1
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Kim S. Pediatric headache: a narrative review. JOURNAL OF YEUNGNAM MEDICAL SCIENCE 2022; 39:278-284. [PMID: 36102115 PMCID: PMC9580058 DOI: 10.12701/jyms.2022.00528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 08/26/2022] [Indexed: 11/25/2022]
Abstract
Headache is one of the most common neurological disorders in children and adults and can cause significant distress and disability in children and their families. The spectrum of pediatric headaches is broad, and the underlying etiology is variable. The symptoms and phenotypes of headaches in children may differ slightly from those in adults. It is important to have a good understanding of headaches in children and to distinguish between primary and secondary headaches through appropriate history assessment and neurological examination. Accurate diagnosis and appropriate drug selection are helpful for effective treatment. This article reviews headaches in children and adolescents, focusing on approaches for diagnosis and management.
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Affiliation(s)
- Saeyoon Kim
- Department of Pediatrics, Yeungnam University College of Medicine, Daegu, Korea
- Corresponding author: Saeyoon Kim, MD Department of Pediatrics, Yeungnam University College of Medicine, 170 Hyunchungro, Nam-gu, Daegu 42415, Korea Tel: +82-53-620-3471 • Fax: +82-53-629-3533 • E-amil:
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2
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Boris JR, Moak JP. Pediatric Postural Orthostatic Tachycardia Syndrome: Where We Stand. Pediatrics 2022; 150:188336. [PMID: 35773520 DOI: 10.1542/peds.2021-054945] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/06/2021] [Indexed: 11/24/2022] Open
Abstract
Postural orthostatic tachycardia syndrome (POTS), first described in 1992, remains an enigmatic, yet severely and variably debilitating, disorder. The pathophysiology of this syndrome is still not understood, and there remains no biomarker indicating the presence of POTS. Although research interest has increased in recent years, there are relatively fewer clinical and research studies addressing POTS in children and adolescents compared with adults. Yet, adolescence is when a large number of cases of POTS begin, even among adult patients who are subsequently studied. This article summarizes reported research in POTS, specifically in pediatric patients, including discussion of aspects of diagnostic criteria, risk factors and outcomes, neurohormonal and hemodynamic abnormalities, clinical assessment, and treatment. The goals of this review are increased recognition and acknowledgment of POTS among pediatric and adolescent providers, as well as to provide an understanding of reported abnormalities of homeostasis, such that symptomatic patients will be able to be recognized and appropriately managed, enabling them to return to their activities of daily living.
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Affiliation(s)
| | - Jeffrey P Moak
- George Washington University School of Medicine and Health Sciences, and Children's National Hospital, Washington, DC
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3
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Snapper H, Cheshire WP. Oral and intravenous hydration in the treatment of orthostatic hypotension and postural tachycardia syndrome. Auton Neurosci 2022; 238:102951. [PMID: 35123367 DOI: 10.1016/j.autneu.2022.102951] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 12/07/2021] [Accepted: 01/25/2022] [Indexed: 01/21/2023]
Abstract
Hydration with water and salt is the mainstay of treatment for autonomic nervous system disorders that impair orthostatic tolerance. The goal is to expand intravascular volume to compensate for the downward displacement of blood volume that occurs when standing and thereby sustain cerebral perfusion and restore quality of life. Despite strong consensus recommendations for salt supplementation as standard treatment of these disorders, published evidence of benefit is relatively weak, and no randomized clinical trials have occurred. This review summarizes the physiological rationale for hydration and evaluates the literature on oral and intravenous hydration in the treatment of neurogenic orthostatic hypotension, postural tachycardia syndrome, and recurrent vasovagal syncope. We conclude that oral salt replacement is indicated for treatment of neurogenic orthostatic hypotension because these patients have excessive renal sodium excretion, and for treatment of chronic orthostatic intolerance because these patients are often hypovolemic. As not all patients are able to tolerate sufficient oral hydration, there is also a role for intravenous volume-loading in severe cases of postural tachycardia syndrome. We offer guidance, based on review of the literature and the clinical judgment of a cardiologist and neurologist with experience treating autonomic disorders, regarding the option of ongoing intravenous hydration for treatment of severe, refractory cases of postural tachycardia syndrome.
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Affiliation(s)
- Howard Snapper
- Department of Cardiology, Wellstar Healthcare System, Marietta, GA 30060, USA.
| | - William P Cheshire
- Division of Autonomic Disorders, Department of Neurology, Mayo Clinic, Jacksonville, FL 32224, USA
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4
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Yanagimoto Y. Transition of adult patients with pediatric orthostatic intolerance from child-centered care to adult-centered care. Front Pediatr 2022; 10:946306. [PMID: 36389345 PMCID: PMC9650207 DOI: 10.3389/fped.2022.946306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 09/12/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Yoshitoki Yanagimoto
- Department of Pediatrics, Kansai Medical University, Hirakata, Japan.,Department of Pediatrics, Kansai Medical University Medical Center, Moriguchi, Japan
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5
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Williams EL, Raj SR, Schondorf R, Shen WK, Wieling W, Claydon VE. Salt supplementation in the management of orthostatic intolerance: Vasovagal syncope and postural orthostatic tachycardia syndrome. Auton Neurosci 2021; 237:102906. [PMID: 34823150 DOI: 10.1016/j.autneu.2021.102906] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 09/23/2021] [Accepted: 11/06/2021] [Indexed: 02/07/2023]
Abstract
Salt supplementation is a common non-pharmacological approach to the management of recurrent orthostatic syncope or presyncope, particularly for patients with vasovagal syncope (VVS) or postural orthostatic tachycardia syndrome (POTS), although there is limited consensus on the optimal dosage, formulation and duration of treatment. Accordingly, we reviewed the evidence for the use of salt supplementation to reduce susceptibility to syncope or presyncope in patients with VVS and POTS. We found that short-term (~3 months) salt supplementation improves susceptibility to VVS and associated symptoms, with little effect on supine blood pressure. In patients with VVS, salt supplementation is associated with increases in plasma volume, and an increase in the time taken to provoke a syncopal event during orthostatic tolerance testing, with smaller orthostatic heart rate increases, enhanced peripheral vascular responses to orthostatic stress, and improved cerebral autoregulation. Responses were most pronounced in those with a baseline sodium excretion <170 mmol/day. Salt supplementation also improved symptoms, plasma volume, and orthostatic responses in patients with POTS. Salt supplementation should be considered for individuals with recurrent and troublesome episodes of VVS or POTS without cardiovascular comorbidities, particularly if their typical urinary sodium excretion is low, and their supine blood pressure is not elevated. The efficacy of the response, in terms of the improvement in subjective and objective markers of orthostatic intolerance, and any potential deleterious effect on supine blood pressure, should be routinely monitored in individuals on high salt regimes.
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Affiliation(s)
- E L Williams
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, British Columbia, Canada
| | - S R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - R Schondorf
- Department of Neurology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - W K Shen
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - W Wieling
- Department of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - V E Claydon
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, British Columbia, Canada.
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6
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Hartle M, Bateman L, Vernon SD. Dissecting the nature of post-exertional malaise. FATIGUE: BIOMEDICINE, HEALTH & BEHAVIOR 2021. [DOI: 10.1080/21641846.2021.1905415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
| | - Lucinda Bateman
- The Bateman Horne Center of Excellence, Salt Lake City, UT, USA
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7
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Tu Y, Abell TL, Raj SR, Mar PL. Mechanisms and management of gastrointestinal symptoms in postural orthostatic tachycardia syndrome. Neurogastroenterol Motil 2020; 32:e14031. [PMID: 33140561 DOI: 10.1111/nmo.14031] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 10/20/2020] [Accepted: 10/20/2020] [Indexed: 01/31/2023]
Abstract
Postural orthostatic tachycardia syndrome (POTS) is a disorder of orthostatic intolerance associated with many GI manifestations that can be broadly classified into two different categories: those present all the time (non-positional) and those that occur with orthostatic position change. There are also many conditions that can co-exist with POTS such as mast cell activation syndrome and the hypermobile form of Ehlers-Danlos syndrome (hEDS) that are also oftentimes associated with GI symptoms. In the current issue of Neurogastroenterology and Motility, Tai et al. explored the relationship between functional GI disorders among hEDS patients with and without concomitant POTS and showed that the hEDS-POTS cohort was more likely to have more than one GI organ involved compared to the cohort with hEDS alone, and certain GI symptoms were also more common in the hEDS-POTS cohort. In this review article, we will briefly review the literature surrounding putative mechanisms responsible for GI symptoms in POTS with an emphasis on the contributory role of concomitant hEDS and then discuss management strategies for GI symptoms in POTS.
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Affiliation(s)
- Yixi Tu
- Division of Gastroenterology, Department of Medicine, St. Louis University, St. Louis, MO, USA
| | - Thomas L Abell
- Division of Gastroenterology, Department of Medicine, University of Louisville, Louisville, KY, USA
| | - Satish R Raj
- Department of Cardiac Sciences, Cumming School of Medicine, Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
| | - Philip L Mar
- Division of Cardiology, Department of Medicine, St. Louis University, St. Louis, MO, USA
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8
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Treatment Updates in Postural Tachycardia Syndrome. Curr Treat Options Neurol 2020. [DOI: 10.1007/s11940-020-00643-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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9
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Chen G, Du J, Jin H, Huang Y. Postural Tachycardia Syndrome in Children and Adolescents: Pathophysiology and Clinical Management. Front Pediatr 2020; 8:474. [PMID: 32974246 PMCID: PMC7468430 DOI: 10.3389/fped.2020.00474] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 07/06/2020] [Indexed: 12/21/2022] Open
Abstract
Postural tachycardia syndrome (POTS), characterized by chronic (≥6 months) orthostatic intolerance symptoms with a sustained and excessive heart rate increase while standing without postural hypotension, is common in children and adolescents. Despite the unclear pathogenesis of POTS, the present opinion is that POTS is a heterogeneous and multifactorial disorder that includes altered central blood volume, abnormal autonomic reflexes, "hyperadrenergic" status, damaged skeletal muscle pump activity, abnormal local vascular tension and vasoactive factor release, mast cell activation, iron insufficiency, and autoimmune dysfunction. A number of pediatric POTS patients are affected by more than one of these pathophysiological mechanisms. Therefore, individualized treatment strategies are initiated in the management of POTS, including basal non-pharmacological approaches (e.g., health education, the avoidance of triggers, exercise, or supplementation with water and salt) and special pharmacological therapies (e.g., oral rehydration salts, midodrine hydrochloride, and metoprolol). As such, the recent progress in the pathogenesis, management strategies, and therapeutic response predictors of pediatric POTS are reviewed here.
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Affiliation(s)
- Guozhen Chen
- Department of Pediatrics, Peking University First Hospital, Beijing, China
- Department of Pediatrics, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
- Research Unit of Clinical Diagnosis and Treatment of Pediatric Syncope and Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Junbao Du
- Department of Pediatrics, Peking University First Hospital, Beijing, China
- Key Laboratory of Molecular Cardiovascular Science, The Ministry of Education, Beijing, China
| | - Hongfang Jin
- Department of Pediatrics, Peking University First Hospital, Beijing, China
- Research Unit of Clinical Diagnosis and Treatment of Pediatric Syncope and Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Yaqian Huang
- Department of Pediatrics, Peking University First Hospital, Beijing, China
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10
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Raj SR, Guzman JC, Harvey P, Richer L, Schondorf R, Seifer C, Thibodeau-Jarry N, Sheldon RS. Canadian Cardiovascular Society Position Statement on Postural Orthostatic Tachycardia Syndrome (POTS) and Related Disorders of Chronic Orthostatic Intolerance. Can J Cardiol 2020; 36:357-372. [DOI: 10.1016/j.cjca.2019.12.024] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 12/15/2019] [Accepted: 12/16/2019] [Indexed: 11/26/2022] Open
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11
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Abstract
Postural orthostatic tachycardia syndrome (POTS) is a clinically heterogeneous disorder with multiple contributing pathophysiologic mechanisms manifesting as symptoms of orthostatic intolerance in the setting of orthostatic tachycardia (increase in heart rate by at least 30 beats per minute upon assuming an upright position) without orthostatic hypotension. The three major pathophysiologic mechanisms include partial autonomic neuropathy, hypovolemia, and hyperadrenergic state. Patients often will exhibit overlapping characteristics from more than one of these mechanisms. The approach to the treatment of POTS centers on treating the underlying pathophysiologic mechanism. Stockings, abdominal binders, and vasoconstrictors are used to enhance venous return in partial neuropathic POTS. Exercise and volume expansion are the main treatment strategies for hypo-volemic POTS. For hyperadrenergic POTS, beta-blockers and avoidance of norepinephrine reuptake inhibitors is important. Attempts should be made to discern which pathophysiologic mechanism(s) may be afflicting patients so that treatment regimens can be individualized.
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Affiliation(s)
- Philip L. Mar
- Division of Cardiology, Department of Medicine, St. Louis University School of Medicine, St. Louis, Missouri 63110, USA
| | - Satish R. Raj
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta T2N 4Z6, Canada
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA
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12
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Medow MS, Guber K, Chokshi S, Terilli C, Visintainer P, Stewart JM. The Benefits of Oral Rehydration on Orthostatic Intolerance in Children with Postural Tachycardia Syndrome. J Pediatr 2019; 214:96-102. [PMID: 31405524 PMCID: PMC6815702 DOI: 10.1016/j.jpeds.2019.07.041] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 07/11/2019] [Accepted: 07/15/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To evaluate whether equal volumes of oral rehydration solution (ORS) or intravenous (IV) saline provide similar improvements in cardiovascular status during controlled orthostatic challenge when administered to subjects with postural tachycardia syndrome (POTS) with orthostatic intolerance. STUDY DESIGN We studied the neurovascular response to fluid loading during orthostatic stress using lower body negative pressure (LBNP) in 10 subjects with POTS with orthostatic intolerance and 15 controls, and on subsequent days before and 1 hour after IV saline infusion or ingestion of ORS. RESULTS Subjects with POTS exhibited reduced tolerance to LBNP (P < .0001) compared with controls (Orthostatic Index of 35 715 ± 3469 vs 93 980 ± 7977, respectively). In POTS, following ORS but not saline infusion, cerebral blood flow velocity (CBFv) was significantly higher than that with no treatment, at -45 mm Hg (P < .0005). Although fluid loading did not confer any advantage in controls, subjects with POTS experienced a significant improvement in orthostatic tolerance following both saline infusion (100 ± 9.7 vs 134.5 ± 17.4; P < .05) and ORS (100 ± 9.7 vs 155.6 ± 15.7; P < .001) when evaluated by normalized orthostatic index (P < .001, compared with untreated baseline). CONCLUSIONS Maintenance of CBFv may have resulted in the improved short-term orthostatic tolerance exhibited by the subjects with POTS following ORS administration. ORS is a convenient, safe, and effective therapy for short-term relief of orthostatic intolerance.
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Affiliation(s)
- Marvin S Medow
- Department of Pediatrics, New York Medical College, Valhalla, NY; Department of Physiology, New York Medical College, Valhalla, NY.
| | | | | | - Courtney Terilli
- Department of Pediatrics, New York Medical College, Valhalla, NY
| | - Paul Visintainer
- Department of Epidemiology and Biostatistics, Baystate Medical Center, University of Massachusetts School of Medicine, Worcester, MA
| | - Julian M Stewart
- Department of Pediatrics, New York Medical College, Valhalla, NY; Department of Physiology, New York Medical College, Valhalla, NY
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13
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Fedorowski A. Postural orthostatic tachycardia syndrome: clinical presentation, aetiology and management. J Intern Med 2019; 285:352-366. [PMID: 30372565 DOI: 10.1111/joim.12852] [Citation(s) in RCA: 159] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Postural orthostatic tachycardia syndrome (POTS) is a variant of cardiovascular autonomic disorder characterized by an excessive heart rate increase on standing and orthostatic intolerance. POTS affects younger individuals 15-45 years old with a distinct female predominance (≈80%). The prevalence ranges between 0.2% and 1.0% in developed countries. The onset of POTS is typically precipitated by immunological stressors such as viral infection, vaccination, trauma, pregnancy, surgery or psychosocial stress. The most common complaints are dizziness, weakness, rapid heartbeat and palpitation on standing. Moreover, patients often report physical deconditioning and reduced exercise capacity as well as headache, 'brain fog', dyspnoea, gastrointestinal disorders and musculoskeletal pain. The aetiology of POTS is largely unknown and three main hypotheses include an autoimmune disorder, abnormally increased sympathetic activity and catecholamine excess, and sympathetic denervation leading to central hypovolaemia and reflex tachycardia. The golden standard for POTS diagnosis is head-up tilt test with a non-invasive beat-to-beat haemodynamic monitoring. Although long-term prognosis of POTS is poorly explored, around 50% of patients spontaneously recover within 1-3 years. After the diagnosis has been established, patient should be thoroughly educated about non-pharmacological measures alleviating the symptoms. Exercise training may be very effective and counteract deconditioning. In more symptomatic patients, different drugs directed at controlling heart rate, increasing peripheral vasoconstriction and intravascular volume can be tested. However, the overall effects of pharmacological therapy are modest and the most affected patients remain handicapped. Future efforts should focus on better understanding of POTS pathophysiology and designing randomized controlled trials for selection of more effective therapy.
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Affiliation(s)
- A Fedorowski
- Department of Clinical Sciences, Malmö, Lund University, Malmö, Sweden.,Department of Cardiology, Skåne University Hospital, Malmö, Sweden
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14
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Pharmacotherapy for postural tachycardia syndrome. Auton Neurosci 2018; 215:28-36. [DOI: 10.1016/j.autneu.2018.04.008] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 03/26/2018] [Accepted: 04/30/2018] [Indexed: 11/20/2022]
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15
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Wells R, Elliott AD, Mahajan R, Page A, Iodice V, Sanders P, Lau DH. Efficacy of Therapies for Postural Tachycardia Syndrome: A Systematic Review and Meta-analysis. Mayo Clin Proc 2018; 93:1043-1053. [PMID: 29937049 DOI: 10.1016/j.mayocp.2018.01.025] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 01/04/2018] [Accepted: 01/16/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To identify the evidence base and evaluate the efficacy of each treatment for postural tachycardia syndrome (POTS) in light of a recent consensus statement highlighting the lack of treatment options with clear benefit to risk ratios for this debilitating condition. METHODS The CENTRAL (Cochrane Central Register of Controlled Trials), PubMed, and Embase databases from inception to May 2017 were searched using the terms postural AND tachycardia AND syndrome. A total of 135 full-text publications were screened after excluding duplicates (n=681), conference abstracts (n=467), and records that did not relate to POTS therapy (n=876). We included 28 studies with at least 4 patients with POTS in which symptomatic response was reported after more than 4 weeks of therapy. This review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Two investigators independently performed the data extraction and evaluated the quality of evidence. RESULTS This study comprised 25 case series and 3 small randomized controlled trials that evaluated 755 and 103 patients with POTS, respectively. Interventions directed at increasing intravascular volume, increasing peripheral or splanchnic vascular tone, controlling heart rate, and increasing exercise tolerance demonstrate moderate efficacy (range, 51%-72%). Few data exist on their comparative effectiveness. Significant heterogeneities were seen in terms of patient age, symptom severity, and the measures used to evaluate treatment efficacy. CONCLUSION The current evidence base to guide optimal management of patients with POTS is extremely limited. More high-quality collaborative research with standardized reporting of symptom response and treatment tolerability is urgently needed.
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Affiliation(s)
- Rachel Wells
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, South Australia, Australia; South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia; Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Adrian D Elliott
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, South Australia, Australia; South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Rajiv Mahajan
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, South Australia, Australia; South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia; Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Amanda Page
- Centre for Nutrition and Gastrointestinal Diseases, University of Adelaide, Adelaide, South Australia, Australia; South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Valeria Iodice
- University College London, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, South Australia, Australia; South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia; Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, South Australia, Australia; South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia; Royal Adelaide Hospital, Adelaide, South Australia, Australia.
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Stewart JM, Boris JR, Chelimsky G, Fischer PR, Fortunato JE, Grubb BP, Heyer GL, Jarjour IT, Medow MS, Numan MT, Pianosi PT, Singer W, Tarbell S, Chelimsky TC. Pediatric Disorders of Orthostatic Intolerance. Pediatrics 2018; 141:peds.2017-1673. [PMID: 29222399 PMCID: PMC5744271 DOI: 10.1542/peds.2017-1673] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/06/2017] [Indexed: 01/18/2023] Open
Abstract
Orthostatic intolerance (OI), having difficulty tolerating an upright posture because of symptoms or signs that abate when returned to supine, is common in pediatrics. For example, ∼40% of people faint during their lives, half of whom faint during adolescence, and the peak age for first faint is 15 years. Because of this, we describe the most common forms of OI in pediatrics and distinguish between chronic and acute OI. These common forms of OI include initial orthostatic hypotension (which is a frequently seen benign condition in youngsters), true orthostatic hypotension (both neurogenic and nonneurogenic), vasovagal syncope, and postural tachycardia syndrome. We also describe the influences of chronic bed rest and rapid weight loss as aggravating factors and causes of OI. Presenting signs and symptoms are discussed as well as patient evaluation and testing modalities. Putative causes of OI, such as gravitational and exercise deconditioning, immune-mediated disease, mast cell activation, and central hypovolemia, are described as well as frequent comorbidities, such as joint hypermobility, anxiety, and gastrointestinal issues. The medical management of OI is considered, which includes both nonpharmacologic and pharmacologic approaches. Finally, we discuss the prognosis and long-term implications of OI and indicate future directions for research and patient management.
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Affiliation(s)
| | | | | | | | - John E. Fortunato
- Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
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17
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Távora-Mehta MZP, Mehta N, Magajevski A, Oliveira LD, Maluf DLS, Concato L, Doubrawa E, Ortiz MR, Cunha CLPD. Reduced Systolic Volume: Main Pathophysiological Mechanism in Patients with Orthostatic Intolerance? Arq Bras Cardiol 2017; 107:354-364. [PMID: 27849259 PMCID: PMC5102482 DOI: 10.5935/abc.20160135] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 06/08/2016] [Indexed: 11/20/2022] Open
Abstract
Background Orthostatic intolerance patients' pathophysiological mechanism is still
obscure, contributing to the difficulty in their clinical management. Objective To investigate hemodynamic changes during tilt test in individuals with
orthostatic intolerance symptoms, including syncope or near syncope. Methods Sixty-one patients who underwent tilt test at - 70° in the phase without
vasodilators were divided into two groups. For data analysis, only the first
20 minutes of tilting were considered. Group I was made up of 33 patients
who had an increase of total peripheral vascular resistance (TPVR) during
orthostatic position; and Group II was made up of 28 patients with a
decrease in TPVR (characterizing insufficient peripheral vascular
resistance). The control group consisted of 24 healthy asymptomatic
individuals. Hemodynamic parameters were obtained by a non-invasive
hemodynamic monitor in three different moments (supine position, tilt 10'
and tilt 20') adjusted for age. Results In the supine position, systolic volume (SV) was significantly reduced in
both Group II and I in comparison to the control group, respectively (66.4
±14.9 ml vs. 81.8±14.8 ml vs. 101.5±24.2 ml;
p<0.05). TPVR, however, was higher in Group II in comparison to Group I
and controls, respectively (1750.5± 442 dyne.s/cm5
vs.1424±404 dyne.s/cm5 vs. 974.4±230
dyne.s/cm5; p<0.05). In the orthostatic position, at 10',
there was repetition of findings, with lower absolute values of SV compared
to controls (64.1±14.0 ml vs 65.5±11.3 ml vs 82.8±15.6
ml; p<0.05). TPVR, on the other hand, showed a relative drop in Group II,
in comparison to Group I. Conclusion Reduced SV was consistently observed in the groups of patients with
orthostatic intolerance in comparison to the control group. Two different
responses to tilt test were observed: one group with elevated TPVR and
another with a relative drop in TPVR, possibly suggesting a more severe
failure of compensation mechanisms.
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Affiliation(s)
| | - Niraj Mehta
- Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil
| | - Adriano Magajevski
- Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil
| | | | | | - Letícia Concato
- Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil
| | - Eduardo Doubrawa
- Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil
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Ruzieh M, Baugh A, Dasa O, Parker RL, Perrault JT, Renno A, Karabin BL, Grubb B. Effects of intermittent intravenous saline infusions in patients with medication—refractory postural tachycardia syndrome. J Interv Card Electrophysiol 2017; 48:255-260. [DOI: 10.1007/s10840-017-0225-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 01/24/2017] [Indexed: 10/20/2022]
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Hakim A, O'Callaghan C, De Wandele I, Stiles L, Pocinki A, Rowe P. Cardiovascular autonomic dysfunction in Ehlers-Danlos syndrome-Hypermobile type. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2017; 175:168-174. [PMID: 28160388 DOI: 10.1002/ajmg.c.31543] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Autonomic dysfunction contributes to health-related impairment of quality of life in the hypermobile type of Ehlers-Danlos syndrome (hEDS). Typical signs and symptoms include tachycardia, hypotension, gastrointestinal dysmotility, and disturbed bladder function and sweating regulation. Cardiovascular autonomic dysfunction may present as Orthostatic Intolerance, Orthostatic Hypotension, Postural Orthostatic Tachycardia Syndrome, or Neurally Mediated Hypotension. The incidence, prevalence, and natural history of these conditions remain unquantified, but observations from specialist clinics suggest they are frequently seen in hEDS. There is growing understanding of how hEDS-related physical and physiological pathology contributes to the development of these conditions. Evaluation of cardiovascular symptoms in hEDS should include a careful history and clinical examination. Tests of cardiovascular function range from clinic room observation to tilt-table assessment to other laboratory investigations such as supine and standing catecholamine levels. Non-pharmacologic treatments include education, managing the environment to reduce exposure to triggers, improving cardiovascular fitness, and maintaining hydration. Although there are limited clinical trials, the response to drug treatments in hEDS is supported by evidence from case and cohort observational data, and short-term physiological studies. Pharmacologic therapy is indicated for patients with moderate-severe impairment of daily function and who have inadequate response or tolerance to conservative treatment. Treatment in hEDS often requires a focus on functional maintenance. Also, the negative impact of cardiovascular symptoms on physical and psycho-social well-being may generate a need for a more general evaluation and on-going management and support. © 2017 Wiley Periodicals, Inc.
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Rowe PC, Underhill RA, Friedman KJ, Gurwitt A, Medow MS, Schwartz MS, Speight N, Stewart JM, Vallings R, Rowe KS. Myalgic Encephalomyelitis/Chronic Fatigue Syndrome Diagnosis and Management in Young People: A Primer. Front Pediatr 2017; 5:121. [PMID: 28674681 PMCID: PMC5474682 DOI: 10.3389/fped.2017.00121] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 05/08/2017] [Indexed: 02/02/2023] Open
Abstract
Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a complex disease that affects children and adolescents as well as adults. The etiology has not been established. While many pediatricians and other health-care providers are aware of ME/CFS, they often lack essential knowledge that is necessary for diagnosis and treatment. Many young patients experience symptoms for years before receiving a diagnosis. This primer, written by the International Writing Group for Pediatric ME/CFS, provides information necessary to understand, diagnose, and manage the symptoms of ME/CFS in children and adolescents. ME/CFS is characterized by overwhelming fatigue with a substantial loss of physical and mental stamina. Cardinal features are malaise and a worsening of symptoms following minimal physical or mental exertion. These post-exertional symptoms can persist for hours, days, or weeks and are not relieved by rest or sleep. Other symptoms include cognitive problems, unrefreshing or disturbed sleep, generalized or localized pain, lightheadedness, and additional symptoms in multiple organ systems. While some young patients can attend school, on a full or part-time basis, many others are wheelchair dependent, housebound, or bedbound. Prevalence estimates for pediatric ME/CFS vary from 0.1 to 0.5%. Because there is no diagnostic test for ME/CFS, diagnosis is purely clinical, based on the history and the exclusion of other fatiguing illnesses by physical examination and medical testing. Co-existing medical conditions including orthostatic intolerance (OI) are common. Successful management is based on determining the optimum balance of rest and activity to help prevent post-exertional symptom worsening. Medications are helpful to treat pain, insomnia, OI and other symptoms. The published literature on ME/CFS and specifically that describing the diagnosis and management of pediatric ME/CFS is very limited. Where published studies are lacking, recommendations are based on the clinical observations and practices of the authors.
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Affiliation(s)
- Peter C Rowe
- Division of General Pediatrics and Adolescent Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | | | - Kenneth J Friedman
- Pharmacology and Physiology, New Jersey Medical School, Newark, NJ, United States
| | - Alan Gurwitt
- Yale Child Study Center, Harvard Medical School, University of Connecticut School of Medicine, Newton Highlands, MA, United States
| | - Marvin S Medow
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, New York Medical College, Valhalla, NY, United States
| | | | | | - Julian M Stewart
- Division of Pediatric Cardiology, New York Medical College, Valhalla, NY, United States
| | - Rosamund Vallings
- Primary Care/Chronic Fatigue Syndrome Clinic, Howick Health and Medical, Auckland, New Zealand
| | - Katherine S Rowe
- Department of General Medicine, Royal Children's Hospital, Murdoch Children's Research Institute, Melbourne, VIC, Australia
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Affiliation(s)
- Eun Sook Suh
- Department of Pediatrics, Soonchunhyang University School of Medicine, Seoul, Korea
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Blitshteyn S. Dietary Sodium Intake and Migraine: Is Salt the Answer? Headache 2016; 56:1210-1. [DOI: 10.1111/head.12869] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 04/29/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Svetlana Blitshteyn
- Dysautonomia Clinic, Department of Neurology; University at Buffalo School of Medicine and Biomedical Sciences; Buffalo NY USA
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