The nation's largest pediatricians' group says most children getting attention-deficit drugs don't need heart screening with electrocardiogram tests, challenging advice from a leading heart doctors' association.
The new policy from the American Academy of Pediatrics renews a debate over the safety of the powerful stimulants. More than half of the 4 million U.S. children diagnosed with attention-deficit disorders are being treated with stimulant drugs.
As Seattle heart specialist Peter Hesslein put it, the dispute among influential doctors "is more than a tempest in a teapot."
ADHD drugs like Ritalin, Adderall and Concerta can help children focus more, behave less impulsively and perform better in school. But they also can increase blood pressure and heart rate and carry warnings about risks for sudden deaths in patients with heart problems.
The pediatricians' group says advice earlier this year from the American Heart Association recommending EKGs was overzealous because these rare deaths are more common in the general population than among children on stimulants.
According to the academy, sudden heart-related deaths occur in about four out of 2.5 million U.S. children on stimulants each year, versus between 8 and 62 such deaths yearly among all U.S. children.
The heart doctors' advice subjects healthy children to unnecessary and costly heart work-ups, and it could limit access to effective ADHD treatments, which "could have serious implications," according to the pediatricians' policy.
The academy says children starting stimulants should get a careful physical exam and be checked for family history of heart problems including sudden death, but that routine EKGs aren't needed in most cases.
Confusion over announcement
When the heart association's policy was announced in April, its advice was widely construed as a mandate.
"We immediately in the cardiology world started getting all these phone calls from people saying, 'I've got to have this test, my kid's got to have this medicine,'" said Dr. Mary Mehta, a heart specialist in Pensacola, Fla.
Because of the confusion and criticism, the heart association clarified its stance in May, issuing a little-publicized statement that said physicians should use their own judgment about the screening and that ADHD treatment should not be withheld if an EKG isn't done.
The pediatricians' academy joined in that statement, but decided that a more forceful stance against routine EKGs made more sense. With little fanfare, their new policy was posted online later that month; it's now being published in the August edition of the academy's medical journal, Pediatrics.
"We really were hearing from our members and parents that things were not at all clear," said policy co-author Dr. James Perrin, a Massachusetts General Hospital pediatrician.
He said the academy's policy makes clear that there's no scientific evidence to support "this fairly dramatic practice change."
The heart association's initial statement noted that evidence presented to the Food and Drug Administration showed that between 1998 and 2003, 19 sudden deaths occurred in children taking ADHD medicine. It also noted that from 1,000 to 7,000 U.S. children and teens die of sudden cardiac death each year, often from conditions that EKGs can detect.
Dr. Tim Gardner, the heart association's president, said his group's stance is based partly on the fact that children with heart abnormalities have a higher incidence of ADHD. He downplayed his group's differences with the pediatrics academy, saying both groups emphasize the importance of careful medical evaluations for children starting ADHD drugs.
Concern over long-term risks
Cleveland Clinic heart specialist Dr. Steven Nissen, a drug safety watchdog, said the academy appears to be dismissing concerns that stimulants are used excessively in children with insufficient evidence about long-term risks.
He said the group's pro-drug stance is troubling, coming only a few weeks after it advocated cholesterol drug treatment for children as young as 8 years old.
Peter Hesslein, a heart specialist at Seattle's Swedish Medical Center, said EKGs are inexpensive — less than $100 per test — and easy to do, but that false-positive results are common, often leading to more expensive testing to rule out problems.
Still, Hesslein said other countries have had success with mass EKG screening in certain groups of children, including Italy, where he said sudden heart death rates in young athletes have decreased.
For that reason, he said he thinks routine EKGs for all children "would be worthwhile."