A Dose of Dr. Gwenn

It is difficult when experts seem to disagree on how to manage a child health problem. Early May, 2008,the American Heart Associationn(AHA) came out with a statement advising EKGs in kids about to start stimulant medication for ADHD. While this recommendation was the result of careful and thoughtful analysis of the data at hand, it was counter to current recommendations by the American Academy of Pediatrics (AAP) and American Association of Child and Adolescent Psychiatry. To help clear the waters, all the groups have come together again and made recommendations that make more sense. In fact, shortly after the initial May 6, 2008 AHA statement, a new statement was released by the AHA and AAP that was softer and more consistent with past recommendations to not screen all kids.

There are many issues to consider and it is a bit confusing:

1. There are no studies that actually support the original recommendations by the AHA.

2. The AAP has always advocated a thoughtful approach to heart screening that takes into account family history, review of the patient’s symptoms and physical exam.

3. Widespread screening is costly to all of us in the end and will yield few positive results. It is truly searching for a needle in a haystack.

4. Screening of any kind does place unnecessary anxiety on the majority of families who do not need to go through the procedure with their child and waiting game for the results.

So, how does the this particular screening work? Simple. If a patient has known heart disease, this discussion is moot. Those patients need to get annual screening and their cardiologists will help guide the right tests and the schedule for those tests. The cardiologists will often work with the pediatricians to help arrange these tests in the community near home.

For kids who have no known heart disease, which are the majority of kids being considered for ADHD medication or are already on ADHD medication, a good evaluation of family history, the patient’s history and physical exam are all that is needed. If during any of those evaluations suspicion is raised for heart disease, the option for screening becomes more important and will be discussed based on what information turns up. This isn't a one test fits all. It is a test if needed sort of thing.

So, whenever you are faced with a situation of “to screen or not to screen" with any test, the answer always lies somewhere with the patient and the family. Tests don’t help unless there is a reason for them to help.

If you want to fall back on an “official” statement for the question of "should kids on ADHD medications get EKGs?", fall back on this one:

“Medications that treat ADHD have not been shown to cause heart conditions nor have they been demonstrated to cause sudden cardiac death.”

When you learn of frightening headlines about medications and children, such as this one run recently on FoxNews.com, your initial reaction may be to panic and not give that medication to your child. Keep in mind that the press loves to sensationalize headlines and will over dramaticize a situation to draw you into their website with such stories. Such was the case recently with a very rare and serious drug reaction due to ibuprofen that left a little girl blind.

Ibuprofen, a common pain killer and fever buster, is a common medication for children in many medicine cabinets these days. And, it is safe when used at the proper doses. The problem with any medication, however, is that even at proper doses, there is always the chance of an allergic reaction in any of us – or our children. These reactions range from mild to serious and are due to an over reaction of a person’s immune system from that medication. Prior exposure to a medication is usually needed.

While this child has the most severe of drug reactions a person can have, fortunately most drug reactions are much less severe – typically a rash of some sort.

These reactions are not due to medication error from a physician or negligence on the part of a drug company but bad luck. I’ve had the misfortune of two drug allergic reactions myself and there was no warning and I have diagnosed a range of allergic reactions in children from medications. In all these cases, the one element the reactions shared was the element of surprise.

So, what should you do? Be on the look out for any symptom you don’t expect when any family member is on a medication – whether that medication be over the counter or prescribed. And, call your doctor’s office for advice at the first sign of trouble.

A quick word on Stevens-Johnson Syndrome, the type of reaction the child on the FoxNews.com story had. While often due to a medication, it can also occur from an illness such as a virus. Nonsteroidal antiinflamatory medications are known to be on the list as potential culprits, according to the MayoClinic. It is a type of drug reaction that involves a rash with target-like characteristics and some of the deeper mucous membranes such as the inner lining of the mouth and esophagus and the conjunctivae of the eyes. There’s usually flu-like symptoms such as fever, too. Needless to say, these patients are sick and require very intensive and supportive care to help their body curtain this reaction. This is very rare and occurs in 1 per 7 million cases of drug reactions a year when the target lesions develop.

I want to call your attention to this line on the MayoClinic info page:

“It's difficult to prevent an initial attack of Stevens-Johnson syndrome because you don't know what will trigger it.”

So, what does this mean for medication use in our children? Is ibuprofen safe? First, ibuprofen is safe – go ahead and use it. But, we all have to have a healthy respect for medication - and that is what this story means. We have to learn to use over the counter medications in the right dose and for the right situation so the benefit is worth any potential risk of a reaction. Any time any of us take a medication there is a risk. So, let’s make sure the risk is worth it before we put it into our bodies or our children's mouths.