11 neurological events that aren’t epilepsy

By Dr. Andrew Mower, CHOC Children’s neurologist

You open the exam room door to find an anxious mother pacing with her baby. Her son has been displaying sudden shivering moments, she says. She’s frightened that these episodes were epileptic seizures.

Indeed, watching a child shake and tremble suddenly is worrisome for any parent. But not every paroxysmal event is a seizure or neurological event.

Dr. Andrew Mower, pediatric neurologist at CHOC Children’s

Here are 11 such examples, and a guide to help pediatricians understand what the differential diagnosis is for seizures and other neurological events; recognize elements in the history that helps differentiate whether the paroxysmal spell is a seizure or neurological event or not; and learn what initial diagnostic workup is needed to guide management.

  1. Breath holding

During these episodes, a child appears to stop breathing and may collapse, typically after a startling, frustrating or painful event. The child’s skin may be pale or purple in color, and he may show mild tonic or tonic-clonic movements. Recovery occurs in minutes. The behavior surfaces typically in children between ages 6 months and 2 years.

Though they may appear to be a seizure, these episodes are a physiological response, and not caused by electrical impulses in the brain.

Some factors to consider, however, that would call into question whether this is something other than breath-holding spells include a questionable or unclear trigger, progressively more frequent episodes, movements much more suggestive of a seizure, a very young age of onset, and a child with a developmental delay.

Children showing these red flags may require an EEG. For most, however, a workup is not typically needed, nor is treatment.

Almost all children outgrow breath holding and there is no neurological consequence.

2. Benign paroxysmal vertigo

During these episodes, a child, typically between 1 to 2 years of age, may become suddenly unsteady and fall. The child may become pale, vomit or cry, but retain consciousness. Events last minutes.

These events are considered an early migraine manifestation. Differential diagnoses include labyrinthitis, CNS tumor, epilepsy, unwitnessed head trauma and concussion, near-syncope, cardiac dysrhythmia

More worrisome are events that are unremitting and not episodic; include a loss of consciousness; show other neurological signs such as seizures, weakness or hearing loss; or are experienced by a child with a developmental delay can be more worrisome.

Workup for children exhibiting these events could include a brain MRI, ENT evaluation or EEG.

These episodes are typically not progressive or degenerative, but do indicate a likelihood for migraines in teen and adult years.

3. Shuddering attacks

Patients experiencing these events have shivering moments that last seconds, which can occur sporadically or multiple times a day. They occur most typically in infants ages 6 to 15 months, and they do not lose consciousness.

These events are behavioral, and differential diagnoses include seizure or tics.

Longer episodes; rhythmic twitching; a change of awareness or consciousness; and color change are red flags, as is an event experienced by a child with developmental delay or abnormal exam.

A video captured at home is often sufficient for diagnosis, and no workup is needed. No treatment is necessary for these events, and a child’s prognosis is excellent.

4. Infant gratification

This is a normal phenomenon, more commonly known as masturbation, that can include dystonic posturing, grunting, rocking, eidetic imagery and sweating. Typically experienced by children 2 months to 5 years of age, these events can occur sporadically or multiple times a day.

Children’s skin may change color and they may seem tired afterward. The event can be stopped in progress, but a child may get upset if the parents stop the behavior.

Red flags for this behavior include unresponsiveness, tonic-clonic movements or cyanosis, and a differential diagnosis is partial seizures.

A video captured at home is often sufficient for diagnosis, and no workup is needed. Treatment is behavioral based, and prognosis is excellent.

5. Staring spells

These episodes occur in children of any age, but are common in children with autism. The spells may look like day dreaming or inattention, but are often redirectable.

Often, the events are behavioral or related to frontal lobe processing. Differential diagnoses include absence or complex partial seizures. Episodes wherein children are not redirectable, show a change in coloring or behavior, or have a cognitive decline are more worrisome.

Workups include EEG, ADHD evaluation, neuropsychological evaluation for learning disabilities and cognitive abilities, or a psychological evaluation.

Treatment can include psychology or behavioral therapy, neuropsychology and appropriate educational setting, or stimulant medication as needed.

In general, a child’s prognosis is typically excellent. Children with ADHD have a generally good prognosis, but may have variable response to treatment with stimulant medications. A prognosis for those with learning disabilities depends on the severity, classroom setting and educational factors.

6. Reflux

Shown in younger infants from birth to age 6 months, these events look like twisting and writhing movements that aren’t typically sudden. However, patients may show some sudden flexion and extension of the body, arms or legs. Children’s skin may redden.

Children exhibiting these events may have low muscle tone that contributes to relaxed muscle at esophageal-gastric junction.

Differential diagnoses include seizures, infantile spasms or movement disorders, and red flags include no association with feeding, stereotyped movements like jack-knifing or sudden flexion in clusters, or cyanosis.

Workup includes clinical diagnosis, further investigation following a finding of low tone on exam, sometimes upper GI or other GI studies, EEG or video-EEG monitoring.

Treatment includes H2 blockers or proton pump inhibitors.

Patients’ prognoses are generally excellent with symptoms resolving over time. However, for children with significant GI pathology or neuromuscular conditions, the prognosis is guarded.

7. Tics/Tourette’s syndrome

These episodes include the twitching of one muscle or a group of muscles, but rarely involve larger muscle groups. Though repetitive, they are not typically rhythmic or prolonged. They do not cause falling, and do not typically restrict activities.

They can occur in a variety of ages, and older children may describe a feeling that they must make the movement. Vocal tics include grunting, humming, clicking and sniffling, but rarely formed words.

As pathophysiology, structural and functional neuroimaging studies have shown the involvement of the basal ganglia and related cortico-striato-thalamo-cortical circuits, and the dopaminergic neuronal system.

Differential diagnoses include myoclonic seizures. A change of consciousness, inability to suppress, onset in sleep, and episodes that are rhythmic and repetitive are red flags.

Workup includes a clinical diagnosis, EEG or screening for the presence of ADHD, OCD or other behavioral disorders.

Most children do not need treatment for tics, unless the behavior is disturbing physically or socially. Central alpha agonist medications (Clonodine, Tenex) or dopamine antagonist drugs (Haldol, Risperdal, ORAP, Pimozide) can be useful.

Most children outgrow tics, and up to 15 percent of people diagnosed with Tourette’s outgrow the condition.

8. Stereotypies

Typically shown in early childhood after age 1, these episodes are marked by repetitive stereotyped movements that may or may not be rhythmic. They are self-stimulatory and otherwise without purpose. Examples include hand flapping or rocking. Events may persist into adulthood, especially in patients with autism or an intellectual disability.

These events are behavioral in nature, but a differential diagnosis is automatisms with complex seizures.

Red flags include a change in awareness, which can be difficult to detect in children with autism, and events that are rhythmic and repetitive.

Workup includes and EEG, and treatment is applied behavior analysis or therapy from a psychologist. For children who can be taught not to exhibit the behavior, prognosis is good.

9. Night terrors

These episodes are more common in children around age 3, but can surface earlier and persist into teenaged years and adulthood.

A patient may awake from deep sleep with a terrified look, screaming and showing decreased responsiveness. They may tremble, and episodes may occur several times a night.

Their exact mechanism is unknown, but night terrors may be genetic.

Differential diagnoses include nightmare, seizure, arousal disorder or parasomnia. Episodes are more worrisome if they occur many times a night, include strange repetitive movements like pelvic thrusting or bicycle pedaling motions, or are accompanied by progressive academic or developmental decline.

Workup includes a history and clinical diagnosis, polysomnogram or video EEG sometimes combined with polysomnogram.

Most children grow out of night terrors and do not require treatment, but can benefit from counseling on sleep habits or psychology. Though rarely, medications like clonazepam or amitriptyline can be helpful.

10. Syncope

These events are more common in teenaged patients. They include a sudden and brief loss of consciousness typically with associated loss of muscle tone. Patients may fall or slump forward or backward, and have mild twitching. They might also have a light-headed, giddy feeling or blackening of vision.

Loss of consciousness lasts only seconds, and patients may hear people around them before vision returns. They may feel groggy afterward, but not confused.

Recovery is quick, and episodes typically have a trigger: standing up too quickly, standing in place too long with legs locked, dehydration on a hot day, emotional fright, valsalva including defecation or urination, hair traction, or venipuncture.

These episodes are not a primary neurological event, and a common feature is reduced cerebral perfusions. They stimulate the vagus nerve, which causes bradycardia. Decreased venous tone allows venous pooling and decreased blood return to the heart. Valsalva prevents venous return to heart

Differential diagnoses are complex partial or other types of seizures, or postural orthostatic tachycardia syndrome.

Red flags include no provoking factor, prolonged and prominent tonic-clonic movements or hemi-clonic movements, cyanosis, or occurrence in very young children or those with a neurological or developmental disorder.

Workup includes diagnosis based on clinical history; orthostatic blood pressures; EEG if any red flags are present; and KG/Holter study, tilt-table testing, or cardiology consult if the patient’s clinical history is suggestive of dysrhythmia.

Treatment includes counseling on how to avoid symptoms, including standing up slowly, drinking water and avoiding triggers.

Looking forward, a predisposition to fainting may continue into adulthood. The episodes don’t cause neurologic injury, but a patient could get injured from a fall.

11. Cyclic vomiting

These episodes entail one to five days of copious vomiting, followed by asymptomatic periods. The average age of patients is 5, but episodes can span from infancy to adulthood.

They usually start in early morning or late afternoon. Abdominal pain, anorexia, lethargy, pallor, sweating and salivation accompany the episodes.

Triggers include emotional stress, energy-depleting states, some foods and menstrual cycles.

To diagnose, the patient must have stereotypic episodes of vomiting with at least two acute-onset episodes in the past six months, each occurring at least one week apart and persisting for less than one week.

Red flags include periods of unresponsiveness, tonic-clonic movements, visual changes, other neurological symptoms such as hemiparesis, hematemesis and melena.

Workup includes MRI or GI referral and endoscopy.

IV fluids, anti-nausea medication, pain relief medication is common treatment. Periactin; amitriptyline; antiepileptic medications with migraine indications (Depakote, Topamax, others); and propranolol can be used as prophylactics.

Learn how to refer to a CHO Children’s neurologist.

Acute and Chronic Headache Management in Children and Teens

When child and adolescent patients complain to their parents about a headache, it can be anything from a plea to stay home from school in hopes of avoiding a test, to a sign of something more serious. Dr. Sharief Taraman, a pediatric neurologist at CHOC Children’s, offers advice to the referring community on acute and chronic headache management in children and teens, including headache hygiene, non-medical intervention options, and referral guidelines.

Dr. Sharief Taraman, a pediatric neurologist at CHOC Children’s

Types of headaches often seen in children and adolescents

Migraine symptoms in kids

  • At least 5 attacks that meet the following criteria:
  • Headache lasting 1 – 72 hours
  • Headache has at least two of the following features:
    • Pain on both side or one side of the head
    • Pain is pulsating
    • Moderate to severe intensity
    • Aggravated by routine physical activities
  • At least one of the following:
    • Nausea and/or vomiting
    • Sensitivity to light or noise
  • Chronic migraines are indicated by 15 headache days per month over a three-month period, and at least half of those are migraines.
  • About 1 out of every 20 kids, or about 8 million children in the United States, gets migraines. Before age 10, an equal number of boys and girls get migraines. But after age 12, during and after puberty, migraines affect girls three times more often than boys.

Tension headache symptoms in kids

  • Headache lasting from 30 minutes to seven days
  • Headache has at least two of the following characteristics:
    • Pain in two locations
    • Pressing or tightening feeling (not a pulsing pain)
    • Mild to moderate intensity
    • Not aggravated by routine physical activity such as walking or climbing stairs
  • No nausea or vomiting – many children experience a loss of appetite
  • Either sensitivity to light or sensitivity to sound
  • Tension headaches occur most often in children ages 9-12

Cluster headache symptoms in kids

  • At least five headaches that meet the following criteria:
    • Severe pain in one location: within the eye, above the eyebrow, or on the forehead, that lasts from 15 minutes to three hours when left untreated
  • Headache is accompanied by at least one of the following symptoms on the same side of the body as their headache:
    • Conjunctival injection and/or lacrimation
    • Nasal congestion and/or excess mucus in the nose
    • Eyelid swelling
    • Forehead and facial swelling
    • Droopy eyelid and/or small pupil
    • A restlessness or agitation
    • Cluster headaches usually start in children at around 10 years old

Post traumatic headache symptoms in kids

  • Acute post traumatic headache: lasts less than three months and caused by a traumatic injury to the head
  • Persistent post traumatic headache: lasts more than three months and caused by a traumatic injury to the head
  • Both acute and persistent headaches develop within one week of: the injury to the head, regaining of consciousness following injury to the head, or discontinuing medicine that impairs the ability to sense a headache following a head injury
  • Extended recovery risk factors:
    • Prolonged loss of consciousness or amnesia
    • Females
    • Initial symptom severity
    • Premorbid history of ADHD, mood disorders, and migraines

Sleep apnea headache symptoms in kids

  • Typically a morning headache
  • Pain is present on both sides of the head
  • Lasts more than four hours
  • Not accompanied by nausea, nor sensitivity to light or sound

Medication overuse headache symptoms in kids

  • Headaches on 15 or more days per month
  • Takes over-the-counter medication for headaches more than three times per week over a three-month period
  • Headache has developed or gotten worse during medication overuse
  • Pattern of headaches resolves or improves within two months after discontinuing the overused medication.

Remind parents of headache hygiene tips

There are a number of things parents can do to prevent headaches, says Dr. Taraman. Remind parents to practice headache hygiene:

Non-medical interventions

A variety of non-medical interventions can be helpful for children who are suffering from headaches, including ice packs; warm baths; taking a nap in a cool, dark room; neck and back massage; and taking a walk.

Medication as treatment for headaches in children

Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen, should be limited to no more than three days per week, with no more than two doses per day, in order to avoid medication overuse headaches.

Triptans are often used to treat moderate to severe migraines or cluster headaches, but should not be prescribed to patients with cardiovascular disease, uncontrolled hypertension, basilar migraine or hemiplegic migraine.

Encourage patients to keep a headache diary

Encourage your patients to keep a journal of their headaches so you can identify a pattern. Patients should keep track of:

  • Headache start date and time
  • What happened just before the headache?
  • How much did your head hurt, on a 0-10 pain scale?
  • Where did your head hurt?
  • What did you feel just before and during the headache?
  • What did you do to make yourself feel better?
  • Did you feel better, on a 0-10 pain scale?
  • Headache end date and time

When to refer cases of headaches to pediatric neurologists

Dr. Taraman offers the following guidelines on when to refer headaches to a pediatric neurologist for imaging:

  • Diagnosis of neurofibromatosis of tuberous sclerosis
  • Immunosuppressed child
  • If the child is awoken on a regular basis by headache pain or vomiting
  • Headaches beginning shortly after arising from bed in the morning (i.e., positional headache)
  • Syncope
  • Chronic progressive headaches
  • Persistently posterior headaches
  • Chronic headaches in patients less than 3-5 years old

When patients have a history of the following symptoms during headaches, Dr. Taraman offers the following guidelines on when to refer headaches for imaging and possible neurology consultation:

  • Double vision
  • Abnormal eye movements and/or nystagmus
  • Unilateral ptosis or complete 3rd nerve palsy
  • Motor or gait dysfunction or hemiplegia
  • Hemisensory disturbance
  • Confusion
  • Vertigo

CHOC is the only specialized imaging facility in Orange County just for children, and we only use board-certified pediatric radiologists and specially trained pediatric radiology technologists, nurses and child life specialists.

Parents should immediately be sent to the emergency room for headaches when:

There are some clear instances of severe headaches that warrant an immediate trip to the emergency room, says Dr. Taraman. These include:

  • Thunderclap headache: severe, sudden onset of pain that occurs anywhere in the head, and grabs your attention like a clap of thunder. Pain usually peaks within 60 seconds to a few minutes.
  • Any headache that comes with acute focal neurologic deficit.
  • Changes in vision due to papilledema, which can include blurred or double vision, flickering, or complete loss of vision.
  • If the child had a shunt placed for a condition such as hydrocephalus, and it becomes obstructed or infected, they can show symptoms of untreated hydrocephalus.

Learn more about the Neuroscience Institute at CHOC Children’s.

 

Return to Learn Concussion Guidelines Every Medical Provider Should Know

While most medical providers are familiar with Return to Play laws – a step-wise progression addressing when student athletes with concussions should return to sports/physical activity – there is no similar legal process for “Return to Learn” guidelines addressing when students with concussions should return to school.

Further, a study in the December 2016 Pediatrics found that only a few states have Return to Learn concussion laws, and these varied in delineation of responsibility. Some of the laws were restricted to student athletes, excluding students who sustained non-sport related concussions.

Dr. Chris Koutures, pediatrician and sports medicine specialist at CHOC Children’s.

When returning a student to the classroom after a concussion, we try to balance stimulation levels and worsening of symptoms, explains Dr. Chris Koutures, a board certified pediatrician and sports medicine specialist at CHOC Children’s.  While too much cognitive exertion can lead to headaches, problems concentrating, fatigue and trouble with emotional control, over restriction from classroom and academic activities can result in social isolation and anxiety about falling behind or lower grades that can also slow the recovery process.

“Returning to the classroom after a concussion optimally takes a team approach including the student, family, medical and education teams,” Dr. Koutures says. “Flexibility and creativity in paying attention to individual student needs and concerns can make this process more rewarding for all parties.”

Dr. Koutures advises the patient’s care team to follow CHOC’s recommended six stages for returning a student to school after a concussion, including the following added guidelines:

Step-wise Return to Learn Progression

Step 1: No formal academic activity

  • Recent studies suggest that full or prolonged limitations in cognitive activity may actually delay recovery
  • In first few days after concussion, allow 15-20 minute intervals of single-task activities that do not provoke symptoms and are not excessively taxing
    • Listen to light music
    • Draw or color
    • Journal writing
    • Audiobooks
    • Passive television or movies (at home), larger screen preferred, lower volume
    • Some texting, smartphone use; want to balance maintaining key social contacts with not having symptom-flare
    • Conversations with 1-2 other people
  • Separate the 15-20 minute bursts of activity by 30-40 minutes minimum of non-cognitive activity
  • If symptoms flare before 15-20 minute limit, stop activity and try again later
  • If patient can handle 2-3 periods of 15-20 minute activity over the course of day, can consider advancing toward partial return to school

Step 2: Light academic activity

  • Attend 1-2 periods or 1-2 hours of school
  • Select consecutive classes; have child help make decision
  • No physical education or other activity classes
    • Caution with more noisy classes such as woodshop, music/band, chorus
  • Tend to avoid first class in morning to allow more sleep and arrival at school without busy parking lot and hallways
  • Main goal: be in class; no responsibility for note-taking, participating in class /responding to teacher, in-class work, homework or testing
    • Audible learning (most kids handle this better than visual learning after a concussion)
    • Should have pre-printed notes for reference or have others take notes and share
  • Sit away from louder students, windows, projectors, or other light/noise stimulation
  • Sit close to teacher
  • Allow to wear earplugs and sunglasses as needed
  • May allow brief 1-2 minute periods of putting head on desk for rest
  • May leave class early to avoid the noise and commotion of hallways during passing periods

Step 3: Increased academic activity

  • Expand day to 3-4 periods or hours per day
  • Incorporate break periods (nutrition break, lunch)
    • Have quiet place to rest
  • Recommend against assemblies or rallies due to noise stimulation
  • Continue to avoid physical education or activity classes
  • Main goal is to be in class and handle longer day; still not responsible for note-taking, participating in class/responding to teacher, in-class work or homework

Step 4: Full-time attendance

  • Full-day attendance without activity or other higher-stimulation classes
  • May expect some increased fatigue at end of school day
    • If student wants to nap after school, limit to no more than one hour
  • May start to take own notes, though helpful to have pre-printed teacher’s notes or other student notes
  • Incorporate “to do” lists with short-block (10-15 minute) work periods followed by short (5 minute) breaks
  • Break period and breaks in class (especially if block schedule) may still be needed
  • If possible, move most challenging courses to time of day when student feels the best

Step 5: Return to Majority of Academic Activities

  • Once handling full day attendance, can resume taking notes in class, verbal responses to teacher, and in-class work
  • May begin homework starting with limits to 30-60 minutes a night and priority on essential concepts that are needed for eventual testing or continuity of learning
    • Waive any projects, papers, essays or other assignments that are not required for future learning needs
    • Try to limit burden of make-up work; focus should be on those assignments that are necessary for future learning
      • Sequential classes (math, foreign languages, science) tend to be the most challenging for make-up work
    • No tests or quizzes at this stage
    • Audible learning – listen/speak responses vs. writing, dictating work, audiobooks may be more favorable at this point

Step 6: Return to Full Academic Activity

  • Full-day attendance without symptoms, fulfilling all in-class duties and completing usual homework assignments
  • Can resume tests and quizzes
    • Strongly consider waiving missed tests or quizzes
    • Combine missed tests or quizzes to allow more quick completion of make-up work
    • Allow student to take missed tests/quizzes to gain exposure/mastery of material without being graded, or only receive grade if results are in usual level of achievement
    • Assign grades at end of grading period based on level of work prior to concussion
  • May need more time for test completion
  • May need individual room placement for testing
  • May limit testing/make-up testing to one test per day
  • May allow open book, use of notes, word banks or home-based testing
  • Consider alternate forms of testing such as spoken test, or multiple choice vs. longer essay responses that might be more taxing for the student
  • Students may still benefit from more audio learning
  • Can resume physical education (with physician release) and activity courses.

To contact Dr. Chris Koutures, please call 714-974-2220.

Learn more about CHOC’s concussion program.

Infantile Spasms: What Pediatricians Should Know

Though seizures in children are always worrisome, pediatricians should be especially watchful for infantile spasms, a type of epilepsy that occurs in young infants typically between ages 3 and 8 months, a CHOC Children’s neurologist says.

These seizures should be considered a medical emergency due to the potentially devastating consequences on the developing brain, Dr. Mary Zupanc says. Many children with infantile spasms go on to develop other forms of epilepsy because a developing brain undergoing an epileptic storm essentially becomes programmed for ongoing seizures and cognitive/motor delays.

To that end, here’s what pediatricians should look for:

  • Infantile spasms often occur in clusters, with each spasm occurring every five to 10 seconds over a period of minutes ranging from three to 10 minutes or longer.
  • Though there is almost always a cluster of spasms in the morning when the child awakens from sleep, infantile spasms can occur at any time during the day or night.

Infantile spasms can be easily missed because they can mimic common symptoms and conditions such as sleep disturbances, gastroesophageal reflux, startle and shuddering attacks.

Diagnosis, treatment

If infantile spasms are suspected, a pediatrician should quickly refer the child to a pediatric neurologist. CHOC neurologists admit these children urgently for long-term video electroencephalogram (EEG) monitoring to confirm the diagnosis.

Infantile spasms are diagnosed on the basis of clinical spasms, in association with a markedly abnormal EEG showing a hypsarrhythmia pattern. A hypsarrhythmia pattern is characterized by very high amplitude electrical activity and multifocal areas of the brain demonstrating epileptic discharges.

High-dose adrenocorticotropic hormone, or ACTH, is CHOC neurologists’ first line of treatment for infantile spasms, per the American Academy of Neurology’s 2004 practice parameter. Vigabatrin (Sabril), the parameter states, is probably effective in the treatment of infantile spasms, especially in children with tuberous sclerosis and infantile spasms.

If started within four to six weeks of seizure onset therapy has better success at stopping spasms, eliminating the hypsarrhythmia pattern and improving developmental outcomes regardless of etiology.

The course of treatment is approximately six weeks. During this time, and for two to three months after the ACTH course, immunizations should not be administered. The effectiveness of ACTH may be as high as 85 percent, though a recent published study placed the efficacy at a slightly lower percentage, regardless of etiology.

Side effects, causes

Side effects of ACTH, a steroid, include high blood pressure, increased appetite and weight gain, increased sugar in the blood, temporary suppression of the immune system, and sometimes gastritis. All side effects are monitored during the time of the ACTH, and they disappear after the course of treatment.

Successful therapy is marked by two achievements: the cessation of the infantile spasms and the elimination of the hypsarrhythmia pattern. But because clinical spasms can be very subtle and the hypsarrhythmia pattern may sometimes only be seen during deep sleep, therapy’s success can only be confirmed through objective long-term video EEG monitoring.

The etiologies for infantile spasms can include:  tuberous sclerosis; cortical dysplasias; stroke; infection including meningitis and encephalitis; hypoxic-ischemic injury; trauma; or genetic conditions such as Down syndrome and metabolic disorders.

 

What CHOC Physicians are Grateful for this Thanksgiving

As Thanksgiving approaches, CHOC Children’s physicians explain what they’ll consider when giving thanks this holiday.

 

“CHOC has provided me with lifelDr. Neda Zadehong blessings. I am grateful to have grown up at and with this hospital, from the initial CHOC Tower to the current Bill Holmes Tower, through pediatric residency training and beyond.  To now be a member of such a remarkable team of providers — including our nurses and support staff — is both humbling and inspiring. Every day, I am especially thankful for the families who cross our threshold, and entrust the care of their most precious children to us. With continued commitment and dedication toward the health and well-being of our children, the future will be brighter than any of us can imagine.”
– Dr. Neda Zadeh, genetics

 

Dr. Kenneth Grant

 

 

“I am thankful to be working for an organization that creates an environment where our patients become our family. I am also grateful that CHOC Children’s has the foresight to invest in the innovative ideas we have to improve the health care we provide.”
 – Dr. Kenneth Grant, gastroenterology

 

 

 

mackey_tg

 

“I am thankful for the opportunity with be partnered with an excellent children’s hospital. I am also thankful for the pleasure of working with other positive people who provide outstanding care to the children of Orange County. Together, we work to improve the care and services we deliver to our most important resource — our children.”
– Dr. Daniel Mackey, pediatrics

 

 

 

 

Dr. Lilbeth Torno

“I am grateful for the incredible team we have in oncology, inlcuding   doctors, nurse practitioners, physician assistants, nurses, the research team, members of ancillary services, our inpatient, clinic and OPI staff, administrative support, and other subspecialists, who all have great minds and compassionate hearts, and walk the difficult cancer journey with our patients and their families. I am humbled to be with such great company here at CHOC, who care deeply for children.”
– Dr. Lilibeth Torno, oncology

 

 

 

goodman_tg“I am most grateful to the people behind the scenes at the hospital who do all the invisible jobs that are so important to keep CHOC Children’s running: the housekeepers, lab and x-ray technologists, bio-medical engineers, pharmacy technicians, scrub technicians, security guards and maintenance staff that work tirelessly, 24-hours a day.”
– Dr. Gary Goodman, critical care

 

 

 

 

 

Dr. William Loudon

“I am most thankful for the ability to practice alongside of the caring and professional staff and physicians at CHOC, who all share the common goal of caring for children. Working together, we are able to tackle incredibly complex and varied problems that present in the amazingly diverse population of children that we serve.”
Dr. William Loudon, neurosurgery

 

 

 

 

 

 

“I am thankDr. Amy Harrisonful for so many things here at CHOC. I feel truly blessed every day to have found a professional community of like-minded caregivers who share a passion and dedication for continued improvement in the care we provide. I am also so grateful for the opportunity to meet and care for such incredibly courageous patients and to become a part of their families. Finally, I am thankful to my teams within the pulmonary division, the Cystic Fibrosis Center and the muscular dystrophy clinics for their selfless care of our patients. I wish our entire community a healthy and happy holiday season.”
Dr. Amy Harrison, pulmonology

 

choc_zupanc

“I’m thankful for the opportunity to serve my patients and families, and to help them secure bright futures through CHOC’s world-class care. I am also so grateful to work among a team that is steadfastly committed to the health and well-being of children in our community and beyond. “
Dr. Mary Zupanc, neurology

 

 

 

 

 

 

 

aminian

“I am thankful for the platform CHOC has given us to provide service to a community that inspires me daily. I am humbled to just be part of it all.”
Dr. Afshin Aminian, orthopaedics