time? What exactly is shaking? Fingers, arms, legs, head? What makes the tremor better or worse? What other problems (if any) have you noticed? Arm or leg stiffness, jerky movements of the head, arms, or legs, and swelling of the legs can all indicate that there may be a condition other than ET, or in addition to ET, that is affecting your child.
Next, the doctor will do a physical exam. Most of the time the doctor will do a full exam, listening to your child’s heart and lungs, and checking the child’s belly. They will look at your child’s eyes, their smile, look at how they walk or crawl, and check to see how “strong” their muscles are. The type of exam to evaluate tremor will depend on the age of your child. For babies, most of the exam involves checking for normal infant reflexes, then presenting an object to the baby just out of reach to check for postural tremor, and then giving the baby something to play with to see they if shake when they try to bring it to their mouth (action tremor). Young children will be given crayons to draw with or blocks to build with and observed for different types of tremor during this “playtime”. Children over five will have an exam very similar to an adult evaluation for tremor, including being asked to draw a spiral, write their name, pour water from one cup to another, and drink from a cup.
After this exam, the doctor will likely schedule some tests, including blood tests to check your child’s blood sugar, thyroid levels, liver function, and other tests. They may order an X-ray called an MRI of the brain. MRIs are safe in children. Some children may need to be sedated to lay still for the test or may need a type of scan that requires “contrast” dye to be injected before the scan. There are some small risks with sedation and contrast that your child’s doctor will talk with you about before scheduling the test. Most doctors will not recommend a CT scan in children under 15 years old as there is a small (less than 1 in 1000) chance that a child can get cancer from high radiation exposure in some CT scans. If your doctor is recommending a CT, be sure to ask about the risk and other ways they could get the information they are seeking.
When all these tests are complete, you will have another visit with your child’s doctor to discuss the results. ET is considered a diagnosis of “exclusion” which means there is no test that will tell you that your child definitely has ET. The purpose of these tests is to make sure there is nothing else causing the tremors that needs a different treatment.
There are some ways you can help your child during the doctor visit and during the testing. First, tell them what to expect. Talk to them about what is in this post so they know what will happen during the visit. Next, if your child is old enough to talk to the doctor themselves, give them a chance to do so before you answer the questions for them. They may be experiencing symptoms that you haven’t seen and that they haven’t told you about. When you answer for them before giving them a chance to answer, the doctor may not get all the information they need. Lastly, when possible, take your child to the place they will get their blood drawn or have their MRI scan before the day of the appointment. This will help them be more at ease. You can also “practice” at home what will happen during these tests to help them be less anxious.
Once you and your child’s doctor are comfortable with the diagnosis, then they can begin to discuss treatment options with you. There are a number of natural treatment options for children with ET as well as medical treatments available.
Dr. Darlene A. Mayo (née Lobel) is a board certified neurosurgeon who is internationally known as an expert in the treatment of essential tremor and other movement disorders.
Darlene A. Mayo MD FAANS
Dr. Darlene A. Mayo (née Lobel) is a board certified neurosurgeon who is internationally known as an expert in the treatment of essential tremor and other movement disorders. She earned a Bachelor of Science degree from Duke University and her Medical Doctorate from Medical College of Georgia. She completed clinical fellowships in Stereotactic and Functional Neurosurgery and Epilepsy at UCLA and Emory, finishing training in 2007. She also completed two research fellowships, first in Grenoble, France, where she worked for two years with Professor Alim-Louis Benabid at Clinatec on the clinical protocol and implementation of a brain computer interface system, designed to aid quadriplegic patients. She then completed a fellowship in the Neural Engineering Laboratory at Mayo Clinic in Rochester, Minnesota, where she worked on the design and preclinical assessment of an intraspinal microstimulation system to restore neurologic function after spinal cord injury. Dr. Mayo worked for two years as a Neurosurgeon and Assistant Professor at University of Florida-Jacksonville and for nearly five years as a Neurosurgeon and Associate Professor of Neurosurgery and Biomedical Engineering at the Cleveland Clinic, where she had a busy practice treating patients with essential tremor and Parkinson’s disease. She also co-led an essential tremor support group for two years in the Cleveland area.
Dr. Mayo is a renowned author with over 25 publications, including peer-reviewed manuscripts, books, and book chapters, and is an internationally acclaimed speaker. She has spent years researching ways to improve tremors, having served as a consultant and lead investigator on clinical trials in the U.S. and abroad. She also serves as an ad-hoc reviewer for neurosurgical and biomedical engineering journals, and serves on grant review panels, as reviewer and as chair. Her expertise is widely sought after as a reviewer, invited speaker, and as an expert in deep brain stimulation by other scientists and researchers.
She has a passion for teaching, which extends not only to medical students and residents in training, but to her patients and to anyone who is looking to learn more about medical conditions. Dr. Mayo is an internationally acclaimed speaker and holds leadership positions in the Council of State Neurosurgical Societies. She has served as Co-Investigator and Consultant in clinical trials in the US and in France, has authored numerous publications, including peer-reviewed manuscripts and book chapters, serves as an ad-hoc reviewer for neurosurgical and biomedical engineering journals, and serves on grant review panels, as
reviewer and as chair. Her expertise is widely sought after as reviewer, invited speaker, and as an expert in deep brain stimulation by other scientists and researchers. www.diannshaddoxfoundation.org