Arrhythmia in Children: Symptoms, Causes & Treatment

What Is Arrhythmia in Children?

Arrhythmia in children is a condition where the heart beats at an abnormal rate or rhythm. The heart may beat too fast (tachycardia, over 100 bpm in older children), too slow (bradycardia, under 60 bpm), or with an irregular pattern. While often harmless, some arrhythmias require medical attention and treatment.

The heart's rhythm is controlled by electrical signals that coordinate the contractions of the heart muscle. In a normally functioning heart, these electrical impulses originate in the sinoatrial (SA) node, often called the heart's natural pacemaker, located in the upper right chamber (right atrium). The signal then travels through the heart in a precise pathway, causing the chambers to contract in a coordinated fashion that efficiently pumps blood throughout the body.

When something disrupts this electrical system, an arrhythmia occurs. In children, the heart's conduction system may have extra pathways, abnormal tissue, or other variations that can cause the electrical signals to travel incorrectly. This can result in the heart beating too fast, too slow, or in an irregular pattern. The severity of an arrhythmia depends on its type, how long it lasts, and how it affects the heart's ability to pump blood effectively.

It's important for parents to understand that children's hearts naturally beat faster than adults' hearts, and the normal heart rate varies significantly by age. Newborns may have resting heart rates of 100-160 beats per minute, while teenagers typically have rates of 60-100 beats per minute. Additionally, it's completely normal for a child's heart rate to increase during physical activity, excitement, fever, or anxiety, and to slow down during sleep.

Types of Arrhythmias in Children

There are several types of arrhythmias that can affect children, each with different characteristics and implications. Understanding these types helps parents and caregivers recognize symptoms and seek appropriate care when needed.

Supraventricular tachycardia (SVT) is the most common sustained arrhythmia in children, affecting approximately 1 in 250 children. In SVT, abnormal electrical signals cause the heart to beat very rapidly, often 180-300 beats per minute. Episodes may come on suddenly and can last from seconds to hours. While frightening, SVT is rarely life-threatening and can often be managed effectively.

Wolff-Parkinson-White (WPW) syndrome is a specific type of SVT caused by an extra electrical pathway between the upper and lower chambers of the heart. This accessory pathway allows electrical signals to bypass the normal route, leading to rapid heart rates. WPW affects about 1-3 per 1,000 people and is one of the most common causes of SVT in children.

Premature beats are extra heartbeats that occur earlier than expected. Premature atrial contractions (PACs) originate in the upper chambers, while premature ventricular contractions (PVCs) start in the lower chambers. These are extremely common in children and are almost always harmless, often requiring no treatment.

What Are the Symptoms of Arrhythmia in Children?

Symptoms of arrhythmia in children include a racing or pounding heart (palpitations), dizziness or lightheadedness, fainting or near-fainting, chest discomfort, difficulty breathing, unusual fatigue, and in infants, poor feeding or irritability. Many children with arrhythmias have no symptoms at all.

The symptoms a child experiences depend largely on the type of arrhythmia, how fast or slow the heart is beating, how long the abnormal rhythm lasts, and whether it affects the heart's ability to pump blood effectively. Some children may be completely unaware of their arrhythmia, while others experience significant symptoms that affect their daily activities.

Older children who can describe their symptoms often report feeling their heart "racing," "pounding," "fluttering," or "skipping beats." These sensations, known as palpitations, are one of the most common complaints. Children may also experience a general feeling of unease or anxiety during an episode, which can be distressing for both the child and parents.

Infants and young children cannot describe their symptoms, making detection more challenging. Parents should watch for signs such as poor feeding, excessive sleepiness or lethargy, irritability, rapid breathing, pale or grayish skin color, or sweating during feeding. These nonspecific symptoms can indicate that the heart is not pumping blood efficiently due to an arrhythmia.

Recognizing Symptoms by Age

The way arrhythmia presents varies significantly with age, requiring parents to be aware of age-appropriate warning signs. In newborns and infants, symptoms are often subtle and may be mistaken for other conditions. Parents might notice that their baby seems unusually tired, feeds poorly, or has episodes of rapid breathing or skin color changes.

Toddlers and preschool-aged children may clutch their chest, become suddenly quiet or withdrawn, or complain of "something funny" happening in their chest. They may stop playing abruptly and want to sit down. Some children describe the sensation as their heart "running" or feeling like they have "butterflies" in their chest.

School-aged children and teenagers can usually describe their symptoms more precisely. They may report that their heart is beating very fast or irregularly, that they feel dizzy or lightheaded, or that they have difficulty catching their breath. Some children notice that episodes occur during specific activities like exercise, while others experience symptoms at rest or during emotional stress.

What Causes Arrhythmia in Children?

Arrhythmia in children can be caused by congenital heart defects, genetic conditions affecting the heart's electrical system (like WPW or Long QT syndrome), electrolyte imbalances, infections, fever, medications, caffeine, or can occur without any identifiable cause. Many childhood arrhythmias have a structural or hereditary basis.

Understanding the underlying cause of a child's arrhythmia is important for determining the most appropriate treatment approach. In many cases, particularly with benign arrhythmias like occasional premature beats, no specific cause is identified, and the arrhythmia is considered a normal variant that requires no intervention.

Congenital heart defects are one of the most significant causes of arrhythmias in children. Structural abnormalities in the heart can disrupt the normal electrical pathways, leading to various rhythm disturbances. Children who have undergone heart surgery for congenital defects may develop arrhythmias due to scar tissue that interferes with electrical conduction. Approximately 10-30% of children with congenital heart disease experience some form of arrhythmia.

Genetic and inherited conditions play a substantial role in childhood arrhythmias. Conditions like Wolff-Parkinson-White syndrome, Long QT syndrome, Brugada syndrome, and catecholaminergic polymorphic ventricular tachycardia (CPVT) are inherited disorders that affect the heart's electrical system. These conditions can run in families, which is why family history is an important part of evaluating a child with arrhythmia.

Triggers and Contributing Factors

Even in children with an underlying predisposition to arrhythmia, certain factors can trigger or worsen episodes. Identifying and managing these triggers can help reduce the frequency and severity of arrhythmic episodes.

Caffeine and other stimulants are common triggers for arrhythmias in children and teenagers. Energy drinks, coffee, certain sodas, and some medications contain caffeine that can increase heart rate and trigger abnormal rhythms in susceptible individuals. Parents should be aware of their child's caffeine consumption, particularly if the child has a known arrhythmia.

Fever and illness can temporarily increase the heart rate and trigger arrhythmias. During infections, the body's inflammatory response and changes in electrolyte balance can affect the heart's electrical system. Children with known arrhythmias may experience more frequent episodes when they are sick.

Dehydration and electrolyte imbalances can significantly impact heart rhythm. Minerals like potassium, magnesium, and calcium are essential for proper electrical conduction in the heart. Conditions that cause vomiting, diarrhea, excessive sweating, or inadequate fluid intake can lead to electrolyte disturbances that trigger arrhythmias.

How Is Arrhythmia Diagnosed in Children?

Arrhythmia in children is diagnosed through electrocardiogram (ECG/EKG) recordings, Holter monitors (24-48 hour continuous ECG), event monitors worn for weeks, echocardiograms to assess heart structure, exercise stress tests, and sometimes electrophysiology studies. The diagnostic approach depends on symptom frequency and severity.

Diagnosing arrhythmias in children often requires a systematic approach because episodes may occur infrequently and unpredictably. The goal is to capture an ECG recording during an episode to identify the specific type of arrhythmia. Healthcare providers use various monitoring techniques depending on how often symptoms occur.

The initial evaluation typically begins with a thorough medical history and physical examination. The doctor will ask about the child's symptoms, including when they occur, how long they last, what triggers them, and any associated symptoms like dizziness or fainting. Family history of heart conditions, sudden death, or arrhythmias is particularly important, as many arrhythmias have a genetic component.

A standard 12-lead electrocardiogram (ECG or EKG) is usually the first test performed. This non-invasive test records the heart's electrical activity for a brief period and can detect many types of arrhythmias. However, if the arrhythmia is intermittent, the ECG may appear normal between episodes. Even so, some conditions like WPW syndrome can show characteristic patterns on a routine ECG.

Extended Monitoring Options

When arrhythmias occur infrequently, extended monitoring is necessary to capture an episode. A Holter monitor is a portable device worn for 24-72 hours that continuously records the heart rhythm. This is useful for children who have symptoms at least once daily. The child keeps a diary of activities and symptoms during the monitoring period to correlate any arrhythmias with specific events.

For less frequent symptoms, event monitors or loop recorders may be used. These devices are worn for several weeks and can be activated by the patient when symptoms occur, or they can automatically detect and record abnormal rhythms. Some newer devices can transmit recordings directly to the healthcare provider's office.

Implantable loop recorders are small devices surgically placed under the skin that can monitor heart rhythm for up to three years. These are reserved for children with rare but significant symptoms, particularly unexplained fainting, where capturing the heart rhythm during an episode is crucial for diagnosis and treatment planning.

When Should You Seek Emergency Care?

Seek emergency care immediately if your child faints, has difficulty breathing, experiences chest pain, has bluish lips or skin, becomes extremely weak, or has a rapid heartbeat that won't slow down after 15-20 minutes. Call your local emergency number for any of these symptoms.

While most arrhythmias in children are not dangerous, certain symptoms require immediate medical attention. Parents should know when to seek emergency care versus when to schedule a routine appointment with their child's doctor.

Syncope (fainting) during physical activity is a particularly concerning symptom that warrants immediate evaluation. Fainting during exercise can indicate a serious underlying arrhythmia that could be life-threatening. Similarly, fainting accompanied by seizure-like activity, injury from falling, or occurring without warning should prompt an emergency evaluation.

Sustained rapid heartbeat that doesn't respond to vagal maneuvers and lasts more than 15-20 minutes needs medical attention. While SVT episodes can often be stopped at home, prolonged episodes may require medication to restore normal rhythm. If your child appears distressed, pale, sweaty, or complains of chest pain during an episode, seek care promptly.

How Is Arrhythmia Treated in Children?

Treatment for arrhythmia in children ranges from observation only for benign arrhythmias, to vagal maneuvers for stopping SVT episodes, medications like beta-blockers for prevention, and catheter ablation for definitive cure. Treatment choice depends on the arrhythmia type, severity, and impact on the child's quality of life.

The approach to treating arrhythmias in children is highly individualized, taking into account the specific type of arrhythmia, how frequently it occurs, how well it's tolerated, and whether it poses any long-term risks. For many children, particularly those with occasional premature beats or brief, well-tolerated episodes of SVT, no treatment may be necessary beyond reassurance and monitoring.

The treatment philosophy in pediatric cardiology generally follows a stepwise approach, starting with the least invasive options and progressing to more definitive treatments only when necessary. This approach recognizes that many childhood arrhythmias improve over time and that all treatments carry some risks that must be weighed against the benefits.

For children whose arrhythmias significantly affect their quality of life or pose health risks, several effective treatment options are available. Modern treatments have become increasingly safe and effective, allowing most children with arrhythmias to live normal, active lives.

Vagal Maneuvers

For children with SVT, vagal maneuvers are often the first-line intervention during an episode. These techniques stimulate the vagus nerve, which can slow the heart rate and potentially stop the abnormal rhythm. Parents of children with SVT are typically taught these techniques to use at home when episodes occur.

The diving reflex, triggered by applying cold water or ice to the face, is one of the most effective vagal maneuvers in children. For older children, a modified Valsalva maneuver (bearing down as if having a bowel movement or blowing through a straw against resistance) can be effective. These techniques are safe and can be repeated if the first attempt is unsuccessful.

Medication Options

When vagal maneuvers are insufficient or arrhythmias occur frequently enough to impact quality of life, medication may be recommended. Several classes of medications can help prevent or control arrhythmias in children.

Beta-blockers are commonly used as first-line preventive therapy for SVT and other arrhythmias. These medications slow the heart rate and reduce the heart's sensitivity to stimulating hormones like adrenaline. Common beta-blockers used in children include propranolol, atenolol, and nadolol. Side effects can include fatigue, dizziness, and sleep disturbances.

Other antiarrhythmic medications like flecainide, sotalol, or amiodarone may be used for arrhythmias that don't respond to beta-blockers. These medications require careful monitoring due to their potential side effects and drug interactions. Regular follow-up appointments and periodic ECG monitoring are typically necessary.

Catheter Ablation

Catheter ablation is a minimally invasive procedure that can permanently cure many types of arrhythmias. During the procedure, thin, flexible tubes (catheters) are inserted through blood vessels and guided to the heart. The tip of the catheter delivers energy (radiofrequency heat or cryotherapy cold) to destroy the small area of heart tissue causing the abnormal electrical signals.

For SVT and WPW syndrome, catheter ablation has a success rate exceeding 95% with a low complication rate. The procedure is typically performed in children who have frequent, symptomatic episodes that don't respond to medication or in children who prefer a definitive cure over long-term medication use. Most children can go home the same day or the next day after the procedure.

Can Children with Arrhythmia Live Normal Lives?

Yes, most children with arrhythmias can live completely normal lives, including participating in sports and physical activities. With proper diagnosis, appropriate treatment when needed, and regular monitoring, the vast majority of affected children thrive without significant limitations.

One of the most reassuring aspects of childhood arrhythmias is that they rarely prevent children from living full, active lives. With modern understanding and treatment options, parents can feel confident that their child's arrhythmia can be effectively managed while allowing normal childhood activities and development.

For most children with benign arrhythmias like occasional premature beats or infrequent, well-tolerated SVT episodes, there are no activity restrictions. These children can participate fully in sports, physical education, and recreational activities. The goal is to allow children to live as normally as possible while ensuring appropriate monitoring and safety measures.

Some children with more significant arrhythmias may have temporary or specific activity restrictions recommended by their cardiologist. These recommendations are individualized based on the type of arrhythmia, how well it's controlled, and the child's specific circumstances. Even when restrictions are necessary, they are often less limiting than parents initially fear.

Sports and Physical Activity

The question of sports participation is one that many parents of children with arrhythmias have. Guidelines from the American Heart Association and other organizations help cardiologists make recommendations about safe activity levels for children with various types of arrhythmias.

Children with SVT who have good control of their arrhythmia, either through medication or after successful ablation, can usually participate in all sports without restriction. Those with occasional, brief episodes that are well-tolerated may also be cleared for full activity with the understanding that they should stop and rest if symptoms occur.

Regular follow-up with a pediatric cardiologist is important for children with arrhythmias who are active in sports. This allows for ongoing assessment of the arrhythmia and adjustment of recommendations as the child grows and their activity level changes.

Emotional and Psychological Support

Living with a heart condition can be challenging for children and families, even when the condition is not serious. Children may experience anxiety about their heart, fear of having episodes, or frustration with activity limitations. Parents often worry about their child's safety and may struggle with knowing when to seek medical attention.

Open, age-appropriate communication with children about their condition helps reduce anxiety and empowers them to recognize symptoms and know what to do. Teaching children about their arrhythmia, including how to perform vagal maneuvers if appropriate, gives them a sense of control over their condition.