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Moments That Matter: Understanding Pediatric Seizures and Epilepsy · Meaningful Medicine with Novant Health

• 0:03
  Melanie Cole (Host): Welcome to Meaningful Medicine, a Novant Health Podcast,
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  bringing you access to leading doctors who answer questions they wish you would ask.
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  From routine care to rare conditions, our physicians offer tips to navigate medical
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  decisions and build a healthier future.
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  I'm Melanie Cole, and today we're talking about the moments
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  that matter, understanding pediatric seizures and epilepsy.
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  Joining me is Dr.
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  Mohammad Shawa.
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  He's a pediatric neurologist with Novant Health.
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  Dr.
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  Shawa, thank you so much for joining us today.
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  So as we start, please define for us epilepsy versus seizures.
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  The umbrella that they're under.
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  Explain what epilepsy really is.
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  Dr. Mohammed Shahnawaz:
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  Absolutely.
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  So I think, really to best answer that question, you need to understand
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  how the normal brain works, which is.
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  It has normal electrical activity, and that's the thing that lets you kind of do
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  everything that we do on a regular basis.
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  So all of our movements, our vision, our feelings and sensations, all of That
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  is electrical activity of the brain.
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  And a seizure is really abnormal, continuous electrical activity of the
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  brain that comes out in physical symptoms.
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  There's lots of different types of seizures out there, And the
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  one that most commonly people know about is what people used to refer
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  to as grand mal seizures, right?
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  This is full body shaking or full body stiffening.
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  Your eyes roll up into the back of your head.
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  This is now what we call a type of generalized seizure, which is your
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  whole brain all at once, having that abnormal electrical activity.
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  It's just coming out looking like that full body shaking.
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  There are other types of seizures as well, in particular called focal
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  seizures where focal seizures or where it's just one part of your
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  brain that's involved in that seizure.
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  Just depends on what part of the body it controls, how it may appear.
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  So just the simplest example I give people is, let's say it's in the part of
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  the brain that controls your right arm.
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  You might just get right arm shaking or right arm stiffening and that's it.
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  and you can keep walking and talking and doing everything else.
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  It's just staying right there.
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  seizures are a symptom of what we would call epilepsy.
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  Epilepsy is a term.
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  All it means is that you've had two or more seizures in your life.
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  And you're at-risk for having more.
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  And so that's when we give somebody a diagnosis of epilepsy is once they've had
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  two very clear seizures, or in certain cases when they've had one seizure and
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  they have high-risk factors that tell us, Hey, you're more likely to have a seizure.
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  Melanie Cole (Host): Well, thank you for telling us that, And the criteria
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  by which you determine that we're gonna call it epilepsy to begin with, so.
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  mentioned a few things that could happen with seizures and there's grand mal,
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  And we used to hear, we hear about PEth mal ones that are bigger and smaller.
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  What are some of the signs?
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  What would we notice?
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  I mean, are they always that obvious doctor or sometimes are
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  they a little bit more subtle?
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  Dr. Mohammed Shahnawaz:
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  So some seizures can be relatively subtle, right?
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  So, it, particularly in children, there's a concept called absence seizures,
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  which is another type of generalized seizure that we talk about, where
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  patient's are typically there in the middle of doing something And then they.
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  just stop.
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  They stop talking.
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  They stop interacting.
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  Some of them will stare.
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  Some of 'em will blink, and they'll be unresponsive to people.
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  Often, in many kids, this kind of gets tossed aside as, oh, they're just staring,
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  or they're daydreaming, or other things, and sometimes even diagnosis as a DHD
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  for many years before it's recognized.
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  Same thing with focal seizures, right?
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  Focal seizures can sometimes just involve a little shake of the
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  hand or a little shake of the arm.
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  People dismiss it as, oh, it just happened one time.
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  It's not a big deal.
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  And then it happens again.
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  They're like, Hmm, I was tired.
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  It just happened until, focal seizures in particular.
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  I will tell you that sometimes in state, instead of staying in one
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  part of the brain, they can spread to the rest of the brain and become
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  one of those full body convulsions.
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  And that's when it becomes a lot more clear to people.
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  And so on that line, I'll say that there's a few things that
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  can help people recognize seizures even when they're being subtle.
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  Because I'll tell you, regardless of the seizure type, they have
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  certain characteristics about it.
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  Number one is seizures.
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  When they happen in individuals, they're often what we call stereotyped,
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  which means they start the same way, progress the same way And
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  the same way every single time.
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  So say one time you see your kid shaking their right arm, another time you see
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  them shaking their left leg makes it a little bit less likely it's a seizure.
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  But now let's say you see 'em shaking their right arm two times.
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  It looks kind of very similar.
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  The next thing is that after seizures, people are often
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  confused, sleepy, not themselves.
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  Sometimes if it's a focal seizure, it may involve a weakness of whatever extremity
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  was involved, And so Those are all post seizure symptoms that you can kind of see.
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  And the last one I always say is that people should always re remember
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  that seizures are abnormal electrical activity of the brain, right?
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  And we all do funny looking things sometimes.
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  Sometimes we're daydreaming or zoned off so much that, you know, we're
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  thinking of something deeply that somebody could come up and wave in
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  our face or talk to us constantly And we might not respond necessarily.
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  And so I always say, if you're worried about a seizure, don't try and just
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  go wave at somebody or talk to them.
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  Actually go and physically touch them, especially if they're a
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  younger child and you're not sure you can even pick them up, move them.
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  If it stops whatever it is they're doing or changes it, it makes it way
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  less likely that that's a seizure.
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  'cause your touch can't stop electrical activity of the brain.
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  So these are some of things that people can try and do that maybe for those
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  more, what we would refer to as subtle seizures, that they could try and
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  recognize in that way.
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  Melanie Cole (Host): Wow.
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  that was really great advice and something that people should know really.
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  Right.
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  Away.
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  Now if you do notice a child having a seizure, we've always wondered
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  what do we do in that time?
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  Doctor, what are you supposed to do?
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  If it's a big seizure, the kind that, you know, we've seen before And in the
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  media, what are you supposed to do?
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  Dr. Mohammed Shahnawaz:
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  Yeah, so particularly for generalized seizures, right?
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  Those are the ones that you really need to be focusing on safety
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  precautions, but really all seizures.
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  You should be focusing on safety precautions.
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  And particularly for generalized seizures, there used to be a lot of the antiquated
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  kind of approaches that people used to do.
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  There used to be, you know, old tales of, oh, you need to watch
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  out for them swallowing their tongue, and all of these things.
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  And as science has kind of progressed and we've shown more evidence and data around
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  it, all these things aren't necessarily true and So, really sounds kind of funny
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  the way I would think about it, but the practical sense of words, you would
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  do nothing as in don't hold 'em down.
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  Don't restrict their movements in any way, shape or form.
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  Don't put anything in their mouth.
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  You just want to try and clear out the space around 'em.
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  Make it a safe space so that when they're shaking or stiffening, they're
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  not hitting up against something or harming themselves that way, and
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  you really want to try and time it.
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  the reason we time it is because seizures in and of themselves are actually not
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  necessarily life-threatening or dangerous to individuals unless you're having
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  one of those generalized full body shaking or stiffening seizures lasting
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  longer than five minutes, and really, in particular, you're having a lot of
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  them lasting longer than five minutes.
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  And so in these situations you just wanna make sure you know
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  what, how much time has passed.
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  Especially if it's the first-time you're seeing a seizure, you
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  should probably call EMS as well.
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  If you have a diagnosis of epilepsy.
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  Sometimes it's, you're familiar with what needs to be done and if you're on
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  medications for that epilepsy, sometimes it's, we need to go on higher doses.
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  And so it's contacting your neurologist and letting 'em
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  know in those situations.
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  Melanie Cole (Host): So no lying them on their side or spoons in the mouth.
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  The things that we've all heard all these years.
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  Dr. Mohammed Shahnawaz:
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  Yeah.
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  You can always try and tilt them to their side, but again, you wanna do
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  it in a safe way where you're not restricting their movements while you're
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  doing it to get them on their side.
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  definitely no, nothing in the mouth, like no spoons, no fingers.
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  the risk there is if you put something in someone's mouth.
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  When they're having a generalized seizure, they clamp down and they bite
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  and they can break off whatever it is.
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  They can break their tooth, and now you've actually created more
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  danger that way rather than safety.
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  So you really wanna stay
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  away from those things.
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  Melanie Cole (Host): That's great advice, really important to know.
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  So, evaluation, diagnoses, you spoke about the criteria for
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  determining that it's epilepsy.
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  So what does it look like for a patient if this happens once or more than once?
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  What happens?
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  How do they get diagnosed?
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  Dr. Mohammed Shahnawaz:
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  Absolutely.
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  So honestly, epilepsy is what we call as a clinical diagnosis.
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  And so what that means is if you've had two events that sound very consistent
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  with seizures, it has all those features we talked about previously.
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  Really already, that's a diagnosis of epilepsy.
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  Now, where I like to focus on is because just getting a diagnosis of epilepsy
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  is not necessarily enough, right?
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  You wanna find out the why.
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  Why do you have epilepsy?
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  And in particular, can we classify your epilepsy as a
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  very specific type of epilepsy?
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  Because that can make a difference.
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  And so there's a number of tests that we often do to try and help determine that.
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  the first test that anybody ever gets once they have their first
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  seizure-like event is an EEG.
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  An EEG is where we hook up little electrode stickers to
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  the brain or to the scalp.
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  And we are looking for electrical activity that, not something that a
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  patient's gonna notice, not something that a family's gonna notice.
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  It's just electrical activity that the brain does to let the world know, Hey,
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  look, something's wrong with me, or I'm a little more likely to have a seizure.
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  Just that type of EEG could sometimes help us determine do you have a
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  generalized epilepsy or do you have a focal epilepsy or something else going on.
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  The other test that we can often get is something an MRI of the brain, an
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  MRI of the brain is, at the end of the day, I always describe it to people.
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  It's just a picture, right?
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  And so a picture, sometimes people get an MRI of their brain when they have epilepsy
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  and it's normal or reported as normal.
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  I always tell families that just means that that picture looks normal right now.
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  And that's kind of in a sense, a reassuring thing that we don't see any
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  big, bad, scary causes of epilepsy.
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  And the last thing that sometimes we have to get in certain
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  patient's is genetic testing.
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  especially in pediatrics.
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  I will tell you there's a number of genetic causes for epilepsy.
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  There's a few hundred, sometimes there's probably at this point, many
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  hundred, diagnoses that are related to genetic causes of epilepsy.
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  And so depending on your story, depending on your EEG or your
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  MRI findings, sometimes we need to get genetic testing as well.
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  And so Those are really the common tests that we get to try
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  and figure out that why question.
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  'cause it's very important we figure out the why.
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  Because it can help guide treatment, help come up with the best treatments
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  for you or otherwise in the
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  future.
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  Melanie Cole (Host): Wow.
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  That's so interesting, doctor, and really an exciting time in your field
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  as we think of the diagnoses and those modalities you use to diagnose now.
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  Speak about treatments, what's going on in the epilepsy world today?
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  What's exciting?
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  What treatment options are available and how do you tailor them for each child's
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  need, because they're all different.
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  Dr. Mohammed Shahnawaz:
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  Absolutely.
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  Yeah.
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  So number one, when you get a diagnosis with epilepsy, the first
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  treatment anybody should ever get is anti-seizure medications.
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  The goal of anti-seizure medications is that we help reduce and get you to seizure
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  freedom when we start them, and there's always newer medications and things coming
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  out there, but I'll tell you, at least in pediatrics particularly, right, there's
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  certain pediatric epilepsy syndromes that we know have great treatments that
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  are first-line standard treatments that have been around for decades, and they
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  do really good for those patient's.
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  There are those other patient's who maybe don't fall into those typical pediatric
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  epilepsy syndromes, where there are newer medications that are coming out
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  that are helpful in certain situations.
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  We always start with the first-line ones that we know can be helpful, And
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  then if they're not doing well on those, then sometimes we'll go to those newer
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  agents that have different ways that they work compared to the older agents.
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  I'm a epileptologist actually, also, especially by training, so I'm a pediatric
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  neurologist, And then we do extra training to become an epileptologist,
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  And so I actually have a special interest in what we refer to as drug resistant
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  epilepsy, which is the concept that you have been on two or more anti-seizure
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  medications at maximally tolerated doses.
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  And you are still having seizures in those situations, it is very unlikely
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  that a third anti-seizure medication is gonna get you to seizure freedom.
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  And so that's when we really should be talking about other
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  more advanced therapies out there.
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  So I just kind of briefly walked through those with families.
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  But the one that's been around for probably a thousand years or longer
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  is something called ketogenic diet.
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  Which ketogenic diet, it's not like the thing that, layman people use for
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  weight loss or other things like that in epilepsy, patient's soften a little more
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  strict than that where you're eliminating lot of carbohydrates and you're getting
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  'em a lot of your nutrition from proteins and fats to help redirect the brain and
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  make it less likely to have a seizure.
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  I always help families for that one.
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  the end of the day, all of these patient's are human beings first
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  and their epilepsy comes second.
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  So if you have a teenage kid who loves eating his pastas and pizzas and those
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  types of things, keto diet is probably not the best option for that individual.
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  the next thing that we have is we're talking about more devices.
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  And in particular when I kind of classify as something called
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  VNS or Vagus nerve stimulator.
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  This is a device that's implanted in under the skin And the chest, and it
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  stimulates a large nerve called the vagus nerve that goes up to your brain.
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  It works in many ways, but the main way that it works is it stimulates this
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  nerve over time, throughout the day, and I, and basically kind of quiets
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  down the brain, makes it a little bit less likely to have seizures over time.
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  And so it's a good option for many patient's, especially when
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  you have genetic epilepsies or other things like that.
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  But the last option, which I don't say last, but just the
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  last of these three I'll say, is something called epilepsy surgery.
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  This is the concept that, remember we went and talked about focal seizures.
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  It's just one part of your brain that's having this abnormal electrical activity.
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  If we can identify that part of the brain where those focal seizures are
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  coming from, sometimes we can go in and do surgeries, working closely
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  with our pediatric neurosurgeon and actually a multidisciplinary team,
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  including neuropsychologists and everybody to figure out where that
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  part of the brain is that's abnormal or causing you to have focal seizures.
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  We can go and scar it up, remove it with the surgery, or there's also
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  newer devices, in particular something called RNS, where we can implant, the
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  simulation right into that area of the brain where it detects seizures
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  before you notice them and tries to make sure that they don't progress to
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  the scent that it's causing problems.
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  So there's a lot of newer therapies out there and there's
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  a lot of excitement around it
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  all.
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  Melanie Cole (Host): Cool.
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  Thank you so much for telling us about all of those.
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  Now, when you mentioned the multidisciplinary need for these
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  patient's, so how can families support their child with epilepsy at
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  home, at school, everyday activities because it really, uh, create a fear.
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  Affect the quality of life, but as you mentioned, the ketogenic diet.
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  And so there's a lot of people that are involved in helping maintain that
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  normalcy so that families can, really go about and have the best quality of life.
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  How can we support our children?
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  Dr. Mohammed Shahnawaz:
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  I think the biggest thing is talking about it honestly.
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  one of the things that, like I mentioned, is families get so scared
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  of a diagnosis of epilepsy and having patient's who have seizures.
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  Because it's one of those diseases that's not outwardly visible.
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  It's one that you walk around and nobody can know.
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  It happens until you have a seizure in front of them.
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  And so for me, it's always kind of trying to focus on reminding families
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  and parents and individuals that.
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  You're a human being first.
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  You have to live your life.
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  You're, you need to keep moving forward in life.
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  And we will keep treating the seizures as we need to and without whatever
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  treatment options we have available to us.
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  in that sense, right, it is important to recognize that patient's with
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  epilepsy, they may have more difficulty in certain aspects of their life.
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  In particular, epilepsy patient's are known to be at a higher risk for learning
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  difficulties, mental health-related issues and everything else that comes with those.
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  And so it's important to recognize those as the issues.
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  And once we do recognize that an epilepsy patient's having it is getting that
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  multidisciplinary team involved, getting those supports involved and making sure
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  that they're getting thorough care.
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  For example, again, I'm in pediatrics, so we see a different population of
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  patient's with epilepsy, but some of these patient's with epilepsy are because
• 17:02
  they've had a brain injury And so they may have also cerebral palsy, which
• 17:06
  means I've had a brain injury and my muscles don't move right because of it.
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  It's important to get those patient's into physical therapy and
• 17:13
  treating their cerebral palsy while you're treating their epilepsy.
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  Same thing with those patient's who maybe, again, don't have that outward clear like,
• 17:21
  hey, this person has a neurologic disease.
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  they have epilepsy, they have seizures, and they're dealing with severe depression
• 17:27
  or anxiety or other things like that.
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  That's when we should get together a multidisciplinary
• 17:32
  team with a child psychiatrist.
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  A psychologist or a therapist to kind of talk to them more about
• 17:38
  the long-term coping mechanisms.
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  A neuropsychologist who does evaluations thoroughly to kind of evaluate that
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  overlap between neurologic disease and learning difficulties and mental health
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  and how they all interplay together.
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  And make sure we're getting 'em all the right supports for it so that they can
• 17:55
  continue living that full thorough life that they, that everybody wants to live.
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  it's known that in patient's, especially with drug resistant epilepsy, many of
• 18:04
  them, they can tolerate the seizures.
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  they're like, it's just a small seizure, it's okay.
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  But the thing that really gets to them is their quality of life,
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  everything else that goes around it.
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  And so, sometimes it gets tossed to the side where we're so
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  focused on the seizures, we're not thinking of the quality of life.
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  And I think.
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  Talking about it, not just with families, but making sure families feel comfortable
• 18:24
  talking about it with patient's.
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  All of This is very important in
• 18:28
  that, aspect of things.
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  Melanie Cole (Host): Certainly it is, and especially as you say with children,
• 18:33
  they wanna play and they wanna be at school and be with their friends, And
• 18:37
  that fear can really be pervasive.
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  So Dr.
• 18:40
  Shana was, as we wrap up.
• 18:43
  What are some messages of reassurance or hope that you can offer families that have
• 18:47
  received a recent diagnosis of epilepsy for their child and all of the great
• 18:53
  work that you're doing at Novant Health?
• 18:55
  Dr. Mohammed Shahnawaz:
• 18:55
  So I think that's, big thing is know there are options, right?
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  People sometimes they get so stuck in that medication aspect of things,
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  especially if you haven't had a consultation with an epileptologist.
• 19:08
  They've tried medicine after medicine, after medicine, And then they're not
• 19:11
  really getting that alternative treat.
• 19:14
  I think especially with some of the newer therapies and things out there, um, there
• 19:18
  are medications that may work better for you or there may be other treatment
• 19:21
  options that are better for you And that we can get you to seizure freedom.
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  And at the very least, if we don't get to seizure freedom, it's the goal
• 19:29
  of, Hey, let's make these seizures not be so burdensome on you so
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  that you can continue to live life.
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  Make them as small as possible, less, less frequent as possible.
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  There's always hope and there's always options on that front.
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  so don't be discouraged, right?
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  One medication doesn't work.
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  That doesn't mean that that's the end of it all.
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  we're done for, I tell families this too, but particularly
• 19:51
  with certain epilepsies, right?
• 19:52
  People get so worried about, oh, my kid, and now he has epilepsy.
• 19:56
  He can't grow up to be an adult.
• 19:58
  He can't live a normal life.
• 19:59
  He can't have a career.
• 20:01
  But I'll tell you, I know doctors and I know lawyers who have epilepsy and live
• 20:05
  with epilepsy and have their medications and their seizures are fully controlled.
• 20:10
  And so you can live a full professional life, well into old age, even
• 20:14
  with the diagnosis of epilepsy.
• 20:15
  And it's a scary thing, but.
• 20:18
  Just know that there's treatment options and we'll, we can always work together to
• 20:21
  try and figure that out.
• 20:22
  Melanie Cole (Host): Thank you so much Dr.
• 20:24
  Shawa, for joining us today and really sharing your incredible expertise
• 20:30
  for patient's and their families.
• 20:31
  Thank you again.
• 20:33
  And to find a physician, you can always visit novant health.org.
• 20:37
  And for more health and wellness information from our experts,
• 20:40
  visit healthy headlines dot.
• 20:43
  If you found this podcast helpful, please share it on your social
• 20:46
  channels and check our entire podcast library for topics of interest to you.
• 20:51
  That concludes this episode of Meaningful Medicine, a podcast from
• 20:55
  the specialists at Novant Health.
• 20:57
  I'm Melanie Cole.
• 20:58
  Thanks so much for joining us today.