All posts by CHOC Children's

The Effects of Too Much Screen Time on Children’s Vision

By Dr. Rahul Bhola, pediatric ophthalmologist at CHOC Children’s

Technology has become an integral part of our daily lives. As we become increasingly more reliant on and absorbed in technology, many children are exposed to smart devices at less than 5 years of age. These devices have also become an integral teaching tool in classrooms—more than half of teachers in the United States use smart devices in elementary school. According to the U.S. Department of Education, 97 percent of classrooms in the U.S. have at least one computer. School screen time coupled with at-home smart device usage can on an average expose a student aged 8-18 years to media for more than ten hours a day.

As children’s exposure to screen time rises, many parents wonder how harmful excessive exposure to electronic media can be. While on one hand, an early exposure to technology might prepare children for future careers in technology-related fields, or jobs that require mastery of technology as a fundamental key to success. On the other hand, children overly immersed in this technology and not otherwise challenged can become socially stunted and ridden with health-related issues due to decreased physical activity.

Dr. Rahul Bhola
Dr. Rahul Bhola, pediatric ophthalmologist at CHOC Children’s.

One of the biggest health issues related to smart devices are vision related. A recent study by the National Eye Institute found that the frequency of myopia, also known as near-sightedness, has jumped exponentially in Americans over the last few decades. Two clear reasons for this spike in myopia are an increased amount of time spent looking at things up close and also a lack of outdoor activities. Focusing on things too close to the eyes for a prolonged period puts excessive strain on the eyes and has been found to hasten the progression of myopia. Although genetic risks of myopia cannot be modified, limiting the amount of strain on eyes by avoiding excessive time spent looking at things up close can minimize environmental risk factors. It is imperative to prevent prolonged exposure of up-close work (such as reading) in children by allowing small breaks (during prolonged reading sessions, for example).

The American Academy of Pediatrics (AAP) recently revised the recommendations for screen time in childhood.

  • 18 months and younger: no screen time is still best. The exception is live video chat with family and friends.
  • 18 months to 2 years: limit screen time and avoid solo use. Choose high-quality programming, and watch with kids to ensure understanding.
  • 2 to 5 years: limit screen time to an hour a day. Parents should watch as well to ensure understanding and application to their world.
  • 6 or older: place consistent limits on the time spent and types of media. Don’t let screen time affect sleep, exercise or other behaviors.
screen time
The American Academy of Pediatrics released new guidelines on how much screen time is appropriate for children.

A separate study recently found that excessive screen time usage in adolescents was associated with development of acute onset esotropia, or crossing of the eyes, and that limiting usage of these gadgets decreased the degree of eye crossing in these patients. A portion of the patients in this study had to undergo surgery to correct esotropia.

Excessive screen time can also lead to “Computer Vision Syndrome” which is a combination of headaches, eye strain, fatigue, blurry vision for distance, and excessive dry eyes. There’s a number of things you can do to help avoid these symptoms:

  • Check the ergonomics of the workstation. Placing the screens 20 to 28 inches away from the child’s eyes and aligning the top of the screen at eye level so that the children look down at the screen while they work.
  • Restrict entertainment-related screen time to two hours or less a day
  • Practice the 20-20-20 rule: After every 20 minutes of screen time, take a 20-second break and look 20 feet away.
  • Remind children to blink regularly to avoid excessive dry eyes.

la, pediatric ophthalmologist at CHOC Children’s

Pink Eye: What Parents Should Know

By Dr. Sidney Weiss, pediatric ophthalmologist at CHOC Children’s

‘Pink eye’ is a common term for a viral infection of the conjunctiva of the eye- also called viral conjunctivitis. When a child gets pink eye, this means there is an inflammation of the membranes covering the inner eyelid and the whites of the eye. This can occur in one or both of the eyes. It may appear alone, or as part of a generalized upper respiratory infection involving fever, sore throat and nasal blockage.

It has also been called ‘swimming pool conjunctivitis’ because the infection is often spread in swimming pools.  Chlorine in swimming pool water does not effectively kill viruses nor does it prevent the spread of this infection.

Besides being characterized by pink or even red eyes, there is often some drainage from the eye that may include a colored discharge, or clear tears. The infection is contagious so long as the eye is red and especially so long as discharge is coming from the eye. Your child may complain of sensitivity to light, eye discomfort and blurry vision. Pink eye may be uncomfortable, but very rarely will it threaten vision. If the child’s cornea becomes affected, the vision may be affected more significantly. If you suspect this, consult your child’s pediatrician.

Viral conjunctivitis usually resolves on its own within a few days. If you do consult your pediatrician, they may recommend supportive care, such as increased hygiene, removing the discharge as it appears, and frequent hand washing. They also may prescribe a topical antibiotic for the eye in order to prevent a super-infection by bacteria.

pink eye
Dr. Sidney Weiss, pediatric ophthalmologist at CHOC Children’s

There are several other potential causes of pink or red eyes.

Bacterial infections of the eye are less common than viral infections, but the signs and symptoms are quite similar, including a red or pink coloring, sensitivity to light, and eye discomfort. The discharge associated with bacterial infections tends to be thicker and more colorful. Antibiotic drops are generally quite effective in resolving these infections.

Eyes that appear to have a pink tone do not necessarily mean that a virus is present.  Dry eyes, environmental toxins, and eyes allergic to environmental irritants may appear pink, and may even have a clear discharge.

Allergies are also a very common cause of pink or even red eyes, with itching being a common characteristic. The whites of the eye may even appear swollen, and a clear or off-white discharge is common. Topical over-the-counter antihistamines are generally effective in moderate cases, but prescription topical steroid drops may be necessary to resolve the tougher cases.

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A Reunion of Heroes: Katie’s Story

After recently being discharged, Katie Flathom stopped by the CHOC Children’s cardiovascular intensive care unit (CVICU) again to make some introductions.

Suddenly, the 16-year-old has a group of heroes in her life: the coach who resuscitated her on school campus and the CHOC team that treated Katie for three weeks and will continue her care as she navigates life with a newly diagnosed heart condition.

During a recent athletic conditioning class in school, Katie collapsed and went into sudden cardiac arrest.

Her trained and quick-thinking conditioning coach snapped into action and resuscitated Katie with CPR until paramedics could arrive and transport her to CHOC.

“It was the longest 10 minutes of my life,” said Greg Vandermade, Katie’s coach at Mater Dei High School who also credits other students for alerting him to Katie’s condition and calling 911, as well as fellow staff who assisted by obtaining an automated external defibrillator (AED) to shock Katie’s heart into a normal rhythm.

At CHOC, Katie continued to have irregular heartbeats that required further defibrillation and cardioversion, procedures that help restore the heart’s natural heart rhythm, said Dr. Anthony McCanta, a CHOC cardiologist.

Katie also went on extracorporeal life support, a treatment that takes over the heart’s pumping function and the lungs’ oxygen exchange until a patient can recover from injury. This allowed the CHOC Children’s Heart Institute team to continue to treat her life-threatening arrhythmias with medication, Dr. McCanta said.

Dr. McCanta performed an electrophysiology study procedure and implanted beneath Katie’s skin a subcutaneous implantable cardioverter defibrillator, a device that helps prevent sudden cardiac arrest in patients.

After Katie’s discharge and further testing, she was diagnosed with Arrhythmogenic Right Ventricular Dysplasia, or ARVD.  A rare type of cardiomyopathy  where the muscle tissue in the heart’s right ventricle is infiltrated and replaced by fatty tissue and scar tissue, ARVD weakens the heart’s ability to pump blood and makes the heart susceptible to life-threatening arrhythmias.

The diagnosis also means Katie, a cross country and track athlete, will need to give up running for good.

“It was hard at first,” she said.

But instead of sitting on the sidelines, Katie’s decided to pick up golf, a sport that’s compatible with ARVD.

Katie has even begun incorporating a golf swing into her physical therapy sessions at CHOC, and she had two clubs in tow as she, her family and coach Greg visited the CVICU recently.

heroes
When Katie came back to visit the CVICU team and reunite her heroes, her CHOC care team presented her with a heart-shaped pillow, which they all signed with well wishes.

There, Dr. McCanta and the CHOC team presented Greg with a plaque recognizing him for his swift response and efforts that surely saved Katie’s life.

“Coach Greg responded to Katie with CPR on the spot and saved her life that day,” Dr. McCanta said. “His heroic actions, and those of Katie’s schoolmates and staff, including obtaining and appropriately using the AED, are the reason that Katie is alive today.”

Katie’s story underscores the importance of being trained in CPR and in the use of AEDs, Dr. McCanta said.

“Having AEDs in schools and training staff and students in CPR with an AED are some of the most important interventions that we have in saving lives of young people experiencing sudden cardiac arrest,” he said.

Getting AEDs installed in schools is among the goals of CHOC’s Life-Threatening Events Associated with Pediatric Sports – or LEAPS – program.

Coincidentally, Katie’s own grandmother, a nurse and health services coordinator in the Irvine Unified School District, has collaborated with LEAPS and helped get AEDs installed on her district’s campuses.

“Never did I think though that this would happen to one of my own family members,” said Marcia, Katie’s grandmother.

Learn more about pacemakers and cardioverter defibriilators

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My Journey to Becoming a NICU Nurse: April’s Story

By April Bell, registered nurse at CHOC Children’s and mother of CHOC NICU graduates Mikayla and Emma

I’ve been a nurse at CHOC for 15 years. I started working here as a nurse aide while I was in nursing school and after graduation, I entered the RN Residency program as a nurse in the medical/surgical unit. I learned a lot about time management and honed my nursing skills starting IVs, inserting feeding tubes and catheters, and giving medications. I enjoyed the time I spent on that unit, but after about five years I was looking for another challenge. The new pediatric intensive care unit (PICU) and new cardiovascular intensive care unit (CVICU) had just opened on the sixth floor, and I was considering a nurse fellowship in the PICU. However, before I could start that process, I found out I was pregnant with twins.

Not only twins, but very high-risk twins called monoamniotic-monochorionic, or “MoMo.” These types of twins share one amniotic sac and the risk is that their umbilical cords could become tangled and/or compressed. These rare twins have a 50 percent survival rate. I knew they would most likely be delivered early; my OB-GYN did not want to deliver past 32 weeks gestation. We ended up making it only to 28 weeks, as their cords were knotted together twice and wrapped around my daughter, Mikayla’s neck, twice.

Mikayla weighed only one pound, 13 ounces when she was born. Emma was two pounds, six ounces.

nicu nurse
April was a registered nurse in the medical/surgical unit at CHOC Children’s when her twins were born premature. Their family’s experience in the neonatal intensive care unit (NICU) inspired her to become a NICU nurse.

From the moment the twins were delivered, the neonatal intensive care unit (NICU) team that was in my delivery room made a huge impression on me including the neonatologist who was present at the delivery, Dr. Daryoush Bassiri. I met Dr. Bassiri the week before my twins were born, when I was admitted to St. Joseph’s Hospital, next door to CHOC. He told me what I could expect if they were born at 27, 28, 29, 30 weeks, etc. The nurses who were at the delivery were also very supportive and kept me informed about what the plan was for the babies.

Both of my daughters need to be intubated right after delivery, but the nurses made sure I could see them briefly before they left for the NICU. The next few days were quite a roller-coaster, starting when Emma became very sick. Because her lungs were not fully developed, she was placed on a ventilator to help her breathe. The pressure of the ventilator caused her lungs to collapse. She needed two chest tubes to resolve her collapsed lungs. Her lungs also developed pulmonary hypertension (a type of high blood pressure) and pulmonary interstitial emphysema (where air collects outside the normal air space). All of Emma’s lung problems are common conditions in premature babies, but it was still a very scary time. I wasn’t sure if she was going to make it. She was given nitric oxide, a medication to treat breathing problems in premature babies, and finally she started to slowly improve. She took a turn for the better, only to face another setback: she was diagnosed with a heart defect called patent ductus arteriosus (PDA). In some premature babies, the opening between the aorta and the pulmonary artery does not close, as it does in most children.

Her sister, Mikayla, although smaller, was doing much better. She only needed to be intubated for about a day and a half and was on bubble CPAP (continuous positive airway pressure), non-invasive ventilation support for newborns. Mikayla had the same PDA diagnosis as her sister, and received medication to close her PDA. Emma could not get the medication because the doctors were worried about her kidneys, after how sick she had been. So the doctors decided that a surgical repair know as PDA ligation was the way to go. Once again, we were worried about her. She had an excellent surgeon, Dr. Brian Palafox, who explained everything to me and Emma’s dad. Although he told us what possible complications could come from the surgery, everything went very smoothly.

The next few months were filled with more ups and downs, but nothing quite as scary as the first few days. After they mastered breathing on their own, working on feedings was another struggle. They had an amazing team of developmental therapists, lactation consultants and of course, their bedside nurses. I learned so much from everyone that took care of my twins. As a medical/surgical nurse, I had floated to the NICU before, but I had no idea what each preemie went through.

Emma spent 75 days and Mikayla spent 77 days in the NICU. Towards the end of my twins’ NICU stay, I realized that the NICU was where I wanted to be as a nurse. I spoke with one of the NICU managers and told her I was interested in transferring to the NICU. I was surprised to learn that they were, in fact, just starting a nurse fellowship program. When I started my NICU fellowship, I went with the RN Residents to a special NICU consortium taught by the NICU educator at the University of California Irvine. We were there with nurses from NICUs all over Southern California. I finished the NICU fellowship when my daughters were just about 1 year old. I feel like the classes really helped me understand so much more about the development of the neonate and how to care for them.

During the last seven years in the NICU, I have taken care of a variety of babies, from small micro-preemies to babies who have undergone surgery, and babies with heart defects. I helped open the CHOC Children’s NICU at St. Joseph’s Hospital. I have also had the privilege to care for babies in our Small Baby Unit.

After having two micro preemies of my own, I feel I can really relate to a lot of the parents. I have been on the other side of it and know how frustrating and worrisome it can feel.

I enjoy sharing my story with my patient’s families. I have seen firsthand how strong and resilient these babies can be.

I was working the night that we opened the new, all private room NICU. At the end of my night shift, I helped transfer my patients upstairs and get them settled into their new rooms. It was amazing to see how smoothly everything went that morning. It was also exciting to see the babies in their own rooms. My twins were always with other babies in a pod, and it would have been so nice to have a private room. I would’ve loved to have been able to stay overnight and sleep right next to my babies when they were in the NICU, like the parents can do now in our new NICU. It was hard to leave the NICU when my daughters were there. The noise in the pods could get loud at times, and occasionally a baby would be sick and need sterile procedures which meant all non-clinical staff had to leave the unit. The patients did not always have privacy. I am excited for the patients and families that will benefit from our new private room NICU.

Looking at my daughters today, you would never know what they have been through. They are almost 8 years old and they are just about to start second grade. They’re very smart and are excelling in school. They started reading in pre-kindergarten and have been reading at an advanced level ever since; they almost read better than their older brother, Joey. The only long-term effect from being born so premature and facing a mountain of health challenges has been with Emma, who has a raspy voice from left vocal cord paralysis, a common complication from the surgery. I am so grateful to have two healthy girls.

I am also very grateful for the way the CHOC NICU cared for my own children, and I am extremely proud to be part of it as a caregiver.

Take a virtual tour of our new NICU

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5 Things You Didn’t Know About Being a Pharmacist

By Michael Shaaw, clinical pharmacist at CHOC Children’s

When most people think about what their pharmacists do at the pharmacy, the first thing that comes to mind might be counting pills. Yes, that is one responsibility of our job, but since pharmacists are one of the most accessible healthcare professional out in the community, here are five facts you might want to know about what we do so that you will be able to get the most out of your encounter with your pharmacist.

It takes a lot of schooling to become a pharmacist

In order to become a pharmacist, one typically would spend about six to eight years in school, including undergraduate course work and obtaining a doctoral degree in pharmacy. In the recent years, many pharmacy school graduates spend an extra one to two years undergoing residency or fellowship training in subspecialty areas such as critical care medicine, emergency medicine, pediatric, geriatric or oncology.

Pharmacists offer many other services beside dispensing your prescription

Aside from filling your prescriptions, a pharmacist can also administer immunizations such as flu vaccines, shingles, and travel vaccines. We can provide medication counseling and medication therapy management to help you better understand and be informed about the medicines that you’re taking in order to better manage your condition. You can also ask a pharmacist for recommendations on over-the-counter products, as well as smoking cessation and other chronic disease monitoring services such as blood pressure and cholesterol levels.

Pharmacists do a lot more than just counting pills

When a pharmacist receives a prescription, he or she will check for any allergy or drug interaction that could potentially do you harm. The pharmacist also makes sure that the dose of the prescribed medicine is appropriate for the stated indication, and raises any concerns to the prescribing physician and provide recommendations when appropriate.

There are pharmacists working in different settings other than retail stores or hospitals

Aside from working in retail or hospital settings, many pharmacists also work in areas such as academia, public health, government, pharmaceutical research, informatics, and managed care. They utilize their knowledge in pharmacology and medicine to further advance our healthcare system.

Pharmacists can save you money

Although pharmacists cannot change your copay set forth by the insurance company, most of the time they can recommend you other medication that’s similar to the one prescribed to you but at a lower cost (such as suggesting a suitable generic in place of a brand name medication). Pharmacists can also provide information about rebates and other cost-saving tips to help lower the cost of the medication

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Meet Dr. Reshmi Basu

CHOC Children’s wants its medical staff and patients to get to know its growing team of physicians, including primary and specialty care providers. Today, meet one of our pediatricians Dr. Reshmi Basu. Following medical school at University of California, San Diego, she completed her residency at CHOC. She’s been a member of the CHOC medical staff for eight years.

pediatrician
Dr. Reshmi Basu, a CHOC Children’s pediatrician

What are your clinical interests?

I am especially interested in asthma, sleep issues in children (infants through adolescents), and helping new mothers breastfeed.

Are you involved in any research?

I am a physician leader for the American Academy of Pediatrics, Chapter Quality Network U.S. Immunization Project. Practices here in Orange County and across the nation are participating in the project to improve vaccination rates for children two years and younger.

What are your most common diagnoses?

In our practice, we see a lot of patients with viral respiratory illnesses, ear infections, abdominal pain, asthma, allergies, eczema and headaches. We also spend much of our time on routine well checks for infants, teens and young adults. These appointments are important for keeping children current on vaccinations, and making sure they are growing and developing normally. We work hard to address parents’ concerns during these visits, as well.

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

I am proud to be a CHOC Children’s provider because CHOC undoubtedly provides the highest quality of care for patients and families. One of my patients was being treated for cancer during the holidays. Not only did CHOC make sure she received the most advanced medical care, the hospital’s child life team did everything they could to bring the holidays to her. Her room was filled with inspirational banners, Christmas lights and even beautiful new bedding on her hospital bed.

When did you decide to become a pediatrician?

I decided to become a pediatrician after my pediatrics rotation in medical school. I had always liked working with children, and was already drawn to pediatrics after volunteering at CHOC Children’s at Mission Hospital. (I grew up in Mission Viejo.)  As a volunteer, I enjoyed spending time at the hospital, whether it was holding the babies or coloring with children. After my pediatrics rotation, though, I realized that children need advocates to fight for them, and that is something I wanted to do. My goal is to help all my patients grow and thrive to become healthy, successful adults.

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

I pursued medicine and eventually pediatrics because of my interest in science and my love for children. If I wasn’t a pediatrician, then I think being a teacher would be another way for me to help children.

What are your hobbies and interests outside of medicine?

I enjoy spending time with my husband and children. I have a 5-year-old daughter and 3-year-old son who keep me very busy. We like being outdoors, whether it’s playing at the park or riding our bikes. We travel as often as we can. I also like to read, when I can find any free time.

What’s the funniest thing a patient said to you?

Several of my pre-school aged patients have told me I look like Doc McStuffins. This helps me to connect with them and put them more at ease during their visits. I dressed up as Doc McStuffins for Halloween a few years ago, and my younger patients were star struck!

Looking for a pediatrician? Find one near you.

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Insider Tips from CHOC Walk Team Captains

You’ve gathered your family and friends, fundraised for the betterment of CHOC Children’s patients, shared your personal reasons for wanting to give back to CHOC, and now the morning of CHOC Walk in the Park is approaching. Keep in mind these tried and true tips from some of our longstanding CHOC Walk teams:

Fundraising tips

  • Remember that in fundraising, every dollar counts in making a difference. Have fun while raising money for the children. – Team Hope
  • We recommend teaming up with a CHOC Guild. The Littlest Angel Guild in Yorba Linda/Anaheim Hills gave us a lot of help and guidance. It will also give you a chance to meet more people with a common goal to give back to CHOC. It’s also great to have a corporate sponsor. We are so lucky and grateful for Hill Brothers Chemical Company and their generosity. Hill Brothers Chemical Company has supported Miranda, our family, The Littlest Angel Guild, and CHOC since 2009. – Team Miranda
  • We’ve had success with bake sales and Dining for Dollars, where we partner with local restaurants who will donate a portion of proceeds on a certain night toward our CHOC Walk team’s fundraising goal. –Team IronJax
  • Get the word out and be creative! Make a list of everyone you know and send a personalized email inviting them to support your team. Hold garage sales, lemonade stands and bake sales. Save up money by recycling bottles and cans throughout the year. Hold an open house boutique where vendors come together to sell their items and donate a portion of their proceeds to your team. Most importantly, keep at it and don’t get discouraged! Every dollar raised is one dollar closer to your goal. It all adds up! –Team Robby Batman Gomez
  • Sending creative emails that include personal photos to your network go a long way. I send a save the date out about two months ahead of the walk, and remind people the reasons why we walk, thank all the past walkers from our team, and give an update on funds we’ve raised in the past. During the fundraising process, I send an email to my team with a video slideshow showing Mac’s year. I do this to share what a wonderful, fulfilled life he has because of CHOC. –Team MAC

Participant check-in/Packet pickup

  • One thing that helped tremendously when picking up other team members’ wristbands and shirts, was having their email, phone number and shirt size on hand. I picked up 14 walker packets and having the emails ready to go was a huge help. – Team Brave Boyle
  • If you’re picking up for other people, just make sure they have the $85 or more in their account in order to get their wristband for them. It’s also best to distribute wristbands to your friends or teammates BEFORE the walk day as it will be chaotic and people may be late. – Team Brave Boyle
  • Don’t forget if you signed up to have your shirt shipped you don’t need to go to check in. Your shirt and wristband will arrive the week before the Walk. If you don’t receive anything, call our office at 714-509-4000. –Team Kailualani
  • If you have cash or check donations, it helps to enter them online in your fundraising headquarters on chocwalk.org to speed up the check-in process! –Team Kailualani

Team spirit

  • Have fun with your team! Our team makes signs to show our team pride and support for CHOC, and we all dress in a theme. –Team CHOC Children’s HR Walking for Noah
  • Many teams make banners and signs for their CHOC patients to show their support and why they walk – no idea is too small! -Team Torres
  • It’s a great idea to get your kids involved in the Walk to teach them about philanthropy and volunteering at an early age. -Team Torres

Event day tips

  • Before our first CHOC Walk, we got good advice about meeting as a group somewhere outside the park, in Downtown Disney. As a newbie that was a GREAT help. – Team Brave Boyle
  • On the day of the walk, allow extra time to park and find your way to the front of Disneyland as the trams are not running. – Team Hope
  • If you arrive late, you won’t be able to walk the full CHOC Walk route and will be redirected to a certain entrance based on your timing, so don’t be late! The opening ceremony is at 6:15 a.m., the Walk begins at 6:30 a.m., and the entrance cutoff time is 7:30 a.m. – Team Kailualani
  • Consider getting a hotel within walking distance to skip out on the traffic and enjoy a fun night around town before the CHOC Walk. Some nearby hotels offer special rates for CHOC Walk participants. Afterward, don’t try and exit toward Harbor, you’ll feel like a salmon trying to swim upstream. –Team IronJax
  • Give your team a timeline for CHOC Walk, consisting of:
    • Recommended time to leave the house the morning of CHOC Walk, and explain why you’ll need extra time due to the size of the crowd.
    • What time to meet at your team’s chosen meeting area.
    • What time you plan on entering the park.
    • Contact information for other team members in case someone has a hard time locating your team the morning of CHOC Walk.
    • Places where you plan on taking a group picture during the route.
    • Location to meet and regroup at the end of the route. We usually do a giant group thank you, and I designate an area because we can get split up during the route. –Team Justin’s Helpers
  • Don’t forget you can purchase discounted Disney tickets AFTER the walk with your CHOC Walk wristband. There will be ticket carts available in Downtown Disney near ESPN Zone, as well as the ticket booths in the esplanade, and you will need to have your wristband on in order to purchase. -Team Torres
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Return to Learn Concussion Guidelines Every Parent Should Know

When a child has a concussion, the rules for getting back to sports are laid out by state Return to Play laws. But when it comes to getting back to the classroom, the rules aren’t as clear.

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

“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.

return to learn
Dr. Chris Koutures, a board certified pediatrician and sports medicine specialist at CHOC Children’s.

“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, including parents, 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
Learn about the CHOC Children’s Concussion Program now.

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Meet Dr. Rahul Bhola

CHOC Children’s wants its patients and families to get to know its specialists. Today, meet Dr. Rahul Bhola, an internationally recognized expert in pediatric ophthalmology.

Dr. Bhola comes from a family of physicians. His parents practiced internal medicine for more than 40 years in India, and the empathetic and holistic care they provided to their patients inspired him to pursue a career in medicine.

“Very early on in medical school, I developed a special interest in pediatrics, and the surgical finesse of ophthalmology later cemented my passion for pediatric ophthalmology. A gift of vision is the most important sense a child can have,” Dr. Bhola says. “Giving a ray of light to those who struggle with vision is very gratifying to me. Treating children is important to me because they have their entire lives ahead of them and improving their vision positively impacts their entire family.”

Dr. Bhola attended medical school and completed an internship at University College of Medical Sciences in Delhi, India. He completed two residencies in ophthalmology at Maulana Azad Medical College in New Delhi, India and the University of Louisville, Kentucky. He pursued fellowships in pediatric ophthalmology at the University of California Los Angeles and University of Iowa.

“The biggest reason I was inspired to join CHOC was the mission of the hospital. I feel that CHOC’s mission to nurture, advance and protect the health and well-being of children is in close alignment with my personal goals as a physician,” Bhola says. “I seek to nurture the healthcare of children by delivering state-of-the-art ophthalmology care to our fabulous community. CHOC has the resources, reputation and experience to provide great care.”

At CHOC, Dr. Bhola will provide comprehensive eye care, treating patients with a variety of eye disease and disorders. In addition to treating refractive errors (the need for glasses), Dr. Bhola will provide more specialized care for diseases like amblyopia (lazy eyes), pediatric and adult strabismus (crossing or drifting of eyes), blocked tear duct, diplopia (double vision), pediatric cataracts, pediatric glaucoma, tearing eyes, retinopathy of prematurity, ptosis (droopy eyelids), traumatic eye injuries and uveitis.

Dr. Rahul Bhola
Meet Dr. Rahul Bhola, pediatric ophthalmologist at CHOC Children’s.

The Need for Regular Eye Screenings

Dr. Bhola is passionate about providing education on the need for regular eye screenings. For example, kids complaining of headaches may be taken to a neurologist. However, eye problems like refractive errors (the need for glasses), convergence insufficiency and strabismus can result in headache from excessive straining of the eyes, which may affect school performance and even social withdrawal in some children. These conditions are likely to be identified at regular vision screenings.

Unique Approach To Treating Pediatric Glaucoma

Dr. Bhola is among the very few surgeons nationally skilled in treating pediatric glaucoma surgically using the illuminated microcatheter. This highly-specialized, minimally-invasive approach of canaloplasty has been used for treating pediatric glaucoma only within the last five years. The onset of juvenile glaucoma often occurs between the ages of 10 and 20. It can be secondary to genetics, or traumatic.

“Even though childhood glaucoma is an uncommon disorder, it often goes undetected and can eventually result in blindness, underscoring the importance of regular eye screenings,” says Dr. Bhola.

As a Level II pediatric trauma center, and the only one in Orange County dedicated exclusively for kids, CHOC’s trauma team treats a variety of critically injured from across the region. This includes children who have sustained sports injuries, during which damage to the structure of the eye can cause glaucoma.

Patient-Centered Care

Dr. Bhola’s philosophy of care is to treat his patients as if they were his own children.

“My main philosophy is to provide patient-centered care, delivered with compassion and excellence. I remember their life events, and celebrate their achievements with them. It’s important that a patient remembers and trusts you completely with their care. I love when my patients send me holiday cards and copies of their school photos and let me know how they are doing. They became part of my family. I always treat every patient of mine like they are my own child,” Dr. Bhola says.

He also focuses on treating the whole person rather than the disease, and involving patients in their care.

“I don’t treat the disease, I treat the individual. Healing is more than treating the disease. I want to be at their level so I always talk to them directly and not only talk to their parents. I involve their entire group during treatment,” he says.

At CHOC, Dr. Bhola is eager to provide holistic eye care for his patients.

“My practice will offer complete comprehensive vision care to all patients, which includes both medical as well as surgical care. Our patients come to us for glasses, contacts, regular vision screenings, and we also provide more specialized care like glaucoma, cataract and strabismus surgeries,” Bhola says. “Systemic disorders such as diabetes, sickle cell anemia, juvenile rheumatic disease and lupus, have coexisting eye issues that may go undetected if children aren’t seen for regular eye screenings. CHOC patients with systemic disorders such as diabetes now have better access to holistic care.”

As division chief for CHOC Children’s Specialists ophthalmology, Dr. Bhola is passionate about providing state-of-the-art care to patients and training the next generation of pediatric ophthalmologists.

“My main goal is to build a state-of-the-art ophthalmology division, not only delivering excellent patient care but also engaging in vital research and disseminating education to the next generation of ophthalmologists and referring providers,” Bhola says.

When not treating patients, Dr. Bhola enjoys cooking, practicing yoga and meditation and spending time with his wife and two daughters.

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Meet Dr. Katherine Williamson

CHOC Children’s wants its patients and families to get to know its specialists. Today, meet Dr. Katherine Williamson, a CHOC pediatrician.

Dr. Katherine Williamson
Dr. Katherine Williamson, a CHOC Children’s pediatrician

Q: What is your education and training?
A: I studied international relations at Pomona College, then went on to the University of California, San Francisco to study medicine. I completed my pediatric residency training at CHOC Children’s.

Q: What are your administrative appointments?
A: I am the chair for pediatrics at Mission Hospital where my practice rounds on newborn babies. I am a partner within my practice at Southern Orange County Pediatric Associates (SOCPA), which is part of the CHOC Children’s Primary Care Network. Within this network, I am the SOCPA lead for the IT team where we are beta testing a new electronic health record system to be used at CHOC Children’s and in the CHOC Primary Care Network.

Q: What advocacy work are you involved in?

A: I am the vice president for the Orange County chapter of the American Academy of Pediatrics, (AAP-OC) where we focus on child advocacy and serve as an academic and resource base for pediatricians and pediatric sub-specialists. Through our legislative advocacy efforts in the last few years, we have helped to pass SB 277 to keep kids vaccinated in California, and raise the smoking age for cigarettes and vaping from 18 to 21 years of age. On a community level, we have created a mental health committee bringing together pediatricians and mental health providers working to address the mental health needs of our Orange County youth. And we have newly created the School Health Committee where we are working to increase communication and collaboration between pediatricians and schools, with goals that include the creation of an electronic HIPAA-protected communication system between teachers and pediatricians, and to better understand how to address the unmet needs of children with learning disabilities.     

Q: What are your special clinical interests?
A:  Child nutrition and exercise, and healthy body image

Q: How long have you been on staff at CHOC?
A: I did my pediatric residency at CHOC from 2008 to 2011, then stayed on staff as a transport physician which is still currently one of my roles. I joined my pediatric practice, Southern Orange County Pediatric Associates (SOCPA) in 2012, which has partnered with CHOC in the past year to form the CHOC Primary Care Network, thus keeping me in the CHOC family on many levels.

Q: What are some new programs or developments within your specialty?
A: Southern Orange County Pediatric Associates (SOCPA), along with two other pediatric private practice groups in Orange County – Seaview Pediatrics and Pediatric & Adult Medicine – have partnered in the last year with CHOC Children’s to form the CHOC Children’s Primary Care Network. I am very excited to be a part of this partnership because through our collaboration we can share the best evidence-based medicine practices and increase communication between CHOC inpatient services, sub-specialists, and children’s primary care practices, thus improving patient care. In the near future we will have a shared electronic health record system that unlike so many EHRs in the country will be geared toward pediatrics because we are designing it ourselves.

Q: What are your most common diagnoses?
A:  Pharyngitis, bronchospasm, fever, otitis media, common cold, pneumonia, acne, jaundice

Q: What would you most like community/referring providers to know about you or your division at CHOC?
A: Kids come first! And all kids needs a medical home.

Q:  What inspires you most about the care being delivered here at CHOC?
A: I have been a part of the CHOC family for many years, from residency through now, and I am inspired by CHOC’s multi-disciplinary team approach to take care of our kids. I have seen CHOC grow with the new tower, expansion of the specialty departments, and most recently CHOC’s extension to the community with the CHOC Children’s Primary Care Network to reach out to kids in their medical home. It’s all about the kids!

Q: Why did you decide to become a doctor?
A: I believe every person has a right to quality health care, and I have been fascinated by the human body since I was a kid. Like I tell my patients, it’s the coolest machine you will ever own. I love being a part of keeping kids healthy, and I love teaching parents and kids about their own bodies so that they can take ownership in their health and well-being too.

Q: If you weren’t a physician, what would you be and why?
A: One of two things, or maybe both – a journalist, and/or a Broadway performer. I loved to sing and act on stage much of my childhood, and I believe telling a story, whether fictional or non-fictional, is the best way to relate and reach out to others.

Q: What are your hobbies/interests outside of work?
A: Anything outdoors – running, swimming, biking, and scuba diving. And traveling abroad whenever I can.

Q: What have you learned from your patients, or what is the funniest thing a patient has ever told you?
A: I learn every day from my patients to find joy in the little things in life – from seeing how your finger lights up red when you touch the otoscope light to the wonders that bribery with stickers can do. I am laughing every day!

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