What is the recommended treatment for a child experiencing palpitations?

Treatment of Palpitations in Children

The recommended treatment for a child experiencing palpitations depends on the underlying cause, with supraventricular tachycardia (SVT) being the most common significant arrhythmia requiring intervention, which should be treated with vagal maneuvers first, followed by adenosine if necessary, and then electrical cardioversion for hemodynamically unstable patients.

Initial Assessment and Classification

When evaluating a child with palpitations, first determine hemodynamic stability and classify the rhythm:

• Hemodynamically stable with normal vital signs: Monitor and evaluate without emergency treatment 1
• Hemodynamically unstable: Requires immediate intervention based on rhythm identification

Types of Arrhythmias Causing Palpitations

1. Sinus tachycardia

   • Usually a physiologic response to fever, pain, anxiety, or dehydration
   • Treatment: Address underlying cause rather than the rhythm itself

2. Supraventricular tachycardia (SVT)

   • Most common significant arrhythmia requiring intervention in children
   • Presents with heart rates typically >220 bpm in infants, >180 bpm in children
   • Regular, narrow-complex tachycardia

3. Ventricular tachycardia (VT)

   • Less common but more serious
   • Wide-complex tachycardia (>0.09 seconds)

Treatment Algorithm for SVT

For Hemodynamically Stable SVT:

1. First-line: Vagal maneuvers 1

   • Infants: Apply ice to face without occluding airway
   • Older children: Carotid sinus massage or Valsalva maneuvers (e.g., blowing through a narrow straw)

2. Second-line: Adenosine 1

   • Drug of choice if IV/IO access is available
   • Initial dose: 0.1 mg/kg (maximum 6 mg)
   • If ineffective, may increase to 0.2 mg/kg (maximum 12 mg)
   • Caution: Can cause transient AV block, bronchospasm, and hypotension 2

3. Third-line (for refractory SVT): 1, 3

   • Procainamide: 15 mg/kg IV/IO via slow infusion
   • OR Amiodarone: 5 mg/kg IV/IO via slow infusion with careful hemodynamic monitoring

For Hemodynamically Unstable SVT:

1. Immediate synchronized cardioversion 1
   • Initial energy: 0.5-1 J/kg
   • If unsuccessful, increase to 2 J/kg
   • Use sedation when possible before cardioversion

Treatment Algorithm for VT

For Hemodynamically Stable VT:

1. Consult pediatric cardiology expert 1
   • Expert consultation strongly recommended before treating hemodynamically stable wide-complex tachycardia

For Hemodynamically Unstable VT:

1. Immediate synchronized cardioversion 1
   • Initial energy: 0.5-1 J/kg
   • If unsuccessful, increase to 2 J/kg (Class I, LOE C)

Special Considerations

Age-Specific Concerns:

• Infants (<1 year): Avoid verapamil as it can cause severe hypotension, bradycardia, and cardiovascular collapse 1, 3

• Children with congenital heart disease: May require specialized management and earlier cardiology consultation 1

Monitoring Recommendations:

• For children with infrequent palpitations and normal initial evaluation, ambulatory cardiac monitoring may be necessary 4, 5
• Options include 24-48 hour Holter monitoring, event recorders, or implantable loop recorders depending on frequency of symptoms

Follow-up Care

• Children with benign palpitations (normal sinus rhythm, premature beats) generally require reassurance and follow-up
• Children with documented arrhythmias should be referred to pediatric cardiology for comprehensive evaluation and management
• For children with frequent isolated premature ventricular complexes (PVCs) but normal ventricular function, follow-up without treatment is recommended 1

Important Pitfalls to Avoid

1. Don't delay cardioversion in hemodynamically unstable patients with tachyarrhythmias

2. Don't use verapamil in infants as it can cause profound hypotension and cardiovascular collapse

3. Don't overlook non-cardiac causes of palpitations (anxiety, fever, anemia, hyperthyroidism, medications)

4. Don't miss underlying structural heart disease that may be associated with arrhythmias and increase risk of sudden death

The treatment approach should be guided by the specific arrhythmia identified, the patient's hemodynamic status, and the presence of any underlying cardiac conditions.