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On April 21st, the American Heart Association (AHA) shocked families and professionals alike when it recommended that all kids that take or may take Ritalin should have an electrocardiogram (ECG). Stimulant drugs like Ritalin, Concerta and Adderall have been used in children for ADHD for 70 years. Why this recommendation now -- and should you get one for your child if he/she takes one of these drugs?
I read and reread the article in Circulation (the official journal of the AHA) four times trying to make sense of the main points and recommendations. I’ve spoken to two high up academic child psychiatrists. I am awaiting a call back from my contact pediatric cardiologist. We’ve consulted before on a boy with severe ADHD whom I’ve treated with Concerta who also has had surgical repair of his heart that was missing his left ventricle when he was born.
The AHA evaluation and recommendations were prompted by reports two years ago of the sudden deaths of 18 children while taking a prescription stimulant drug over a five year period (1999 to 2004). Only seven of these children were found not to have structural heart problems. Their deaths were felt to be caused by severe irregular heart beats associated with their basic cardiac condition and exacerbated by taking the medication.
For six months the Canadian equivalent of the FDA banned Adderall (felt to be the drug of most concern) for children in Canada. However, after considering all the numbers (how many children take the drug) and the relative risk, the ban was rescinded. Now come the AHA recommendations that include obtaining an ECG for any child (even those without any cardiac symptoms or family history) being considered for a prescription stimulant. The AHA recommends that all children currently on stimulants also get an ECG. Also if the first ECG was obtained before the age of twelve a second ECG should be performed when the child is a teenager.
I commented on this problem of sudden death two years ago. Most of you aware of my writing and stance know that I’ve been prescribing stimulant medication to children for thirty years even as I feel we over prescribe and don’t sufficiently pursue effective non-drug interventions for problems of children’s behavior and performance (at school). I’ve never felt that stimulants were dangerous and I believe they are effective in the short term. My calls for caution were based more for ethical than medical reasons.
Two years ago I tried to figure the risk for a child without heart disease of dying suddenly while taking a stimulant. I used seven as the numerator – the number of kids who died without heart disease present -- and four million as the denominator for my estimate of the number of kids under the age of eighteen taking stimulant drugs in America in 2006. I came up with a number with five zeroes after the decimal point (.00000175) or 0.000175 per cent, approximately two ten thousandths of a per cent chance of dying suddenly if the child is taking a stimulant drug. This represents what I call an “existential” level of risk.
I am not certain of my numbers but suggested the likelihood of getting killed on the local freeway on a Saturday night by a drunk driver was probably higher – and still we take freeways because it gets us from one place to another faster. I’m not sure what the accident rate on surface roads are but it’s all meaningless in terms of real risk – much like debating how many angels dance on the head of a pin.
Even taking eighteen as the numerator and lowering the denominator to 2.5 million (the CDC estimate of the number of children taking stimulants) one gets about four times the risk – now seven ten thousandths per cent – but still infinitesimal. So why did the AHA make their recommendation?
I could answer cynically as say this was a real CYA move so that the AHA and pediatric cardiologists could tell child psychiatrists, pediatricians and family physicians, “See we gave you our warning,” should the public mood ever change over the propriety of the widespread use of stimulant drugs in children. But the AHA recommendation brings up an ethical dilemma for parents (and doctors) who want to feel that they took every possible precaution in the unlikely event (and we’re talking on the level of lightning strikes or lotto winners) of a catastrophe.
The AHA acknowledges that an abnormal ECG alone does not represent a complete contraindication towards using a stimulant drug for a child. Rather AHA experts suggest the family and pediatric cardiologist discuss the relative risks. I suppose in a truly borderline decision it might psychologically (because scientifically, the risk is so so low) have a family lean towards not using the medication for the child. As someone who feels the medication is generally over prescribed, I suppose I should be pleased with this result but I’m not, if the basis is a hysteria over existential risk.
I am planning to let parents decide for themselves. I will give them my opinion that I am willing to assume the theoretical added risk in not knowing whether or not a child has asymptomatic cardiac disease. However, if the family wants to obtain an ECG for their child I will support it. I suspect some of the more anxious parents will opt to get the ECG for their kid. Has anyone in this imbroglio figured in the slightly higher rates of suicidality when one prescribes an SSRI to an anxious child? Confronting hypocrisy and propaganda has routinely been my motive for speaking out and writing. Overreaction and hysteria even in well thought out scenarios require my challenging the “authorities” again.
