5 things pediatricians should know about seizures

Seizures can bring up a lot of worries and unknowns, especially when it comes to children.

One percent of the population has epilepsy, which puts the estimated number of children with epilepsy in Orange County alone at about 7,500. It is estimated that one in five people will have a seizure at some point—whether it develops into epilepsy or not—making seizures a more common neurological condition than multiple sclerosis, Parkinson’s and Alzheimer’s disease combined.

There are many common misconceptions about seizures, even within the medical community. Dr. Mary Zupanc, pediatric neurologist and epileptologist and co-medical director of CHOC’s Neuroscience Institute, points to five important points pediatricians should consider when seeing a patient who has had one or more seizures.

Professional headshot of Dr. Mary Zupanc, Pediatric Epileptologist at CHOC Children's, in a while labcoat on a gray background.
Dr. Mary Zupanc, Pediatric Epileptologist at CHOC Children’s
  1. There should be zero tolerance for seizures.

    Seizures are considered epilepsy when a child has had two or more unprovoked seizures—seizures that are not tied to a different underlying condition.

    When epilepsy is diagnosed, treatment should be initiated early. Some families are reluctant to treat their child’s epilepsy, often fearful that antiepileptic medication is worse than epilepsy itself. They worry about the side effects — that it will cause their child to have cognitive impairments and slow them down. However, repeated seizures can translate into progressive injury to the brain, with a decline in cognitive abilities and frequent psychosocial co-morbidities, including anxiety and depression. Furthermore, even if seizures are infrequent, there is a loss of independence for children and adolescents. An example would be an adolescent’s inability to obtain his/her driver’s license.

  2. Epilepsy is progressive.

    “Brain cells that seizure together network together,” Dr. Zupanc says, forming neuronal circuitry that hardwires the brain for continued seizures. Over time, there can be brain cell loss, cognitive decline, and important psychosocial consequences. Furthermore, when seizures continue, there is increased risk among those with epilepsy of sudden, unexpected death or other progressive neurological issues over the subsequent 20-30 years.

  3. Encourage parents to act quickly.

    Recurrent unprovoked seizures is the definition of epilepsy. Epilepsy should be treated and not ignored, for the reasons outlined above. Approximately 60-70% of epilepsy can be completely controlled with antiepileptic medication. Thirty percent of patients with epilepsy have intractable seizures, i.e. a failure to control the seizures with antiepileptic medications. These patients require more comprehensive care, including an evaluation for epilepsy surgery — at a Level IV Epilepsy Center, which is a designated center given only to those centers who provide multidisciplinary care with cutting-edge technology. Some parents fear that epilepsy surgery will cause serious neurological deficits. Most epilepsy surgeries are highly successful without detrimental effects to cognitive or motor functions. With epilepsy surgery, the risk of a severe and permanent injury is under 1%, and the risk of a minor or temporary injury is under 5%. Compared to the risks associated with years of recurrent seizures, the risks of epilepsy surgery are much lower than the risks of continued epilepsy.  

    The effectiveness of epilepsy surgery decreases significantly over time, especially for children who have had epilepsy for seven or more years. In addition, the plasticity of younger brains allows a transfer of functions to other parts of the brain — something adult brains cannot do as readily, Dr. Zupanc says.

    Because of this, she strongly encourages epilepsy surgery early, not waiting until a child is older.

  4. Delay in seizure treatment affects long-term psychological health.

    The psycho-social components of seizures are oftentimes just as important as the physiological ones, says Dr. Zupanc. Depression and anxiety occur in 50- to 60% of children with epilepsy, and there is also a notable increase in suicidal risk.

    These effects are increased when families wait to pursue recommended surgery, she says. Later in life, the surgery may remove the seizures, but the psychological effects are already deeply embedded.

  5. Seizure history should affect your referral choice.

    “It is so important for pediatricians to know that if a child’s epilepsy has not come under complete control after trying two or more antiepileptic medications, he/she should be referred to a higher level of epilepsy care, specifically a Level III-IV Epilepsy Center, as designated by the National Association of Epilepsy Centers,” says Dr. Zupanc. If the child is a young baby, the referral is even more urgent. “If a baby continues to have seizures after just one drug, he/she needs a referral to a Level III-IV epilepsy center immediately.”

    The care plan should include pediatric epilepsy specialists, epilepsy-trained neurosurgeons, state of the art neuroimaging tools, nurse practitioners, pharmacists, dieticians, social workers and neuropsychologists.

    “At CHOC, we treat epilepsy with a multidisciplinary team approach,” says Dr. Zupanc. Additional diagnostic tests are usually necessary to diagnose the appropriate epilepsy syndrome, determine if epilepsy surgery is an option, and/or outline an individualized, optimal treatment plan.

    Furthermore, all of those involved in the child’s care hold a comprehensive epilepsy conference to discuss complex cases and lay out the best possible strategy for achieving a seizure free outcome.

Increasing Performance Excellence at CHOC: Meet Sharon Nielsen Wilson

CHOC Children’s has tapped a seasoned healthcare leader to further increase performance excellence across the pediatric healthcare system.

In her role as executive director of performance excellence, Sharon Nielsen Wilson will find ways to improve and enhance how CHOC patients and families are served across the organization at all levels. Further, Sharon is tasked with facilitating, understanding and supporting change throughout the organization.

“I am thrilled for this new opportunity at CHOC, and I look forward to building upon a strong culture of service and performance excellence to help propel CHOC forward as it strives to become the destination for children’s health,” Sharon said.

Sharon Nielsen Wilson, executive director of performance excellence

Bringing a clinical background as well as a dozen years of experience in improving systems and workflows, Sharon joined CHOC in May 2019 from Kaiser Permanente. She began work there in 2006 as a registered nurse and most recently served as director of performance improvement for its facility in Harbor City, Calif.

Sharon holds a bachelor’s degree in nursing from California State University, Dominguez Hills, and is currently pursing a master’s degree in quality assurance. She is also certified in change management through Implementation Management Association (IMA) and quality insurance through CSUDH.

We caught up with Sharon recently to learn more about her role and what she hopes to accomplish at CHOC.

What is Quality Improvement and why is it important to a healthcare organization?

Quality Improvement (QI) is a proactive and systematic approach to improve processes and systems.

QI models present a systematic, formal framework for establishing QI processes in your practice. Understanding and properly implementing QI is essential to a well-functioning practice and is necessary for improving efficiency, patient safety or clinical outcomes.

Examples of common QI models include:

  • IHI’s Model for Improvement: Thismodel uses plan-do-study-act (PDSA) cycles to test interventions on a small scale. The model combines two popular QI models: Total Quality Management (TQM) and Rapid-Cycle Improvement (RCI).
  • Six Sigma: A method of improvement that focuses on reducing variation.
  • Lean: An approach that reduces waste by decreasing non-value-added work in systems and processes.

How can all CHOC associates take an active role in improving performance excellence?

Associates can take an active role by taking advantage of the certification programs and partnership CHOC’s Performance Excellence team will be offering beginning this fall and together effectively identify, plan and execute improvement projects, deliver successful results and spread changes across the entire system.

The certification programs Performance Excellence will be offering are tailored to each level in the organization. The programs will help build a more solid foundation of knowledge and skills in the art and science of improvement within CHOC.

What do you see as key performance strengths for CHOC – and how can we build upon them to further enhance how we serve patients and families?

I see our associates’ engagement and dedication to CHOC’s mission as some of key performance strengths here at CHOC. Some ways to build on these strengths is to invest in our workforce and infuse performance excellence into our culture. As we continue to build reliability and efficiency into our processes and systems, we will be able to remove frustration and the potential for error and add value to the way we serve one another, our patients and their families.

In the Spotlight: Rishikesh Chavan, M.D.

CHOC welcomed Dr. Rishikesh Chavan to the oncology department in January 2019. As the Medical Director of the Stem Cell Transplant and Cellular Therapy program, he works with young patients going through leukemia, lymphoma or other conditions requiring bone marrow or stem cell transplants. He attended medical school at Lokmanya Tilak Municipal Medical College in India, followed by a pediatrics residency at Tulane University School of Medicine and a Hematology/Oncology fellowship at Baylor College of Medicine. Subsequently, he served as the Medical Director of Stem Cell Transplant at Tulane University and Loma Linda University Children’s Hospital.

Dr. Rishikesh Chavan, Oncology

What are your special clinical interests?

Stem cell transplant and immunotherapy for high risk leukemias/lymphomas. I am also interested in reduced intensity stem cell transplants and gene therapy for immunodeficiencies, aplastic anemia and sickle cell disease patients.

What are some new programs or developments within your specialty?

Comprehensive whole patient care model involving psychology, nutritionists, social workers, child life specialists, pharmacists and care coordinators as an integrated team approach to improve the ease of transition between inpatient and outpatient care, to ensure patient satisfaction and compliance, and to achieve best possible outcomes—all while lowering the cost of care.

What would you most like community/referring providers to know about you or your division at CHOC?

We believe every patient coming to transplant deserves personal attention, and we strive to over-communicate with the referring providers to share updates about their patients’ health as well as
facilitate with transitioning the patients back to the referring providers as soon as the patients are ready to be followed by them.

What inspires you most about the care being delivered here at CHOC?

Healthcare delivery is going through a transformation, and CHOC is at the forefront of this healthcare transformation by bringing the latest evidence-based treatments as well as clinical trials to benefit our kids while simplifying the care they need.

If you weren’t a physician, what would you be and why?

I would be a farmer. I feel it is a skill that requires patience, selflessness and long-term thinking, and that the efforts put in by one generation are likely to benefit the next generation.

What are your hobbies/interests outside of work?

I volunteer at the local library to facilitate a Heartfulness Meditation group (a network of volunteer meditation coaches and a meditation app). I also like to spend time with my kids and dog at the park. When time permits, I try to go to the gym and play tennis. I also read a lot—nowadays audiobooks.

What have you learned from your patients?

Resilience. Given the patients we have, I can never really have a bad day. If I do feel I’m having a bad day, my patients’ situations give me perspective.

CHOC Children’s Hospital honored with resuscitation recognition award

CHOC Children’s Hospital has received the Get With The Guidelines®-Resuscitation Silver Plus Award for implementing specific quality improvement measures outlined by the American Heart Association for the treatment of patients who suffer cardiac arrests in the hospital.

More than 200,000 adults and children have an in-hospital cardiac arrest each year, according to the American Heart Association. The Get With The Guidelines-Resuscitation program was developed with the goal to save lives of those who experience in-hospital cardiac arrests through consistently following the most up-to-date research-based guidelines for treatment. Guidelines include following protocols for patient safety, medical emergency team response, effective and timely resuscitation (CPR) and post-resuscitation care.

“This recognition is more evidence of CHOC Children’s steadfast commitment to the highest standards of patient care,” said Dr. Jason Cook, a pediatric critical care physician and medical leader of CHOC’s resuscitation activities. “We’re grateful to have the American Heart Association’s Get With The Guidelines-Resuscitation program as another resource in CHOC’s toolbelt to ensure the best possible outcomes for our patients.”

CHOC received the award for meeting specific measures in treating pediatric in-hospital cardiac arrest patients. To qualify for the awards, hospitals must comply with the quality measures for two or more consecutive years.

“CHOC is dedicated to helping our patients have the best possible outcomes and ensuring they have happy and healthy childhoods,” said Dr. James Cappon, CHOC’s chief quality officer. “Participating in the American Heart Association’s Get With The Guidelines-Resuscitation program helps us accomplish this by making it easier for our teams to put proven knowledge and guidelines to work on a daily basis.”

“We are pleased to recognize CHOC for their commitment in following these guidelines,” said Lee H. Schwamm, M.D., national chairperson of the Quality Oversight Committee and Executive Vice Chair of Neurology, Director of Acute Stroke Services, Massachusetts General Hospital, Boston, Massachusetts. “Shortening the time to effective resuscitation and maximizing post-resuscitation care is critical to patient survival.”

Get With The Guidelines-Resuscitation builds on the work of the American Heart Association’s National Registry of Cardiopulmonary Resuscitation originally launched in 1999 and has collected in-hospital cardiac arrest data from more than 500 hospitals. Data from the registry and the quality program give participating hospitals feedback on their resuscitation practice and patient outcomes. In addition, the data helps improve research-based guidelines for in-hospital resuscitation.

About Get With The Guidelines

Get With The Guidelines® is the American Heart Association/American Stroke Association’s hospital-based quality improvement program that provides hospitals with the latest research-based guidelines. Developed with the goal of saving lives and hastening recovery, Get With The Guidelines has touched the lives of more than 6 million patients since 2001. For more information, visit heart.org.

Can children outgrow autism?

A study recently published in the Journal of Child Neurology suggests that children may outgrow autism. We spoke to Dr. J. Thomas Megerian, pediatric neurologist and clinical director of the Thompson Autism Center at CHOC Children’s, about what parents should know about these findings.

What can providers tell parents about the study’s findings?

Many parents ask me, “Will my child outgrow autism?” and I always tell them that what we hope for is that with services and growth, the child will improve so much that after as little as a few years, they no longer meet the criteria for Autism Spectrum Disorder (ASD). Outgrowing the label may mean they have learned to compensate or overcome some challenges like socialization or repetitive movements. They may have little features left of ASD, and what symptoms they do have, may cease to interfere with their development or daily lives. When they have progressed to the point where they have outgrown the label, any remaining traits may be so small that only a parent would notice, but a new person who has just met the child wouldn’t pick up on anything.

However, I advise my patients’ parents that if and when their child outgrows the label of autism, they may still have other co-occurring issues like anxiety, attention deficit hyperactivity disorder (ADHD) or learning disabilities that require ongoing care.

So yes, indeed this study should give parents hope surrounding a child’s ability to outgrow the autism label, despite their other potential ongoing issues.

In some instances, schools may suggest a decrease in services because a child has improved and outgrown the label of autism. That same child may still be struggling with organization or learning certain subjects. Parents may be in a position to say that just because their child has outgrown the autism label doesn’t mean they do not have a need for additional support.

What does life look like for a child previously diagnosed with autism who is no longer on the spectrum?

Learning disabilities, obsessive compulsive disorder, and attention deficit disorder are common among children with ASD. Rates of other disorders are common among children with autism, including: gastrointestinal disorders, ear infections, seizures and anxiety. They may clear up later in life or become better managed, but they don’t necessarily go away at the same time as their autism label.

Residual symptoms of these co-occurring diagnoses may last into adulthood. For example, a child may outgrow their ASD label but still have anxiety that can be managed by cognitive behavioral therapy.

Why is early detection and early intervention of autism so important?

Early detection and intervention help many kids outgrow the autism label in the future due to improvements with socialization and repetitive behavior. It’s important for people to remember that just because they have lost the autism label doesn’t mean they don’t have other diagnoses or disorders that may require ongoing treatment.

There’s no question that early intervention makes a big difference in helping kids with the potential to outgrow their ASD diagnoses achieve that milestone even sooner. The trajectory has changed for many of those kids.