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.

CHOC recognized as one of nation’s best children’s hospitals

CHOC Children’s is one of only 50 pediatric facilities in the nation to earn recognition as a best children’s hospital by U.S. News & World Report. The following CHOC specialties are honored in the 2019-20 Best Children’s Hospitals rankings: diabetes/endocrinology, cancer, neonatology, neurology/neurosurgery, pulmonology and urology. Cancer ranked in the “top 20.”

“The national recognition for CHOC’s cancer program is well-deserved. There’s nowhere else I’d rather have gone through treatment than CHOC,” says 17-year-old Sydney Sigafus, CHOC patient and cancer survivor. “Everyone who works at CHOC cares about you as a person, not just a patient. I was included in every decision and conversation about my care.”

The Best Children’s Hospitals rankings were introduced by U.S. News in 2007 to help families of children with rare or life-threatening diseases find the best medical care available. Only the nation’s top 50 pediatric facilities are distinguished in 10 pediatric specialties, based on survival rates, nurse staffing, procedure and patient volumes, reputation and additional outcomes data. The availability of clinical resources, infection rates and compliance with best practices are also factored into the rankings.

“We understand how scary it can be for parents whose children are dealing with life-threatening illnesses or injuries. That’s why we are committed to the highest standards of care, safety and service,” says Dr. James Cappon, CHOC’s chief quality officer. “While we are proud of our accolades, including being named a best children’s hospital, we remain focused on preserving the magic of childhood for all kids, whether they are seriously ill or healthy, or somewhere in between.”

More information about the Best Children’s Hospitals rankings can be found here.

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.

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 CHOC 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.