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Guideline source: American Academy of Pediatrics

Literature search described? No

Evidence rating system used? Yes

Published source:Pediatrics, August 2008

A recent guideline from the American Heart Association (AHA) recommended routine electrocardiography (ECG) in children before they begin pharmacotherapy for attention-deficit/hyperactivity disorder (ADHD). That recommendation contradicts evidence-based recommendations from the American Academy of Child and Adolescent Psychiatry and the American Academy of Pediatrics (AAP). These organizations concluded that sudden cardiac death in persons taking medications for ADHD is rare, with rates no higher than those in the general population of children and adolescents.

There is no evidence that routine ECG screening before beginning medical therapy for ADHD prevents sudden death. Furthermore, limiting children's access to effective ADHD treatment could have serious implications (e.g., substance abuse, academic problems).

No association has been established between sudden cardiac death and medicines used to treat ADHD. Of the 2.5 million children and adolescents who took stimulants for ADHD over five years, 19 died suddenly, resulting in a base rate of fewer than two incidents per year per 1 million children. Reported rates of sudden cardiac death in the general child and adolescent population are substantially higher.

The AAP recommends that physicians carefully assess children being considered for ADHD therapy by using a targeted cardiac history (e.g., patient history of cardiac disease, palpitations, syncope, or seizures; family history of sudden death in children or adolescents; hypertrophic cardiomyopathy; long QT syndrome) and a physical examination, including a cardiac examination.

The AAP encourages physicians to continue to follow current recommendations for ADHD treatment, including the use of stimulants, without obtaining routine ECG before beginning therapy.

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Michael J. Arnold, MD, Assistant Medical Editor.

A collection of Practice Guidelines published in AFP is available at

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