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Pediatricians Against EKGs For Children Taking ADHD Drugs

Posted on: Wednesday, 30 July 2008, 15:05 CDT

Most children taking attention-deficit disorder medications such as Ritalin, Adderall and Concerta do not require heart-screening electrocardiogram tests, according to the American Academy of Pediatrics (AAP).

The statement contradicts advice given earlier this year from the American Heart Association (AHA) that recommended children taking these drugs receive EKGs.

More than half of the 4 million U.S. children diagnosed with attention-deficit disorders are currently being treated with stimulant drugs. ADHD medications can often help children behave less impulsively, increase focus and perform better in school.  

However, they can also increase heart rate and blood pressure, and as a result carry warnings about the increased risk for sudden deaths in patients with heart problems.

The new AAP policy reignites the debate over the safety of these medications.

The United States’ largest pediatricians’ group called the AHA advice given earlier this year “overzealous”, considering these rare deaths are more common among the general population than in children on stimulants.

According to AAP data, annual sudden heart-related deaths occur in only about four out of 2.5 million U.S. children on stimulants, while between 8 and 62 such deaths occur annually among all U.S. children.

The new AAP policy says the AHA advice subjects healthy children to expensive and unnecessary exams, and could limit access to effective ADHD treatments, something that could carry "serious implications".

The dispute among these influential doctors groups "is more than a tempest in a teapot”, according to Seattle heart specialist Peter Hesslein.

The AAP advises children starting stimulants to have careful physical exams, and be checked for family history of heart problems such as sudden death.  But it adds that in most cases a routine EKG is not necessary.

When the AHA announced its policy in April, the advice was widely interpreted as a mandate.

"We immediately in the cardiology world started getting all these phone calls from people saying, 'I've got to have this test, my kid's got to have this medicine,'" Dr. Mary Mehta, a heart specialist in Pensacola, FL, told the Associated Press.

The AHA clarified its position in May in a little-publicized statement advising physicians to use their own judgment with respect to heart screenings, and telling doctors not to withhold ADHD treatment because an EKG had not been performed. 

The AAP agreed, but took a more forceful stance against routine EKGs.

The new AAP policy was posted on its Web site later that month, and will be published in the August edition of Pediatrics, the academy's medical journal.

"We really were hearing from our members and parents that things were not at all clear," policy co-author Dr. James Perrin, a Massachusetts General Hospital pediatrician, told the Associated Press.

Perrin said the academy's policy reflects the lack of scientific evidence supporting "this fairly dramatic practice change."

The AHA’s initial statement cited evidence presented to the U.S. Food and Drug Administration that showed 19 sudden deaths occurred in children taking ADHD medications between 1998 and 2003. It also said that 1,000 to 7,000 children and teens in the U.S. die each year of sudden cardiac death.  An EKG can often detect the underlying conditions responsible for these deaths.

AHA president Dr. Tim Gardner said the association’s policy is based partly on the fact that children with heart abnormalities have a higher incidence of ADHD.

Gardner downplayed the differences in positions between the AHA and AAP, saying both groups acknowledge the importance of thorough medical evaluations for children beginning treatment with ADHD drugs.

Dr. Steven Nissen, a Cleveland Clinic heart specialist and drug safety watchdog, told the AP the academy seems to be rejecting concerns that stimulants are used excessively in children without sufficient evidence of long-term safety.

The group's pro-drug stance is troubling, Nissen said, considering it came only a few weeks after it announced support for cholesterol drug treatments for children as young as 8 years old.

At less than $100 per test, EKGs are inexpensive and easy to perform, according to Hesslein, a heart specialist at Seattle's Swedish Medical Center.  However, false-positive results commonly occur, often leading to additional costly tests to rule out more serious conditions.

Nevertheless, Hesslein said other countries have successfully implemented EKG screening in select groups of children.  For example, in Italy, sudden heart death rates in young athletes have decreased, he said.

For that reason, Hesslein believes routine EKGs for all children "would be worthwhile."

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On the Net:

• American Academy of Pediatrics
• American Heart Association

Source: redOrbit Staff & Wire Reports

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