From the Guidelines
The initial management for Supraventricular Tachycardia (SVT) in pediatric patients with Wolff-Parkinson-White (WPW) syndrome should focus on vagal maneuvers first, followed by adenosine if necessary, while avoiding AV nodal blocking agents. For hemodynamically stable patients, begin with vagal maneuvers such as applying an ice pack to the face for 15-20 seconds or having older children perform a modified Valsalva maneuver. If vagal maneuvers fail, adenosine is the first-line pharmacological treatment, administered as a rapid IV push at a dose of 150 mcg/kg to 250 mcg/kg 1.
Key Considerations
- For hemodynamically unstable patients presenting with hypotension, altered mental status, or signs of shock, immediate synchronized cardioversion at 0.5-1 J/kg should be performed.
- It's crucial to avoid calcium channel blockers (verapamil, diltiazem) and beta-blockers in WPW patients as these medications can block the AV node while allowing conduction through the accessory pathway, potentially accelerating ventricular rates and precipitating ventricular fibrillation 1.
- After acute management, these patients should be referred to pediatric cardiology for electrophysiology evaluation and possible catheter ablation of the accessory pathway.
Medication Considerations
- Digoxin and propranolol have similar efficacy in infants with SVT without pre-excitation, but digoxin is avoided in the presence of pre-excitation because its use in infancy has been associated with sudden cardiac death or ventricular fibrillation 1.
- Amiodarone, sotalol, propafenone, or flecainide can be used for refractory SVT in infants, but flecainide is not used as a first-line medication in children due to the rare occurrence of adverse events 1.
From the FDA Drug Label
Any use of flecainide in children should be directly supervised by a cardiologist skilled in the treatment of arrhythmias in children. Under six months of age, the initial starting dose of flecainide in children is approximately 50 mg/M2 body surface area daily, divided into two or three equally spaced doses. Over six months of age, the initial starting dose may be increased to 100 mg/M2 per day.
The initial management for Supraventricular Tachycardia (SVT) in pediatric patients with Wolff-Parkinson-White (WPW) syndrome should be supervised by a cardiologist skilled in the treatment of arrhythmias in children. The dose of flecainide is based on the age and body surface area of the child, with an initial starting dose of approximately 50 mg/M2 daily for children under six months of age, and 100 mg/M2 per day for children over six months of age 2.
From the Research
Initial Management of SVT in Pediatric Patients with WPW Syndrome
The initial management of Supraventricular Tachycardia (SVT) in pediatric patients with Wolff-Parkinson-White (WPW) syndrome involves several steps:
- Vagal maneuvers: These are often the first line of treatment for SVT in pediatric patients, including those with WPW syndrome 3.
- Adenosine: If vagal maneuvers are unsuccessful, adenosine may be used as a first-line pharmacotherapy for SVT in pediatric patients 3, 4.
- Cardioversion: In cases where the patient is unstable, synchronized cardioversion may be necessary 3.
Pharmacologic Management
The pharmacologic management of SVT in pediatric patients with WPW syndrome may involve the use of antiarrhythmic agents, such as:
- Beta-blockers: These may be used as a first-line treatment for SVT in pediatric patients with WPW syndrome, with the addition of digoxin or procainamide for treatment failures 5.
- Digoxin: This may be used as a first-line treatment for atrioventricular nodal reentry tachycardia (AVNRT), but its use as monotherapy in WPW syndrome is not recommended 5.
- Flecainide: This may be used as a preferred agent for treatment failures with conventional antiarrhythmic agents 5.
Safety of Adenosine
The safety of adenosine for pediatric tachyarrhythmia treatment in the emergency department has been established, with minor side effects being common but serious side effects being rare 4.