1

AMultitudeofMethods:
TreatingPediatricCasesofPosturalOrthostatic
TachycardiaSyndrome(POTS)

LindsayLeTellier
IndependentResearchIG/T
7June2016

Advisor:Dr.JohnFortunato
Instructor:E.LeilaChawkat

Abstract
PosturalOrthostaticTachycardiaSyndrome(POTS)canbeanextremelydebilitating
conditiontoanyoneofanyagewhosuffersfromit,butitcanoftenbeespeciallydifficultonthe
pediatricpatientswhoarediagnosedwiththissyndrome.Whatmakesthissyndromeparticularly
tryingtodealwithisthatitcanaffectcountlessfacetsofapatientsphysicalandmental
wellbeing,andalsothefactthatthesyndromecanonlybetreated,andnotcured.Manydoctors
aroundthenationtreatpediatriccasesofPOTS,andtheyutilizetreatmentmethodsrangingfrom
pharmacologicaltononpharmacologicaltreatmentsinordertocarefortheirpatients.The
tendencyforeachpediatricPOTSpatienttosufferfromtheirconditioninadifferentway
coupledwiththefactthattherearecountlesspossibletreatmentmethodsavailableandyetnot
oneiseffectiveforallsymptomsorallpatientsoftenmakestreatingpediatriccasesofPOTSan
extremelydifficulttasktoattempt.
Thepurposeofthisresearchwasto:a)informthereaderofbackgroundinformationon
POTS,b)analyzeexistingliteraturethatprovidesinformationpertainingtohowpediatriccases
ofPOTScanpotentiallybetreated,andc)toinvestigateaquestionnaireconductedbythe
researcherthatwasusedtogatherdataonhowdifferentdoctorsofdifferentspecialtiesfrom
aroundtheUnitedStatesprefertotreattheiryoungpatientswhosufferfromPOTS.Thisstudy
demonstratedthatthereexistsalargevarietyoftreatmentsforpediatricPOTSamongthe
medicalspecialties.Itcanbeconcludedthatthemosteffectivewaytocareforthesecomplicated
patientsrequiresbothnonpharmacologicalandpharmacologicalmethodsutilizinga
multispecialtyapproach.

Introduction
PosturalOrthostaticTachycardiaSyndrome(POTS)isatypeofautonomicdisorderthat
weighsheavilyonthosewhosufferfromit,anditcanbeespeciallydetrimentalwithinthelives
ofthechildrenwhomustdealwiththesyndrome.Itisconsideredtobeararesyndrome,and
mostpeopleofthegeneralpublichavelittletonoawarenessofwhatPOTSevenisorentails.
ForthosewhodosufferfromPOTS,thesyndromeactsasahighlydominantandinfluential
forceintheirlives,asitcansometimescausepatientstohavetoeatorabstainfromcertain
foods,strictlyregulatetheirphysicalexercise,wearcertaingarments,and/ortakecountless
medications,amongothermajorlifestylechanges(LeGras,2013).
Inadditiontothephysiologicaltaxesthataccompanythissyndrome,itcanalsobe
extremelypsychologicallydraining.POTSpatientsoftensufferfromverylowqualitiesoflife,
withstudiescomparingthequalityoflifeofPOTSpatientstothatofpeoplewithcongestive
heartfailure(Raj,2014).ThemostdifficultaspectofPOTStoisverylikelythefactthatthereis
nocure.Onlyitssymptomscanbetreated.Thisisoftenaverydifficultprocess,aseachcaseof
POTSisextremelydifferentinmanyrespects,andtherefore,therearenospecifictreatment
methodsthatareeffectiveforallpatients.Inpediatriccasesespecially,itisextremely
challengingforphysicianstodesigntreatmentplansfortheirpatientsthatarebotheffectivein
reducingsymptomsandareappropriateforyoungpeople.Veryoften,patientsmustconsultwith
avarietyofdoctorstofindtherightcombinationofdifferenttreatmentmethodsbestforthem.
ThisresearchpaperwilldiscusswhatPOTSisanditsmanyimplicationsonpediatricpatients.
Thisdiscussionwillbefollowedbyananalysisofadetailedstudyconductedbytheresearcherin

whichtheresearcherprovidedaquestionnairetospecialiststogaugedifferencesamong
physiciansofvariousfieldsinwhattheyfeelisthemosteffectivetreatmentofpediatricPOTS.

ReviewofLiterature
PosturalOrthostaticTachycardiaSyndrome(POTS)ischaracterizeddifferentlyinadult
patientsthaninpediatricpatients,withadultsandchildreneachhavingtheirownsetof
diagnosticcriteria.Foradults,theposturaltachycardiabreakpointof30beats/minuteseems
todifferentiatepatientswithfatigueanddizzinessintothosewhohavePOTSandthosewhodo
nothavePOTSonthebasisoftheirsymptoms(Kizilbashetal,2014,p112).Pediatricpatients,
ontheotherhand,arediagnosedonthebasisofthefollowingdefinitionofpediatricPOTS:
The
medicaldefinitionofPOTSinpediatricsisapersistentriseinheartrateofmorethan3040beats
perminutewhenstanding,orastandingheartrateofgreaterthan120beatsperminute.There
maybeadropinbloodpressureaswell(LeGras,2013).
OnestudyconductedbyateamofresearchersattheMayoClinicinRochester,
Minnesota,concludedthatthediagnosticcriteriausedtodiagnoseadultswithOrthostatic
Intolerance(OI)andPOTSisinappropriatefordiagnosingpediatriccasesofOIandPOTS.The
researchersstudydemonstratesthatanorthostaticHRincrementof30[beatsperminute]the
maindiagnosticcriterionforOIinadultsisstillwellwithinnormalrangeforchildrenand
adolescents.IfthisisusedascutofffordiagnosingOIinapediatricagegroupitwouldresultin
verylowspecificity(Singeretal,2012,p5).
POTSisoftenextremelydifficulttodiagnoseinbothadultandpediatriccases.One
commondiagnostictoolthatisusedfrequentlywhenaphysicianisattemptingtodiagnoseboth

pediatricandadultscasesofPOTSisthatofatilttabletest.Inatilttabletest,
[thepatient]
begin[s]bylyingflatonatable.Strapsareputaround[thepatients]bodytohold[himorher]in
place.Afterabout15minutesoflyingflat,thetableisquicklytiltedtoraise[thepatients]body
toaheaduppositionsimulatingachangeinpositionfromlyingdowntostandingup...The
tablewillthenremainuprightforupto45minutes,while[thepatients]heartrateandblood
pressurearemonitored.Thisallowsdoctorstoevaluate[thepatients]body'scardiovascular
responsetothechangeinposition

("TiltTableTest,"2015).Theresearchteam(referenced
earlier)fromtheMayoClinicrecommendsthatatilttablebeusedinaccordancewithother
diagnosticcriteria,astilttabletestingalonecannotcapturethefullspectrumofsymptomsthat
patientswiththissyndromefrequentlyexperience,whichrangefromorthostaticsymptomsto
chronicdizziness,fatigue,exerciseintolerance,gastrointestinaldysmotility,andheadaches
(Singeretal,2012,p6).
Bothpediatricandadultpatientsalikecansufferfromavarietyofdifferentsymptoms
associatedwithPOTS.Symptomsvaryfrompatienttopatient,andcanincludebutarenot
limitedto:bothcardiacsymptoms(rapidpalpitations,lightheadedness,chestdiscomfort,and
dyspnea)andnoncardiacsymptoms(mentalclouding[brainfog],headache,nausea,
tremulousness,blurredortunneledvision,poorsleep,exerciseintolerance,andfatigue(Raj,
2013)aswellaspresyncopalfeelings,tremulousness,andlegweaknesswhenassumingthe
uprightposition(Singeretal,2012,p1)andchronicdizziness...gastrointestinaldysmotility,
andheadaches(Singeretal,2012,p6).
BecauseoftheuniquenatureofeachcaseofPOTSandthevarietyofdifferentsymptoms
thatcoincidewitheachspecificcase,thesyndromeistreatedinagreatvarietyofdifferentways.

Somephysicianstreatthesyndromepharmacologically,otherstreatitusing
nonpharmacologicalmethods,andotherphysiciansuseacombinationofbothpharmacological
andnonpharmacologicaltreatmentmethods.Someofthepharmacologicalmethodsinclude,but
arenotlimitedto:
BetaBlockers,Cerefolin,Clonidine,DDVAP,Erythropoietin,Florinef,
Labetalol,Ibuprofen,Indomethacin,IntravenousSaline,

PlasmaExchange,IntravenousGamma
Globulin,andvasoconstrictors(POTS:Whathelps,2013).Eachofthesemedicationstypically
onlyaddressesasmallnumberorevenjustoneofapatientssymptoms.Some
nonpharmacologicaltreatmentmethodsthatareprescribedbyphysiciansinclude,butarenot
limitedto:engaginginregularphysicalexercise,improvingsleepinghabits,wearing
compressiongarments,avoidingoverheating,maintainingapositiveattitude,avoidingtriggersof
onessymptoms,andincreasingbodyweight(LeGras,2013).Italsooftenhighlyencouraged
thatPOTSpatientsincreaseboththeirfluidintakeaswellastheirsaltintakeinordertoimprove
theirbloodflowandbloodpressure,respectively(LeGras2013).
ExercisecansometimesbeanextremelyeffectivetreatmentmethodforPOTS,including
forpediatriccases.ThisprincipleinspiredtheJohnsHopkinsChildrensCentertoestablish
a
formal,multidisciplinaryphysicaltherapyprogramforpediatricpatientswithPOTStobuildup
theirenduranceandtolerancetobeuprightand,insodoing,engageindailyactivities(PTfor
POTS,2014).AteamofresearchersfromDallas,Texas,ledbyDr.BenjaminLevine,recently
conductedastudyonthebenefitsofregularphysicalexercisetohelptreatPOTSaswellas
testedanexerciseprogramthatcouldpotentiallybeusedtoeffectivelytreatpediatricpatients.
Theyreportedthefollowingconclusions:

[Theresearchers]foundthat3monthsofprogressiveexercisetraininginPOTS
patientsincreasedmaximaloxygenuptakeby11%,indicatinganincreaseinphysical
fitness.Leftventricularmassandenddiastolicvolumeincreasedby12%and8%after
training,resultinginsignificantcardiacremodeling.Theheartbecamemuchlargerand
probablymoredistensibleafterexercisetraining.Bloodandplasmavolumesalso
increasedmarkedlyaftertraining.Ten(53%)of19patientsnolongermetcriteriafor
POTSaftercompletionofthe3monthexercisetrainingprogramandthuswerecured.
Moreimportantly,patientqualityoflife,asassessedby36itemShortFormHealth
Survey,improvedsignificantlyaftershorttermexercisetraininginvirtuallyallofthese
patients,includingthosewithpersistenceoforthostatictachycardia(Levineetal,2010,
p.2866).
AccordingtoDr.JeffreyBoris,apediatriccardiologistattheChildrensHospitalof
Philadelphia,itisimportantwhentreatingpediatriccasesofPOTStoconsiderwhetherornot
certaintreatmentsarefeasibleforchildren.Notalltreatmentmethodsthatareusedtotreatadult
POTSareappropriatefortreatingpediatricpatientswithPOTS(J.Boris,personal
communication,December22,2015).Certainexerciseregimens,forexample,maynotbe
appropriateforsomepediatricpatientsbecausethelengthyprogramsmaybedifficultforyoung
peopletofollow(J.Boris,personalcommunication,December22,2015).Theprogramsoften
takeawhiletobecomeeffective,andsomechildrenmaynothavethepatiencetokeepupwith
theirexercises(J.Boris,personalcommunication,December22,2015).Also,manyofthetypes
ofexercisesthatareusedspecificallytotargetPOTSrequirespecialequipmentwhichchildren

andtheirfamiliesmaynotbeabletoaccess(J.Boris,personalcommunication,December22,
2015).

ResearchMethodsandDataCollection
AquestionnairewasdistributedtoavarietyofphysiciansaroundtheUnitedStatesto
assesshowtheytypicallycareforPOTSwhenitispresentedinpediatricpatientsandtogauge
theiropinionsonhowthesepatientsmosteffectivelytreated.Thequestionnairewasstructuredso
thatitcouldelicitbothquantitativeandqualitativeresults.Someofthequestionsweremultiple
choiceorintheformofaLikertscale,andtheanswerstothesequestionscouldbeobjectively
quantified,whileotherquestionswereopenended,allowingtheresearchertogathermore
detailed,expandedresultsonhowtherespondentschoosetotreatpediatricPOTS.
Iftheresearcherweretochangeanythingaboutthequestionnairethatwasdistributed,it
wouldbetoattempttodistributeittoagreaternumberofphysicians.Thiswasonelimitationof
thestudy,butnotunusualwhentryingtorecruitparticipantsfromalargegeographicalarea.
Havingmoredatawouldpossiblyallowtheresearchertodrawmoredetailedconclusions.After
analyzingthedata,theresearcheralsowouldhavelikedtohavesomeadditionalopenended
questionsinthequestionnaire,asthesetypesofquestionsservedtoprompttheparticipantsto
providemorespecificdetailsabouthowtheytreatpediatricPOTS.
Inadditiontodistributingaquestionnaireinordertoacquiredataonthistopic,the
researcheralsoutilizedmetaanalysisinordertogatherdataforthisresearchproject.Avariety
ofdifferentsourcesregardingtreatmentmethodsusedtotreatPOTSwereanalyzedand
synthesized,rangingfromacademicjournalsarticlestoashorterpiecefromtheJohnsHopkins

ChildrensCenterwebsite.Metaanalysiswasutilizedinordertogainanunderstandingofthe
treatmentsbeingusedtotreatpediatricPOTSaccordingtotheliteraturethatisavailableonthe
topic.
Iftheresearcherweretochangeanythingaboutthewayinwhichdatawascollectedfor
thisprojectviametaanalysis,itwouldbetohavedrawninformationfromagreaternumberof
sources.However,itwouldhavebeendifficultfortheresearchertohavedonethis,asthereisa
verylimitedlibraryofliteraturepertainingtothisspecifictopic.

ResultsandDataAnalysis
Ofthefourteenrespondentsofthequestionnaire,sixwerecardiologists,twoofthem
gastroenterologists,twoofthempediatricspecialists,oneofthemaneurologist,oneofthema
psychologist,oneofthemaspecialistinpulmonologyandexercisemedicine,andoneoftheman
autoimmunediseasespecialist(Figure1)(LeTellier).
BecausetherearemanypharmacologicaltreatmentsforpediatricPOTSaswellas
nonpharmacologicaltreatmentmethods,theresearcherwantedtogaininformationonwhich
treatmentmethodthephysiciansthoughttobemoreeffective:pharmacological,
nonpharmacological,oracombinationofbothtypes.ToQuestion#5ofthequestionnaire,Do
youfindpharmacologicalornonpharmacologicaltreatmentmethodstobemoreeffectivewhen
treatingpediatricPOTS?,noneoftheparticipantsrespondedthatpharmacologicaltreatments
aloneweremostbeneficialtotheirpatients(LeTellier).Threerespondentsacardiologist,a
gastroenterologist,andaspecialistinpulmonologyandexercisemedicinerespondedthatthey
findnonpharmacologicaltreatmentmethodstobemosteffectiveintreatingpediatricpatients

10

(LeTellier).Theremainingelevenrespondentsansweredthattheytypicallyfindthata
combinationofpharmacologicalandnonpharmacologicaltreatmentmethodsismosteffectivein
treatingtheiryoungpatients(Figure2)(LeTellier).
TreatingpediatricPOTSbyadvisingpatientstoaltertheirdiets,oftenbymeansof
increasingtheirfluidandsaltintakes,islistedbymanysourcesasanextremelycommon
treatmentmethodforPOTSforpatientsofallages.Thefollowingquestionwasposedtothe
fourteenparticipantstoassesshowimportantalterationofapatientsdietistotreatingthe
patienteffectively:Howimportantisitforapediatricpatient'sdiettobealtered(i.e.increasing
fluidintake,consumingmoresalt)asapartofhisorhertreatmentforPOTS?(LeTellier).
RespondentsansweredusingaLikertscale,ofwhich21.43%statedthatitisimportantfor
pediatricpatientstoaltertheirdiets,whiletheremaining78.57%ofrespondentsstatedthatdiet
alterationsuchasincreasingfluidandsaltintakesisextremelyimportanttotreatingpatients
(LeTellier).Thosewhosaidthatdietalterationisextremelyimportantincludedapsychologist,
anautoimmunediseasespecialist,twogastroenterologists,fourcardiologists,aneurologist,and
twopediatricspecialists(LeTellier).Twocardiologistsandapulmonology/exercisemedicine
specialistselectedthatdietalterationisimportant(Figure3)(LeTellier).
Exercise,accordingtomostsources,isalsoanothercommonlyassignedtreatment
methodforpediatriccasesofPOTS.Therefore,theresearcherposedthefollowingquestionon
thequestionnaire:Howimportantisexercise,specificallycardiovascularconditioning,tothe
careofyourpatients?(LeTellier).Aswiththepreviousquestionaboutdietalteration,allofthe
respondentsselectedthatexerciseiseitherofimportanceorextremeimportancetothecareof
theirpatients,with28.57%ofresponsesstatingthatitisimportantand71.43%statingthatitis

11

extremelyimportant(LeTellier).Twocardiologists,agastroenterologist,andapediatric
specialistselectedimportant,whileapsychologist,anautoimmunediseasespecialist,a
gastroenterologist,fourcardiologists,apulmonology/exercisemedicinespecialist,aneurologist,
andapediatricspecialistselectedextremelyimportant(Figure4)(LeTellier).
BecauseoftheadversepsychologicaleffectsPOTScanhaveonpatients,theresearcher
wantedtogaugehowimportantthephysiciansfeelitisfortheiryoungpatientstoobtaina
psychologicalreferralaspartoftheirtreatment.Nineofthefourteenrespondentstothe
questionnaireratedthatapsychologyreferraliseitherimportantorextremelyimportanttothe
careoftheirpatients(LeTellier).Apsychologist,acardiologist,twogastroenterologists,anda
pediatricspecialiststatedthatpsychologyreferralsareextremelyimportant,whiletwo
cardiologists,aneurologist,andapulmonology/exercisemedicinespecialiststatedthatitis
important(Figure5)(LeTellier).
Inadditiontoevaluatingtheimportanceofdifferentcomponentsoftreatingpediatric
POTS,therespondentswerealsoaskedtostatethreetreatmentmethodsthattheyutilizetotreat
theiryoungpatientsinorderofpreference(LeTellier).Theresearcherhadhypothesizedthatthe
doctorswouldnametreatmentsthatcorrespondedwiththesymptomsthatcoincidewiththeir
specialty.However,thiswastypicallynotthecase,asmostoftherespondentsnamedtreatment
methodsthattendtotreatawidearrayofthesymptomsofPOTS(Figure6).
Sixcardiologistsgaveresponsestothequestionnaire,makingup42.86%ofthe
respondents(LeTellier).Ofthesesixcardiologists,fivestatedFludrocortisoneorFlorinefasone
oftheirpreferredtreatments(LeTellier).FlorinefisaspecificbrandofFludrocortisone,whichis
adrugthatisahumanengineeredformofamineralcorticoidsimilartoaldosterone,whichisa

12

steroidhormoneproducedbythebodysadrenalgland.Itisessentialtothebodysregulationof
elementssuchasbloodpressureandthebalanceofwaterandsaltlevels.Ofthesefive
respondents,twolistedFlorineforFludrocortisoneastypicallythemosteffectivetreatment
methodtheyusewiththeiryoungPOTSpatients,ofthethreemethodstheylisted(LeTellier).
Twoofthecardiologistsalsolistedanincreaseinsaltandfluidintakesasoneoftheirpreferred
treatments,withonestatingthatanincreaseinsaltandfluidintakescombinedwith
Fludrocortisoneistypicallythemosteffectivetreatmentforthisspecificphysiciansyoung
POTSpatients(LeTellier).Twoothercardiologistsstatedthatpatientsmustbetreated
effectivelyonanindividualbasis,becausedifferenttreatmentmethodsaremoreorlesseffective
fordifferentpatients(LeTellier).Otherlisted,preferredtreatmentsincludedPropanolol,
Midodrine,Ritalin,Periactin,severalothermedicationstotargetspecificsymptoms,and
psychologicalcounseling(LeTellier).
Inadditiontothesixcardiologistswhofilledoutthequestionnaire,two
gastroenterologistsgaveresponses(LeTellier).Onerepliedthathe/shepreferstousethe
followingthreetreatments:increasedfluidsandsalts,cardiovascular/recumbentexercises,and
Fludrocortisone(LeTellier).Theothergaveasimilarreply,writingthathe/shepreferstouse
thesetreatments:fluids/salt,physicaltherapy,andFlorinef(LeTellier).Thefirst
gastroenterologiststatedthatacombinationofincreasedfluidsandsaltandexercisesistypically
themosteffective,whilethesecondgastroenterologiststatedthatdependingontheseverityof
symptoms,increasedfluidsandsaltsistypicallymosteffectiveofthethreetreatmentslisted
(LeTellier).

13

Twophysicianswhospecializeinpediatricsfilledoutthequestionnaire(LeTellier).One
ofthesephysiciansstatedthathe/shepreferstousethefollowingtreatmentsforyoungPOTS
patients:dailyaerobicexercise,increasedfluidandsaltintakes,andmedicationsuchasthe
Metoprolol(LeTellier).Theotherphysicianlistedthefollowingthreetreatmentsashis/hermost
commonlyused,ashe/shestatedthatPOTSmustbeeffectivelytreatedonapatientbypatient
basis:stimulantmedications,Fludrocortisone,andAtenolol(LeTellier).Thefirstphysician
statedthatdailyaerobicexercisetendstobethemosteffectivetreatmentofthethreehe/she
listed,whilethesecondphysicianstatedthattheeffectivenessofthetreatmentsvariesbasedon
thepatientandthepatientsothercomorbidconditions(LeTellier).
Inadditiontothetwopediatricspecialists,oneneurologistgaveresponsestothe
questionnaire(LeTellier).Thisphysicianstatedthathe/sheutilizesthefollowingtreatment
methods,inorderofhis/herpreference:salt,Florinef,andMidodrine(LeTellier).Thisphysician
statedthatofthesetreatments,Florinefcombinedwithsaltandfluidistypicallythemost
effectiveintreatingyoungPOTSpatients(LeTellier).
Onepsychologistgaveresponsestothequestionnaire(LeTellier).Thisdoctorstatedthat
he/shepreferstousethefollowingtreatmentsforhis/heryoungPOTSpatients:lifestyle
modifications,CognitiveBehavioralTherapy(CBT),andAcceptanceandcommitmenttherapy
(ACT)(LeTellier).CBTallowspatientstobetterunderstandtheirnegativeexperiencesandreact
morepositivelytothem(MayoClinicStaff,2016).ACTallowspatientstocopemoreeffectively
withlifesdifficulties(Serani,2011).Thepsychologiststatedthatofthesethreetreatments,
lifestylemodificationstendtobemosteffectiveinyoungerpatients(LeTellier).The
psychologiststatedthathe/shemeasurestheeffectivenessoftheselifestylemodificationsby

14

monitoringsymptomreportsandhavingpatientsfilloutquestionnaireswitheachvisit
(LeTellier).
Oneautoimmunediseasespecialistfilledoutthequestionnaire(LeTellier).Tothe
questionthatpromptedrespondentstonamethreetreatmentmethodstheyusefortheirpediatric
POTSpatientsinorderofpreference,thisphysicianreplied:salt,fluids,exercise,trigger
avoidanceAdderallFlorinef(LeTellier).Adderallisamedicationthatistypicallyusedtotreat
AttentionDeficitHyperactivityDisorder(ADHD).Thisphysiciansresponsesuggeststhat
he/shepreferstotreathis/heryoungpatientsnonpharmacologically.However,thisphysiciandid
statethatofthesethreemethods,Adderall,apharmacologicalmethod,istypicallythemost
effectiveintreatinghis/herpatients(LeTellier).
Onespecialistinpulmonologyandexercisemedicinegaveresponsestothequestionnaire
(LeTellier).Inresponsetothequestionthatpromptedrespondentstonamethreetreatmentsthey
usefortheirpediatricpatientsinorderofpreference,thisphysicianstatedthefollowing
treatments:exercise,anincreaseinfluidandsaltintakes,andmedication(LeTellier).This
responsesuggeststhatthisphysicianpreferstoutilizenonpharmacologicalmethodsbefore
resortingtopharmacologicalmeansoftreatmentwhentreatinghis/heryoungPOTSpatients.
Ofthetreatmentstherespondentslistedasthethreetheymostprefertousetotreattheir
youngPOTSpatients,themostcommonresponseswereincreasesinfluidandsaltintakesand
FludrocortisoneorFlorinef(LeTellier).However,eventhoughthesewerethemostcommonly
statedtreatmentsbyallofthephysicianswhogaveresponsestothequestionnaire,theyarenot
necessarilythemosteffectiveoreventhemostcommonlyusedbyalldoctorsintheUnited
States.

15

DataAnalysis:Graphs

Figure1

16

Figure2

17

Figure3

18

Figure4

19

Figure5

20

Figure6

*NOTE:Somerespondentscombinedincreaseinsaltandfluidintakesintoonetreatment,while
othersseparatedthetwomethodsintotwoseparatetreatmentsintheirresponses.

**NOTE:Allgraphswerecreatedusingthefollowingresource:
Createagraph.(n.d.).RetrievedMay31,2016,fromNCESWebsite:
https://nces.ed.gov/nceskids/createagraph/default.aspx?ID=

21

DiscussionandConclusion
TheresultsofthemetaanalysisessentiallyshowedthatpediatricPOTScanbetreatedin
avastvarietyofdifferentwaysandthattheeffectivenessofthesemethodsinsuppressingthe
symptomsofPOTSvariesfrompatienttopatient.Thearticlesanalyzedprovideddetailedlistsof
themanydifferentpharmacologicalandnonpharmacologicaltreatmentmethodsthatareusedto
treatPOTS,rangingfromdrugssuchasBetaBlockers(POTS:Whathelps,2013)toincreasing
onesconsumptionofbothfluidsandsalts(LeGras,2013)tothepotentialbenefitsof
participationinexerciseprogramsdesignedbyphysicaltherapists(PTforPOTS,2014).
Again,basedontheinformationprovidedinthearticlesanalyzed,theeffectivenessofeachof
thesedifferenttreatmentmethodsvariesbasedonthenatureofachildsspecificcaseofPOTS.
Theresultsofthemetaanalysisconfirmtheresearchershypothesisregardingthediverse
treatmentstrategiesforPOTSandthatnoonetreatmentfitsall.Thisisconsistentwithexisting
POTSliteratureinpediatrics.Asstatedpreviously,overall,thereisverylittleliteraturein
existencethatspecificallydetailsthetreatmentmethodsusedtotreatpediatricPOTSaswellas
evaluatestheeffectivenessofthesetreatmentmethods.Thislackofviableresourcesmadeit
difficultfortheresearchertoconcludethemosteffectiveandevidencebasedapproachtocare
forpediatricPOTSpatients.Thus,thefindingsinthisstudyfurtheridentifythethegapinour
knowledgeoftreatingPOTSandsupportthecriticalneedforwelldesignedresearchstudiesin
thefuturetoaddressthisimportantneed.
Again,becausepediatricPOTSpatientsareallextremelydifferent,differenttreatments
andcombinationsoftreatmentsworkmoreeffectivelyfordifferentpatients.Sometimes,inorder
forayoungpatienttodeterminewhatcourseoftreatmentworksbestforhimorher,itis

22

advisablethatthepatientshouldvisitseveraldifferenttypesofdoctorsinordertolearnaboutthe
manydifferenttreatmentoptions,bothpharmacologicalandnonpharmacological,thatare
available,andultimatelydeterminewhatmethodsaremosteffectivefortheindividualandoffer
thegreatestdegreeofimprovementofsymptoms.
Basedonboththemetaanalysisandtheresultsofthequestionnaire,theresearcherwas
abletoconcludethatpediatriccasesofPOTSaretreatedmosteffectivelywhenaphysician
tailorsspecifictreatmentmethodstoapatientsspecificcaseofPOTS.Thisisaconclusionthat
hasbeenwellestablishedamongstthelittleresearchonthistopic,butisstillakeymessagein
thetreatmentmethodsofpediatricPOTS.Theresultsoftheresearchersquestionnaireshedlight
onaveryimportantpoint,whichhasnotbeenwelldescribedpreviously,thatis,thedifferences
andsimilaritiesinpracticestandardsamongdoctorsofdifferentspecialtiestreatingPOTS.
BecauseeachcaseofpediatricPosturalOrthostaticTachycardiaSyndrome(POTS)isso
different,thereisnotonetreatmentforPOTSthatismosteffectiveforallcasesofthesyndrome.
However,theresultsofthequestionnairedidsuggestthefollowingprinciples:themosteffective
waytotreatpediatriccasesofPOTSisthroughbothnonpharmacologicalandpharmacological
methods.Exercise,specificallycardiovascularexercise,canbeveryimportanttothetreatmentof
POTSinyoungpeople.Dietalteration,typicallybymeansofincreasingthepatientssaltand
fluidintakes,canalsobeacrucialcomponentoftreatmentforyoungpatients,andhaving
patientsobtainapsychologyreferralcanalsobeanintegralandextremelyhelpfulassettotheir
treatment.
BecausepediatricPOTSpatientsareallunique,adiversecombinationoftreatmentsis
necessarytobemosteffective.Therefore,itisnecessaryforayoungpatienttoconsultwith

23

severaldifferenttypesofdoctorstodeterminethebestcourseoftreatmentandtolearnaboutthe
manydifferenttreatmentoptions,bothpharmacologicalandnonpharmacological.Ultimately,
thiswillallowthepatienttoactivelyparticipateintheirowncareandchoosewhichmethodswill
workbesttoimprovetheirsymptomsandaddresstheirindividualneeds.

24

References
Boris,J.(2015,December22).[Telephoneinterviewbytheauthor].
Kizilbash,S.J.,Ahrens,S.P.,Bruce,B.K.,Chelimsky,G.,Driscoll,S.W.,HarbeckWeber,C.,
.
..Fischer,P.R.(2014).Adolescentfatigue,POTS,andrecovery:Aguideforclinicians
[.pdf].DepartmentofPediatricandAdolescentMedicine,MayoClinic.
LeGras,M.(2013).OverviewofPOTSsyndrome.RetrievedDecember13,2015,fromPediatric
CardiologyCenterofOregonwebsite:
http://www.pccoforegon.com/blog/overviewofpotssyndrome
LeTellier,L.(2016).[ResultsofpediatricPOTStreatmentmethodsquestionnaire].Rawdatain
preparation.
Levine,B.D.,Fu,Q.,VanGundy,T.B.,Galbreath,M.M.,Shibata,S.,Jain,M.,...Bhella,P.S.
(2010).Cardiacoriginsofposturalorthostatictachycardiasyndrome.Journalofthe
AmericanCollegeofCardiology,55(25),28582868.
MayoClinicStaff.(2016).Cognitivebehavioraltherapy.RetrievedMay31,2016,fromMayo
Clinicwebsite:
http://www.mayoclinic.org/testsprocedures/cognitivebehavioraltherapy/
home/ovc20186868

25

POTS:Whathelps.(2013).RetrievedFebruary22,2016,fromDysautonomiaInternational
Website:http://www.dinet.org/index.php/informationresources/potsplace/potswhathelps
PTforPOTS.(2014,July9).RetrievedApril7,2016,fromJohnsHopkinsChildren'sCenter
website:https://www.hopkinschildrens.org/ptforpots.aspx
Raj,S.R.(2013).Posturaltachycardiasyndrome(POTS).RetrievedDecember13,2015,from
AmericanHeartAssociationwebsite:
http://circ.ahajournals.org/content/127
/
23/2336.long
Serani,D.(2011,February22).Acceptanceandcommitmenttherapy.RetrievedMay31,2016,
fromPsychologyTodaywebsite:
https://www.psychologytoday.com/blog/twotakesdepression/201102/
acceptanceandcommitmenttherapy
Singer,W.,Sletten,D.M.,OpferGehrking,T.L.,Brands,C.K.,Fischer,P.R.,&Low,P.A.
(2012).Posturalorthostatictachycardiasyndromeinchildrenandadolescents:Whatis
abnormal?JournalofPediatrics,160(2),222226.Retrievedfrom
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3258321/
Tilttabletest.(2015,March24).RetrievedMarch13,2016,fromMayoClinicwebsite:
http://www.mayoclinic.org/testsprocedures/tilttabletest/basics/definition/prc20019879

26