What The Doctors

Are Saying
Treating Pediatric Cases of Postural
Orthostatic Tachycardia Syndrome (POTS)

What is Postural Orthostatic

Tachycardia Syndrome?
Postural Orthostatic Tachycardia Syndrome
(POTS) is an autonomic disorder that weighs
heavily on those who suffer from it, and it
can be especially detrimental within the lives
of children. Pediatric patients are diagnosed
based on the following definition of POTS:
a persistent rise in heart rate of more than
30-40 beats per minute. There may be a
drop in blood pressure as well (Le Gras,
2013). The syndrome is often accompanied
by a wide variety of symptoms, ranging from
nausea to gastrointestinal problems. Each
case of pediatric POTS is extremely
different, and it is important that patients
and physicians alike understand the nature
of the patients syndrome when trying to
decide on a treatment plan.

http://www.livestrong.com/article/220585-how-to-diagnose-a-child-who-is-always-tired/

Can POTS be cured?

Unfortunately, there is no cure for POTS.
However, the symptoms of POTS can be
treated, and a wide range of many
different treatments exists for patients,
ranging from pharmacological to nonpharmacological methods. Treating POTS
can be difficult, though, because each case
and each patient is very different, and
most treatments are not effective for all
patients. In order to find an effective
combination of treatment methods, it is
necessary for pediatric patients and their
families to consult a variety of different
doctors in order to find the combination of
treatment methods that works for them.

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What Do Different Doctors

Say About Treatment?
Because POTS can affect so many aspects of
a childs health and well-being, many
different types of doctors can treat pediatric
cases of POTS. In order to gauge how
different types of doctors around the United
States prefer to treat their pediatric POTS
patients, a questionnaire was distributed to
fourteen doctors in order to gather
information on how each of them feels POTS
is best treated in young people. One
particular question prompted the
respondents to list three treatments they use
to treat their young POTS patients, in order
of preference.

The Gastroenterologists

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The Cardiologists
Six cardiologists gave responses to the
questionnaire, making up 42.86% of the
respondents. Of these six cardiologists, five
stated Fludrocortisone or Florinef as one of
their preferred treatments. Florinef is a
specific brand of Fludrocortisone, which is a
human-engineered form of a mineral
corticoid similar to aldosterone, which is a
steroid hormone produced by the bodys
adrenal gland. It is essential to the bodys
regulation of elements such as blood
pressure and the balance of water and salt
levels. Of these five respondents, two listed
Florinef or Fludrocortisone as typically the
most effective treatment method they use
with their young POTS patients. Two of the
cardiologists also listed an increase in salt
and fluid intakes as one of their preferred
treatments, with one stating that an increase
in salt and fluid intakes combined with
Fludrocortisone is typically the most
effective treatment. Two other cardiologists
stated that patients must be treated
effectively on an individual basis, because
different treatment methods are more or less
effective for different patients. Other listed
preferred treatments included the Beta
Blocker Propanolol, Midodrine (a drug that
can treat low blood pressure), Ritalin (for
fatigue/brain fog), Periactin (for headache
prophylaxis), other medications to target
specific symptoms, and psychological
counseling.

The Neurologist
One neurologist took the questionnaire.
This physician stated that he/she utilizes
the following treatment methods, in order
of his/her preference: salt, Florinef, and
Midodrine. This physician stated that of
these treatments, Florinef combined with
salt and fluid is typically the most effective
in treating young POTS patients.

Two gastroeneterologists took the

questionnaire. One replied that he/she
prefers to use the following three
treatments: increased fluids and salts,
cardiovascular/recumbent exercises, and
Fludrocortisone. The other gave a similar
reply, writing that he/she prefers to use
these treatments: fluids/salt, physical
therapy, and Florinef. The first
gastroenterologist stated that a combination
of increased fluids and salt and exercises is
most effective. The second
gastroenterologist stated that depending on
the severity of symptoms, increased fluids
and salts is typically most effective of the
three treatments listed.

The Pediatric Specialists

Two physicians who specialize in pediatrics
took the questionnaire. One of these
physicians stated that he/she prefers to use
the following treatments for young POTS
patients: daily aerobic exercise, increased
fluid and salt intakes, and medication such
as the Beta Blocker Metoprolol. The other
physician listed the following three
treatments as his/her most commonly used,
as he/she stated that POTS must be
effectively treated on a patient by patient
basis: stimulant medications,
Fludrocortisone, and the Beta Blocker
Atenolol. The first physician stated that
daily aerobic exercise tends to be the most
effective treatment, while the second
physician stated that the effectiveness of the
treatments varies based on the patient and
the patients other co-morbid conditions.

The Psychologist
One psychologist gave responses to the
questionnaire. This doctor stated that
he/she prefers to use the following
treatments for his/her young POTS patients:
lifestyle modifications, Cognitive Behavioral
Therapy (CBT), and Acceptance and
commitment therapy (ACT). CBT allows
patients to better understand their negative
experiences and react more positively to
them (Mayo Clinic Staff, 2016). (ctd. nxt pg)

The Psychologist, cont.

The ACT allows patients to cope more
effectively with lifes difficulties (Serani,
2011). The psychologist stated that of these
three treatments, lifestyle modifications
tend to be most effective in younger patients.
The psychologist stated that he/she
measures the effectiveness of these lifestyle
modifications by monitoring symptom
reports and having patients fill out
questionnaires with each visit.

The Autoimmune Disease

Specialist
One autoimmune disease specialist took the
questionnaire. To the question that
prompted respondents to name three
treatment methods they use for their
pediatric POTS patients in order of
preference, this physician replied: salt,
fluids, exercise, trigger avoidance; Adderall;
Florinef. Adderall is a medication that is
typically used to treat Attention Deficit
Hyperactivity Disorder (ADHD). This
physicians response suggests that he/she
prefers to treat her young patients nonpharmacologically. However, this physician
did state that of these three methods,
Adderall is typically the most effective in
treating his/her patients.

OVERALL TRENDS
Some questionnaire questions asked the
respondents to evaluate the importance of
certain, common methods of treatment or to
compare two different types of treatment
methods. Some of these questions elicited
some relatively unanimous results, while
others received mixed feedback.

Pharmacological vs.
Non-pharmacological
POTS can be treated using a variety of
medications, but it is also treated with many
non-pharmacological methods such as
exercise. Questionnaire respondents were
asked which type of treatment they think is
more effective.

The Pulmonology/Exercise
Medicine Specialist
One specialist in pulmonology and exercise
medicine gave responses to the
questionnaire. In response to the question
that prompted respondents to name three
treatments they use for their pediatric
patients in order of preference, this
physician stated the following treatments:
exercise, an increase in fluid and salt
intakes, and medication. This response
suggests that this physician prefers to utilize
non-pharmacological methods before
resorting to pharmacological means of
treatment when treating his/her young
POTS patients.

Countless medications are used to treat

POTS, and there are also many nonpharmacological methods that are used to
treat the syndrome. 78.57% of the
questionnaires respondents stated that they
feel that a combination of pharmacological
and non-pharmacological treatment
methods is most effective in treating POTS
in young patients. No respondents selected
that pharmacological treatment methods
alone are most effective, which suggests that
non-pharmacological methods are essential
to treating pediatric and adolescent cases of
POTS, and even more so than
pharmacological methods.

Importance of Diet
Alteration
It is often recommended to young POTS
patients that they alter their diets, often by
means of increasing their fluid and salt
intakes. Questionnaire respondents were
asked how important they feel diet alteration
is to the care of their patients.
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Importance of Exercise
Exercise can also help to treat the symptoms
of some pediatric POTS patients.
Questionnaire respondents were asked to
rate how important exercise, specifically
cardiovascular exercise, is to the care of their
patients.

100% of the questionnaire respondents

stated that they feel that a young patients
alteration of his or her diet is important or
extremely important when the patient is
being treated for POTS. An increase in fluid
intake can help a patient to increase his or
her blood volume and improve circulation,
while an increase in salt intake can help to
stabilize blood pressure (Le Gras, 2013).
Based on the results of the questionnaire, it
seems as though doctors of all specialties
would recommend that their young patients
should alter their diets by increasing both
their fluid and salt intakes in order to
improve their POTS symptoms.

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As with the question pertaining to the

importance of diet alteration, this question
about the importance of exercise when treating
pediatric POTS also elicited relatively
unanimous results. All of the questionnaire
respondents stated that exercise, specifically
cardiovascular conditioning, is either
important or extremely important to the care
of their young patients. Exercise can help
patients to strengthen their hearts as well as
improve their circulation. Based on the
responses to the questionnaire, it seems as
though exercise is typically an extremely
important component of treating pediatric and
adolescent POTS, by several different types of
doctors standards.

Importance of Psychology
Referrals
POTS can often have great psychological
impacts on young patients. POTS patients
often suffer from very low qualities of life,
with studies comparing the quality of life of
POTS patients to that of people with
congestive heart failure (Raj, 2014). One
survey question asked the respondents to
evaluate how important it is for their young
patients to obtain psychology referrals as
part of their treatment for POTS.

The results of this question were more

widespread than the responses to other
questions, yet the data does still strongly
suggest that it is very important for young
POTS patients to consult a psychologist as part
of the treatment for their syndrome. A
psychologist, a cardiologist, two
gastroenterologists, and a pediatric specialist
were among those who rated psychology
referrals as extremely important to patient
care, while two cardiologists, a pulmonology
an exercise medicine specialist, and a
neurologist stated that they are important.

Based on all of this

information how can
pediatric cases of POTS be
most effectively treated?
Because each case of POTS is so different,
there is not one treatment for POTS that is
most effective for all cases of the syndrome.
However, the results of this questionnaire did
suggest the following principles: the most
effective way to treat POTS is through both
non-pharmacological and pharmacological
methods; exercise, specifically cardiovascular
exercise, can be very important to the
treatment of POTS in young people; diet
alteration, typically by means of increasing the
patients salt and fluid intakes, can also be a
crucial component of treatment; and having
patients obtain a psychology referral can also
be an important and very helpful part of their
treatment. Of the treatments the respondents
listed as the three they most prefer to use to
treat their young POTS patients, the most
common responses were increases in fluid and
salt intake and Fludrocortisone or Florinef.
However, even though these were the most
commonly stated treatments by all of the
physicians who gave responses to the
questionnaire, they are not necessarily the
most effective or even the most commonly
used by all doctors. Again, because pediatric
and adolescent POTS patients are all so
different, different treatments and
combinations of treatments work better for
different patients. Sometimes, in order for a
young patient to determine what course of
treatment works best for him or her, it is
important for the patient to visit several
different types of doctors in order to learn
about the different treatment options and
ultimately find what methods are most
effective for the individual.

https://www.groupanizer.com/blog/engaging-kids-music-starts-parents
http://www.sheknows.com/parenting/articles/981501/does-your-child-need-therapy

References

Le Gras, M. (2013). Overview of POTS syndrome. Retrieved December 13, 2015, from Pediatric
Cardiology Center of Oregon website: http://www.pccoforegon.com/blog/overview-of-potssyndrome
Mayo Clinic Staff. (2016). Cognitive behavioral therapy. Retrieved May 31, 2016, from Mayo Clinic
website: http://www.mayoclinic.org/tests-procedures/cognitive-behavioral-therapy/home/ovc20186868
Raj, S. R. (2013). Postural tachycardia syndrome (POTS). Retrieved December 13, 2015, from American
Heart Association website: http://circ.ahajournals.org/content/127/23/2336.long
Serani, D. (2011, February 22). Acceptance and commitment therapy. Retrieved May 31, 2016, from
Psychology Today website: https://www.psychologytoday.com/blog/two-takesdepression/201102/acceptance-and-commitment-therapy
*The questionnaire discussed was conducted by Lindsay LeTellier, an Independent Research student at
Glenelg High School in Glenelg, MD. The questionnaire was conducted between February and May 2016
via Survey Monkey.
**All graphs were made using https://nces.ed.gov/nceskids/createagraph/