Can propranolol (beta-blocker) be used to treat tachycardia in pediatric patients?

Propranolol for Tachycardia in Pediatric Patients

Yes, propranolol can be safely and effectively used to treat tachycardia in young patients, particularly for supraventricular tachycardia (SVT), with proper screening, dosing, and monitoring protocols. 1

Indications and Efficacy

Propranolol is highly effective for pediatric tachyarrhythmias, particularly:

• Supraventricular tachycardia (SVT): Propranolol prevents recurrence in approximately 70% of cases and is notably effective for SVT in infants and children 2, 3
• Focal atrial tachycardia: Intravenous beta-blockers including propranolol terminate or slow ventricular rate in 30-50% of patients 1
• Ventricular tachycardia with prolonged QT interval: Demonstrated effectiveness in this specific population 4

Historical data shows propranolol improved dysrhythmias in 31 of 41 pediatric patients across various tachyarrhythmias 4.

Critical Pre-Treatment Assessment

Before initiating propranolol, perform the following evaluation 1:

Mandatory screening:

• Complete history focusing on cardiac/pulmonary systems, feeding patterns, and growth
• Physical examination including cardiac auscultation, peripheral pulse palpation, and abdominal examination for hepatomegaly
• Heart rate and blood pressure measurement (compare to age-specific norms)

ECG required if: 1

• Heart rate outside normal range for age
• Strong family history of sudden death or arrhythmia
• Episodes of loss of consciousness
• Maternal history of connective tissue disease

Echocardiogram required if: 1

• Heart rate outside normal range for age
• Heart murmur detected on auscultation
• Segmental infantile hemangioma (if applicable)

Baseline glucose required if: 1

• Preterm infant
• Small for gestational age
• Poor feeding or faltering growth
• History of hypoglycemic episodes

Absolute Contraindications

Do not use propranolol in patients with 1:

• Sinus bradycardia
• Hypotension
• Greater than first-degree heart block
• Heart failure or cardiogenic shock
• Bronchial asthma or reactive airways disease
• Known hypersensitivity to propranolol

Dosing Protocol

For uncomplicated term infants >4 weeks old with normal birthweight and established feeds: 1

• Starting dose: 1 mg/kg/day divided into 3 doses
• Escalation: Increase to 2 mg/kg/day after 24 hours
• Maintenance: 2-3 mg/kg/day (maximum 3.4 mg/kg/day per FDA approval)
• Frequency: Three times daily preferred, though twice daily has shown safety and efficacy 1
• Outpatient initiation: Acceptable without heart rate/blood pressure monitoring for this population 1

For high-risk patients (preterm, <4 weeks old, comorbidities, poor feeding): 1

• Starting dose: 0.5 mg/kg/day
• Setting: Inpatient admission required for 2-4 hours
• Monitoring: Heart rate and blood pressure immediately before first dose, then every 30 minutes for 2-4 hours
• Glucose monitoring: Only in at-risk patients (preterm, low weight, faltering growth, history of hypoglycemia)

Critical Safety Considerations

Hypoglycemia prevention: 1

• Administer propranolol with feeding at intervals not exceeding 8 hours (6 hours in younger infants)
• During acute illness with reduced oral intake, vomiting, or diarrhea: temporarily decrease dose or stop therapy entirely
• Resume only when normal feeding is re-established

Common adverse effects to monitor: 1

• Sinus bradycardia and hypotension
• Sleep disturbance
• Cool extremities
• Diarrhea
• Hypoglycemia/seizures (rare but serious)

Severe adverse events requiring discontinuation occur in approximately 2-10% of patients 2, 5.

Formulation and Dosing Errors

Use the 5 mg/5 mL preparation exclusively to minimize dosing errors 1. Propranolol is available in multiple concentrations, and inadvertent administration of the wrong concentration has led to significant dosing errors in infants 5. A drug dosing card is strongly recommended to aid dose adjustment and prevent errors 1.

Duration and Discontinuation

• Treatment duration: Typically 3-12 months, often continued until 8-12 months of age 1
• Discontinuation: Can be stopped abruptly rather than tapered, though some practitioners taper over 1-3 weeks to prevent rebound sinus tachycardia 1
• Rebound tachycardia: Occurs in 6-25% of cases, may require reinitiation 1

Special Populations

For infants requiring hospitalization at initiation 1:

• Age ≤8 weeks
• Preterm infants <48 weeks postconceptional age
• Poor social support
• Cardiac or pulmonary risk factors

These patients require more conservative dosing schedules and closer monitoring as determined by the supervising physician 1.