Frontline Doctors in Palestine Miss Key Signs of Seizures That Devastate Infants

A new cross-sectional study from the West Bank has quantified a problem that neurologists have long feared but rarely measured directly: many of the doctors most likely to see a baby in the earliest stages of a devastating epileptic condition do not know what they are looking at. The research, published in BMC Pediatrics, surveyed 419 physicians across Palestine and found that fewer than half demonstrated good knowledge of infantile epileptic spasms syndrome, a rare but catastrophic seizure disorder of infancy in which every week of diagnostic delay translates into measurable, often permanent, neurodevelopmental harm.

Infantile epileptic spasms syndrome, historically known as West syndrome, is a developmental and epileptic encephalopathy that typically emerges in the first year of life. Its signature manifestation is the epileptic spasm: a sudden, brief contraction of the trunk and limb muscles that can resemble a startle reflex, colic, or reflux. Clusters of these spasms often occur on waking, and because they are so easily mistaken for benign infant behaviors, the condition is notorious for slipping past the first clinician who sees it. The electroencephalographic hallmark, hypsarrhythmia, is a chaotic, disorganized pattern of very high-voltage waves that reflects profound cerebral dysfunction. Treatment with adrenocorticotropic hormone, oral corticosteroids, or vigabatrin is time-sensitive, and international guidance emphasizes that prompt initiation of therapy substantially improves developmental outcomes.

The stakes are amplified in settings where pediatric neurologists are scarce. In Palestine, access to subspecialty neurology services is limited, which means frontline physicians, including general practitioners, family medicine specialists, and pediatricians working in district hospitals and clinics, effectively serve as the diagnostic gatekeepers. If they fail to recognize spasms, order an urgent electroencephalogram, and escalate the case, the window for effective treatment can close before the child ever reaches a specialist. This structural reality is precisely what motivated the research team, led by investigators at Al-Quds University and collaborating institutions including An-Najah National University and Palestine Polytechnic University, to measure how prepared the frontline actually is.

Between March and June 2026, the team administered a structured, self-administered questionnaire to pediatricians, general practitioners, family medicine specialists, and residents in pediatrics or family medicine practicing across the West Bank. The instrument was designed around the established knowledge, attitudes, and practices framework, a standard tool in health-services research for diagnosing gaps that can be targeted by training. Knowledge was assessed with twenty items scored from zero to twenty, attitudes with twelve Likert-scale items ranging from twelve to sixty, and clinical practices with ten scenario-based items scored from zero to twenty-eight. Knowledge was then categorized as poor at or below fifty percent, fair between fifty and seventy percent, and good above seventy percent, a threshold the authors treated as the adequacy benchmark for safe practice.

The headline numbers are sobering. Overall, 48.7 percent of participants demonstrated good knowledge, 53.0 percent held positive attitudes, and 52.5 percent exhibited good clinical practices. The mean knowledge score was 13.5 out of 20, equivalent to 67.4 percent, which fell statistically significantly below the 70 percent adequacy benchmark. In other words, the average physician in the sample sat just under the line that the investigators considered minimally acceptable, and nearly half of the cohort fell clearly below it. The authors report that the most pronounced deficits concerned the etiology and prognosis of the syndrome, domains that determine whether a clinician understands why urgent action matters and what the child’s future looks like without it.

The stratified analysis revealed a steep gradient across specialties. Pediatricians scored 15.8 on knowledge, compared with 11.6 for primary care physicians and 13.3 for residents, a difference that was highly significant. The same pattern held for attitudes, with mean scores of 44.5, 40.7, and 41.2 respectively, and for practices, where pediatricians averaged 20.4 against 15.9 for primary care physicians and 17.4 for residents. This hierarchy is clinically consequential because primary care physicians are often the first, and sometimes the only, medical professionals a worried parent consults when a baby begins exhibiting unusual movements. The group least equipped to recognize the syndrome is, in this system, positioned at the front door.

The statistical architecture of the study went beyond simple group comparisons. The team used independent samples t-tests and one-way analysis of variance to compare subgroups, Pearson correlations to probe relationships between the three domains, and multiple linear regression to identify independent predictors while controlling for confounders. The correlations were telling: knowledge tracked strongly with practices, with a correlation coefficient of 0.645, and moderately with attitudes at 0.380. This suggests that what doctors know about infantile spasms is tightly coupled to what they actually do when confronted with a suspected case, and that attitudinal readiness alone cannot compensate for missing factual knowledge. In the regression models, specialty group and male gender emerged as the strongest independent predictors of all three scores, indicating that the knowledge gap is not evenly distributed and that training interventions should be targeted rather than generic.

Perhaps the most actionable finding concerns perceived barriers. When asked what most impedes early diagnosis, 37.7 percent of respondents identified lack of provider awareness as the leading obstacle. That figure is striking because it comes from the physicians themselves: the frontline workforce recognizes that its own awareness is the bottleneck. Unlike resource constraints or referral bottlenecks, which require systemic investment, provider awareness is a problem that continuing medical education can, in principle, address directly. The authors conclude that targeted continuing medical education programs, particularly for primary care physicians and residents, have the potential to improve early recognition and management of the syndrome in Palestine.

The study’s design carries both strengths and limitations worth noting. The sample of 419 participants is large for a survey of this kind, and the scenario-based practice items move beyond self-report by asking clinicians to respond to realistic clinical vignettes. The instrument’s content validity was assessed using the scale-level content validity index, and the analysis included checks for multicollinearity using variance inflation factors. However, as a cross-sectional survey, it captures a snapshot rather than a trajectory, and self-administered questionnaires are inherently vulnerable to response bias. The authors also note that the findings apply to the West Bank and may not generalize to other health systems, although the pattern of specialty-dependent knowledge gaps echoes concerns raised in studies from other resource-limited settings.

For the global child-neurology community, the Palestinian data sharpen a broader message. Infantile epileptic spasms syndrome is among the most time-critical diagnoses in medicine, yet its presentation mimics ordinary infant behaviors, and its victims cannot describe their symptoms. Where pediatric neurologists are plentiful, the frontline still matters; where they are scarce, the frontline is everything. The Palestinian study suggests that a modest, well-aimed educational intervention, focused on the primary care physicians and residents who see these babies first, could shift outcomes for a condition in which the difference between prompt and delayed treatment is measured in a child’s lifelong cognitive trajectory. The research was approved by the Al-Quds University Research Ethics Committee and conducted in accordance with the Declaration of Helsinki, with informed consent from all participants, and it appears in the open-access literature so that clinicians and educators elsewhere can build on it.

Subject of Research: Physician knowledge, attitudes, and practices regarding infantile epileptic spasms syndrome in Palestine

Article Title: Infantile spasms in Palestine: knowledge, attitudes, and practices among pediatric and primary care physicians and residents

Article References: Alhaddar, M., Darawsheh, R., Shalalfa, N., Ewidat, S., Abu-Hanieh, D., Abdallah, N., Mohsen, M., Almahdi, A., Alhouseini, M., Nasser, A., Elbaou, B., Alwawi, A., & Zrineh, A. (2026). Infantile spasms in Palestine: knowledge, attitudes, and practices among pediatric and primary care physicians and residents. BMC Pediatrics. https://doi.org/10.1186/s12887-026-07816-0

Image Credits: AI Generated

DOI: 10.1186/s12887-026-07816-0

Keywords: infantile spasms, infantile epileptic spasms syndrome, West syndrome, pediatric epilepsy, primary care, Palestine, West Bank, knowledge attitudes practices, continuing medical education, neurodevelopmental disorders, EEG, diagnostic delay