All posts by CHOC Children's

HPV Roundup: Resources to share with families

CHOC has published a lot of information for parents about human papilloma virus, or HPV, that is informative, straightforward and useful for families with children of all ages.

There are several common misconceptions providers encounter about HPV, including who is at risk, who should receive the vaccine and the risks associated with an untreated infection.

Please feel free to share these resources with families:

Can HPV really lead to cervical cancer?

An adolescent medicine specialist at CHOC Children’s offers HPV facts and explains its link to cervical cancer.

Does my child really need the HPV vaccine?

HPV affects nearly all sexually active men and women at some point in their lives. The HPV vaccine is more effective the younger it is given.

The HPV vaccine: a pediatrician’s perspective

A CHOC Children’s pediatric resident discusses some of parents’ most frequently asked questions about the HPV vaccine and children.

HPV at a glance on choc.org

See facts and figures, an FAQ, vaccine information, common myths debunked and a pediatrician finder tool where families can learn more and get their child the vaccine.

Vaccinating your preteen

The American Academy of Pediatrics presents answers to FAQs about important adolescent immunizations, including a walk through the purpose of each, the proper timing and an in-depth look at the HPV vaccine.

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.

Physician Wellness: Benefits of Gratitude

CHOC Physician Wellness Subcommittee Update
by Dr. Grace Mucci, Pediatric Neuropsychologist

Physician burnout is prevalent. According to the Mayo Clinic, up to 54% of doctors report at least one symptom of burnout. Further, it is estimated that the annual cost of that burnout is $4.6 billion per year in the form of physician turnover and reduced clinical hours, according to a study recently published by the Annals of Internal Medicine.

The experience of burnout results in feelings of cynicism, detachment from work, low sense of personal accomplishment, and emotional exhaustion. The reasons for burnout remain complicated, and a recent systematic review by the Journal of the College of Physicians and Surgeons Pakistan revealed both individual characteristics of physicians and variables within the working environment as contributory factors.

More specifically, work load appeared to be one of the main drivers and includes working hours, overnight duty, administrative duties, schedule and flexibility, and complexity of tasks. Feeling disconnected from colleagues or patients, poor communication or cooperation between colleagues and dealing with patients who disagree with treatment choices are additional sources of burnout.

Just as the causes of physician burnout are multi-factorial, the solutions encompass many strategies that include engaging in various lifestyle changes and systemic interventions.

One individual intervention that has been receiving more interest among researchers is gratitude. A 2017 study at UC Berkeley shows that the health benefits of expressing gratitude include increasing resilience to stress and boosting mental health. Gratitude also has been found to strengthen relationships and enhance mindfulness.

So, just how can we implement gratitude in everyday life? Here are a few ideas that can be applied easily:

  • Express gratefulness for the beauty in nature
  • Give thanks before eating food that has been prepared
  • Acknowledge service people you encounter throughout the day, such as a barista or worker
  • Keep a gratitude journal and write about all the things you’re thankful for prior to retiring for the night
  • Remember to tell your loved ones how much they are appreciated and one thing that you are grateful that they do every day
  • Surprise coworkers or even strangers by performing a random act of kindness
  • Keep a gratitude board where you document things you are thankful for, and be sure to review those items when you are having a difficult moment

At CHOC, several initiatives that promote this practice of expressing gratitude are underway. CHOC has partnered with the Institute for Healthcare Excellence (IHE) to offer an outstanding curriculum that helps build respect, trust and compassion, ultimately improving communication and empathy toward co-workers and patients and restoring joy to the practice of medicine.

In addition, CHOC’s Physician Wellness Subcommittee is busy planning a Wall of Gratitude in the physician dining room, where doctors can show gratitude and appreciation for their peers in real time.

We know that peer-to-peer recognition is important for strengthening the level of engagement and positive bonds among colleagues. We have all experienced the satisfaction of receiving kudos from our peers, and we want to make this easier and more visible to others. As we continue to advance these initiatives, be sure to practice those small but powerful strategies of expressing gratefulness in your everyday life.

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.

Causes and Treatment for Pain Amplification Syndrome

Andrew Shulman, MD, PhD, pediatric rheumatologist at CHOC Children’s, discusses the causes and treatment for this common yet complex condition.

1) What is pain amplification syndrome?

Pain amplification syndrome is a condition (not a disease) in which patients develop an abnormal pain sensitivity. The nervous system registers and processes normal sensations from movement and environmental experience as pain signals. Think of the nervous system as an electronic sensor: The sensor has a detection threshold. All signals with an intensity level below the threshold are perceived as “normal” and all signals above the threshold are “pain.” In children with pain amplification syndrome, the threshold is too low. Normal sensations and movements cause the nervous system to experience pain.

2) What are the causes?

We need to understand much more about what causes pain syndromes, experience over time with many patients with this condition reveals some common triggers. Joint flexibility is the most common cause of musculoskeletal pain in children, and is often responsible for what is known as “growing pains.” Patients with pain amplification syndrome often have flexible joints and have previously experienced joint and muscle discomfort. Some patients have had numerous orthopedic injuries in the past, or a particular traumatic injury that causes pain sensitivity in one part of the body.

In some patients, emotional trauma, psychological difficulties or psychiatric conditions can trigger pain sensitivity. In most patients, sleep is affected and is not restful. Even when psychological factors are not an initial cause, the stress from experiencing pain and the resulting disruption in school and activities can amplify pain sensitivity. We don’t know enough about the genetics of pain perception, but children with pain amplification syndrome commonly have family members with pain difficulties.

3) What are the symptoms?

Symptoms include body aches, joint and muscle pain, abnormal sensations of burning, tingling, numbness or pressure, headache, and chronic abdominal pain. In some cases, light touch to the skin causes pain sensations. Accompanying features include “dysautonomia,” wherein the autonomic nervous system does not perfectly regulate blood flow throughout the body. This results in symptoms of Raynaud’s phenomenon (cold sensitivity of the hands and feet with color changes, numbness, tingling and burning) and dizziness, particularly when standing up. These symptoms are not dangerous but can be uncomfortable and worrisome to patients.

4) What are the treatments?

A number of therapies work together to reset the abnormal pain sensitivity. Physical activity, particularly aerobic exercise, is very important in normalizing the pain threshold. Therapeutic massage can desensitize the nervous system and help the patient feel touch and movement as normal and not painful. Developing a regular, restful sleep schedule is important.

Finally, psychological therapy is often a critical aspect of the therapeutic program. This therapy is focused on stress management and coping techniques. In some cases, medications that decrease nerve signal transmission can be used. These medical treatments only assist the other therapies and are generally not effective in children when used alone.

5) What kind of testing is involved?

No laboratory or imaging tests can confirm the diagnosis of pain amplification syndrome. The diagnosis can be difficult to establish because numerous other medical conditions could potentially cause the symptoms. It’s important to take a step back and look at the “big picture” of a patient’s history and symptoms. Patients commonly have extensive investigations with many specialists before reaching a pain amplification syndrome diagnosis. Physicians with experience in pain amplification syndrome can help recognize the condition. Rheumatologists often help because they are familiar with symptoms and diagnostic challenges posed by autoimmune and inflammatory diseases.

6) Is there a cure?

Pain amplification syndrome is not a disease, so no cure is needed. This is a condition that patients learn to manage and control.

7) What can patients and families expect when treating pain amplification syndrome?

Families can expect more good days and fewer bad days as patients work through the abnormal pain sensitivity. The overall trend is gradual recovery, which can be measured by regular school attendance and activity participation. Reassurance that the patient does not have a serious disease often provides a big boost as the therapeutic program moves forward.

8) How bad does pain have to get before you see a pediatric rheumatologist?

Patients should be evaluated when symptoms become a significant concern and affect school attendance or participation in sports and activities. Pediatricians and subspecialty colleagues should seek rheumatologists’ expertise for help evaluating a pain amplification syndrome diagnosis and/or making treatment recommendations.

For questions or more information, please contact Andrew Shulman, MD, PhD, pediatric rheumatologist at CHOC Children’s, at 714-509-8617.