Complementary and Integrative Medicine Treatment for POTS in Pediatrics: Testing, Diagnosis, and Treatment

POTS is an autonomic nervous system condition affecting millions of Americans each year. Since COVID-19, this condition has been on the rise. While many symptoms are associated with POTS, tachycardia and low blood pressure upon standing are two hallmark traits that cause discomfort. While there is limited research on this condition in adolescents, many people report that their symptoms started in their teenage years. Investigating and addressing the causation of this condition early on in life can help children live productive and vital lives.
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What is POTS Syndrome?

Postural Orthostatic Tachycardia Syndrome (POTS) is a blood circulation disorder in which the body's autonomic nervous system malfunctions when moving from one position to another. POTS symptoms occur when a person goes from lying down to standing up. The most commonly reported complaints are dizziness, lightheadedness, and rapid heart rate. In POTS, there is a miscommunication between your nervous and circulatory systems. In a typical scenario, when your child stands up, gravity pulls blood down to the legs, and the blood vessels in the legs constrict so blood can pump back to the brain, heart, and other vital organs. In this syndrome, the constriction part is not operating correctly, which causes an increase in blood pooling in the lower extremities and a decrease in blood flow to other vital organs. The body will then compensate by increasing the heart rate to pump blood faster throughout the body.

This condition appears to affect females more than males, is more frequent in those with a family history of POTS, and usually occurs between 12 to 15 years old.

What Causes POTS in Pediatrics?

The exact cause of POTS in children is unknown and appears to vary from person to person. There are some possible causes that neurologists and the medical community investigate when a POTS case is present. Here are some of the commonly associated causes:

Hypovolemia

If your child has low blood volume (hypovolemia), that may be the culprit of their symptoms of POTS. By having a decrease in blood, the body is working hard to pump it around the body. A study on the topic found that patients with POTS had a deficiency of plasma by about 13%. Additional research found that total red blood cell volume was 22.7% deficient compared to control groups.

The cause of low blood volume is the main topic of interest when it comes to this. What is coming to the forefront are issues within the renin-angiotensin-aldosterone system (RAAS), which is predominantly carried out by the kidneys. Typically, in the presence of low blood volume, this system would increase plasma renin, increasing angiotensin II and aldosterone levels. This process helps retain sodium in the kidneys, which compensates to restore extracellular fluid. In cases of POTS, this process has been coined the "renin-aldosterone paradox" because this process is not occurring (when it should), and therefore plasma volume stays low.

More recent literature indicates that the main issue with the RAAS is elevated angiotensin II (Ang II), negatively impacting blood vessel capacity, causing inflammation, and acting as a misfired neurotransmitter to the brain. Further evidence is finding issues with receptors that typically respond to Ang II but are not, as well as a defect in angiotensin-converting enzyme 2 (ACE-2), which is responsible for breaking down Ang II. This area of POTS understanding is complex and intricate, which is part of the reason that managing cases of POTS can be difficult.

Stress

One subcategory of this condition is called hyperadrenergic POTS. About 10% of those affected by POTS have a root cause issue stemming from sympathetic nervous system activation (our fight or flight/stress response). This causes an increase in adrenaline (norepinephrine) which raises blood pressure upon standing. The uptick of norepinephrine is multifactorial but is thought to be activated by infection, trauma, or surgery.

Infection, Trauma, Surgery, or Puberty

Changes in the body can trigger episodes of POTS. Many clinical encounters of POTS occur after a viral infection, concussions, surgical procedures, or growth spurts like puberty. It more commonly occurs in a child with a family history of POTS. Two associated illnesses that POTS can appear after are mononucleosis and influenza. About two-thirds of adolescents who end up with POTS are females. Patterns suggest a hormonal correlation, but scientists have identified no specific links. All considered, the autonomic dysregulation that drives this condition seems to be triggered by significant changes or invaders to the body.

Small Fiber Sensory Neuropathy

This condition affects the small nerves that control small blood vessels. Small fiber sensory neuropathy (SFSN) is a sensory disturbance that, in the case of POTS, disturbs the nerves that supply blood to the feet and legs. One study looked at skin biopsies of patients with POTS. Evidence revealed that the neuropathic POTS population could have mild small fiber neuropathy, which can be associated with decreased myocardial sympathetic innervation.

Autoimmunity

In 2021, the most extensive study on POTS patients was published, and concluded that most patients in this study had autoantibodies present. This has provided insight into the theory that POTS may be an autoimmune-driven condition. The antibodies that came up in the study were G-protein-coupled adrenergic A1 receptor antibodies (in 89% of the patients) and muscarinic acetylcholine M4 receptor autoantibodies (in 53% of the patients). While these antibody types are very specific, it would be beneficial to do a general antibody screening and then explore this path if indicated.

How is POTS Diagnosed in Pediatrics?

When children develop symptoms of POTS, parents urgently want to figure out what is happening. This syndrome is evaluated based on medical history and physical exam. The child's doctor will make a clinical diagnosis based on their findings, along with positive results of an Active Stand Test. During this observation, your child will lie on their back and have their heart rate and blood pressure measured. They'll then move to a sitting position and then to a standing position, where their vitals will again be recorded. At standing, the doctor will take multiple readings- at 2 mins, 5 mins, and 10 mins.

Adolescents younger than 19 will test positive for POTS if their heart rate exceeds 40 beats per minute above their resting heart rate at the 10-minute interval. A more controlled way to perform this test is by doing the Tilt Table Test, which does the abovementioned recordings with the patient lying on an exam table that mechanically inclines to a standing position. The patient is secured to the table in this option, which provides a safe space in case they faint during the test. An electrocardiogram (ECG) may be done to rule out any other heart abnormalities.

POTS Symptoms in Pediatrics

Various symptoms are present, impacting many organ systems, especially the heart and blood vessels, and include the following:

• Chest discomfort
• Palpitations
• Lightheadedness or dizziness
• Fainting
• Fatigue
• Exercise intolerance
• Bloating, nausea, or vomiting
• Diarrhea or constipation
• Insomnia
• Cold extremities with color changes on the feet
• Heavy, painful, or prolonged periods
• Headaches, particularly migraines
• Blurred vision
• Muscle or joint pain
• Anxiety
• Depression
• Brain fog

Functional Medicine Labs to Test to Help Personalize Treatment for Pediatrics Suffering from POTS Syndrome

Evaluating the possible root causes of POTS through functional medicine testing can be valuable. Using clinical observation and assessment, your integrative medicine doctor may choose one or many of these tests to run.

Complete Blood Count (CBC)

Obtaining a complete blood count (with differentials) test will help assess blood volume and screen for any acute infections. This test is not specific for viral or bacterial infections, but it can tell you if your child's white blood cells are out of range.  

Comprehensive Metabolic Panel

The renin-aldosterone paradox is an issue that occurs within the kidneys. Screening for kidney function by doing a CMP is ideal. Getting a CMP will reveal blood sugar levels, kidney function, and liver status, which are all important when evaluating areas of dysfunction.

Thyroid Panel

An increased heart rate can sometimes indicate an overactive thyroid gland. Obtaining a full Thyroid Panel from Access Med Labs would rule out the thyroid and its biomarkers as the cause of your child's symptoms. This lab panel also includes thyroid antibodies, which is important to include since autoimmunity can be a major contributor to POTS cases.

ANA with Reflex

An Antinuclear Antibody Test is a screening for autoimmunity. If the test screens are positive, the lab will then reflex it, meaning they will then test for specific types of antibodies. This is one efficient way to determine if autoimmunity is playing a role in the POTS picture.

Epstein-Barr Virus (EBV) Panel

One infection linked to POTS is mononucleosis, which is caused by exposure to EBV (Epstein-Barr Virus). This panel tests all the variations EBV can appear, including acute, chronic dormant, and chronic reactivated. Doing this EBV Test will tell you whether EBV could have been the virus to set off your child's POTS or whether reactivation of a previous infection with EBV is causing the present symptoms.

Norepinephrine

The HP Profile test by Sanesco and NeuroLab will test factors of nervous system function. This is a helpful profile as it will look at neurotransmitters such as norepinephrine and epinephrine, which are relevant in cases of hyperadrenergic POTS.

Additional Labs to Check  

Testing avenues could vary depending on the clinical direction your child's doctor deems relevant. Aside from what is mentioned, more thorough heart testing through an echocardiogram or a 24-Hour Holter Monitor may be necessary. If small fiber sensory neuropathy is in consideration, your child would need to be referred for a skin biopsy.

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Conventional Treatment for POTS Syndrome in Pediatrics

Treatment for POTS starts very conservatively and then progresses to medications if symptoms do not improve. The main goal is to increase blood volume in the vasculature by increasing fluid and salt intake. Additional lifestyle recommendations include sleeping propped up, using compression stockings, a cooling vest to decrease heat intolerance, and an achievable and appropriate workout.

These changes are not enough in many situations, so medications are implemented. Most medications treat the symptoms and target particular areas of the POTS. For example, blood pressure medications like midodrine, heart rate-lowering drugs like metoprolol and propranolol, and corticosteroids like fludrocortisone may be used.

Complementary and Integrative Medicine Treatment for POTS Syndrome in Pediatrics

POTS has an array of symptoms and a variety of possible causes. Understanding the cause will help guide treatment. In lieu of knowing the exact cause, some great complementary and integrative medicine options can support circulation, the nervous system, and stress responses.

Nutrition for POTS

Implementing a nutrition strategy can help reduce some symptoms of POTS. As mentioned above, you'll want to ensure your child increases fluid and sodium intake. Getting sodium from reputable electrolyte sources would be a great way to add sodium to their diet.  

Resources vary regarding recommended dosing, but kids with POTS should generally consume 80-120 ounces of water daily, plus 8 to 10 g of salt per day. Additional recommendations are to limit processed foods and sugary items. Incorporating a variety of fruits, vegetables, lean protein, and whole grains is ideal. Redirecting your child to healthy snack options like nut butter and homemade treats is the best way to keep them on track.

Supplements and Herbs for POTS

Addressing POTS from a natural medicine perspective can be challenging due to the lack of research in this area. The main goal of adding these complimentary options is to relieve symptoms while the root cause is being investigated.

Rhodiola Rosea

Botanicals used for POTS are based on symptom management. In kids who are experiencing stress, anxiety, or depression, Rhodiola may be a good option. This botanical plant has been used for centuries to treat mental health conditions like depression. When used for depression, the standard dosing is 340 mg per day for 12 weeks for adults. When dosing botanicals for kids, it is best to work with a practitioner trained in botanical medicine administration or apply Clark's Rule, which is based on weight. The calculation is to take your child's weight in pounds and divide it by 150 to get the appropriate fraction your child should take. For example, if your child weighs 50 lbs, you would do 50 divided by 150, which equals .33. This indicates that your child should take .33 of the adult dose. In this case, it would be 112.2 mg per day of Rhodiola.

Schisandra

This berry plant can be supportive of many symptoms of POTS. It's an adaptogenic herb, which means it helps the body adapt to life stressors and changes. Mechanistically it supports cardiovascular function, improves physical stamina, and can improve mental health and insomnia. The standard dose for Schisandra is 1.5 to 6g/day for adults. Depending on the product you are using, you'll want to apply Clark's Rule for appropriate dosing for your child.

Oral Rehydration

Administering a reduced-osmolarity oral rehydration salt formulation (ORS) has shown promising results in pediatric cases. One study looked at using ORS in conjunction with the medication propranolol. These results from the research showed that the treatment group had both a decrease in fainting episodes and a decrease in orthostatic intolerance symptoms. This information gives hope for the complimentary use of oral rehydration with a low-dose medication.

Exercise for Managing POTS

Movement is an effective way to minimize the symptoms associated with POTS. Exercise can increase blood volume by increasing circulation and minimizing pooling in the legs. Even if it's for a short stent, the muscle contraction from moving the lower extremities will help pump blood back to the heart. There are specific exercise programs that can help children with POTS gain back exercise. Most of them are geared at starting in horizontally positioned exercises like swimming or recumbent bikes, then working their way up to standing-positioned exercises. Often, people with POTS want to lie down and not get up. However, the lack of movement could worsen the condition.

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Summary

The rising number of POTS cases in our adolescents raises a red flag for the need for integrative and holistic approaches. This condition affects many areas of a person's well-being and appears to have multiple avenues of causing dysfunction. As research continues to evolve, this may open the door for more precise complementary and integrative medicine modalities to employ. At this time, investigating all potential causes and imbalances in your child's life may be the best route for symptom relief and restoration of health.