A-Fib in Kids

A-Fib in KidsWe all know that children are a special population of humans (please don’t say “kids aren’t little adults”- it engenders fear of caring for kids instead of empowering providers for staying abreast of the issues that make caring for kids unique and special – ok… I’ll get off soapbox now), but it seems like “adult problems” are becoming more recognized in children now.  We have discussed issues like Pulmonary Embolism, Cholelithiasis, Acute Cholecystitis, and Renal Stones. Here is another item to add to that list of conditions seen commonly in adults, that may make you scratch your head if/when you encountered it with one of your pediatric patients – A-Fib in Kids:

 

A-Fib in Kids: Basics

  • Atrial Fibrillation (A-Fib) is derived from several, small reentry circuits (unlike A-Flutter that has one reentry circuit). [Zachary, 2000]
    • It is unusual in children because the small atrial mass/size is less likely to support numerous reentry circuits.
    • When present, it leads to ineffective atrial contractions.
  • A-Fib should be suspected with any irregular, narrow complex rhythm.
    • May be a rapid, normal, or even slow rate.
    • May also be associated with wide complexes if there is another concurrent conduction abnormality (ex, Wolf-Parkinson-White Syndrome).
  • A-Fib in kids is most often associated with another condition: [Zachary, 2000]
    • Known congenital heart disease.
      • Most common association.
      • Particularly true in patients who have had surgical corrections / palliations.
    • Acquired heart disease
    • Cardiac masses (act as local irritant)
      • Atrial myxoma
      • Rhabdomyoma
    • Metabolic / electrolyte abnormalities
    • Medication toxicities
      • Digoxin
      • Sympathomimetics (part of the reason we don’t recommend “cold” preparation medicines to young children)
      • Albuterol
    • Intoxicants
      • Alcohol (“holiday heart” in kids!) [Koul, 2005]
      • Cocaine and other stimulants.
    • Other systemic stressors

 

Lone A-Fib in Kids

  • While most often, children will have an associated underlying cardiac or systemic condition, this is not always the case. [El-Assaad, 2017; Ceresnak, 2013; Mills, 2013 ]
    • A-fib affecting previously healthy kids is referred to as “Lone Atrial Fibrillation.”
    • Prevalence found in one large study found to be 7.5 / 100,000 children. [El-Assaad, 2017]
    • Pathophysiology is likely multifactorial:
      • Atrial dilatation
      • Diastolic dysfunction
      • Genetic predisposition
        • May have a familial association.
        • Always good to ask about family history! [El-Assaad, 2017]
  • Risk factors found to be: [El-Assaad, 2017]
    • Obesity (BMI >94th percentile)
    • Older children
      • Odds increased with age
      • Children 15-19 years of age with highest adjusted odds ratio
    • Male gender
  • Recurrence rate of a-fib in these patients is 15% at one month, 21% at 6 months, and 23% at 12 months.
  • Acute cerebrovascular stroke occurred in 2% within 1 year. [El-Assaad, 2017; Mills, 2013]
    • No consensus on use of heparin or long-term anticoagulation in these patients.

 

A-Fib in Kids: Management

  • A-Fib that presents associated with signs of systemic instability, needs synchronized cadioversion.
  • The management of stable patients with a-fib is lacking consensus, because of its rare nature. [El-Assaad, 2017]
    • Treat electrolyte derangements.
    • Consider potential for other associated causes.
    • Control rate.
    • Discuss with your friendly, neighborhood pediatric cardiologist (as her/his experience will likely determine ultimate management).
    • May need to consider Electrophysiology Study as some can have association with SVT. [El-Assaad, 2017; Ceresnak, 2013; Mills, 2013]

 

Moral of the Morsel

  • A-fib is not just for old adults! While rare, children can develop it, even without other cardiac or systemic conditions.
  • If unstable, you know what to do! Use the juice!!
  • If stable, think about causes… and discuss with your pediatric cardiology friends.

 

References

El-Assaad I1, Al-Kindi SG2, Saarel EV3, Aziz PF4. Lone Pediatric Atrial Fibrillation in the United States: Analysis of Over 1500 Cases. Pediatr Cardiol. 2017 Jun;38(5):1004-1009. PMID: 28374048. [PubMed] [Read by QxMD]

Mah DY1, Shakti D2, Gauvreau K2, Colan SD2, Alexander ME2, Abrams DJ2, Brown DW2. Relation of Left Atrial Size to Atrial Fibrillation in Patients Aged ≤22 Years. Am J Cardiol. 2017 Jan 1;119(1):52-56. PMID: 27780555. [PubMed] [Read by QxMD]

Mills LC1, Gow RM, Myers K, Kantoch MJ, Gross GJ, Fournier A, Sanatani S. Lone atrial fibrillation in the pediatric population. Can J Cardiol. 2013 Oct;29(10):1227-33. PMID: 24074972. [PubMed] [Read by QxMD]

Ceresnak SR1, Liberman L, Silver ES, Fishberger SB, Gates GJ, Nappo L, Mahgerefteh J, Pass RH. Lone atrial fibrillation in the young – perhaps not so “lone”? J Pediatr. 2013 Apr;162(4):827-31. PMID: 23092527. [PubMed] [Read by QxMD]

Di Rocco JR1, During A, Morelli PJ, Heyden M, Biancaniello TA. Atrial fibrillation in healthy adolescents after highly caffeinated beverage consumption: two case reports. J Med Case Rep. 2011 Jan 19;5:18. PMID: 21247417. [PubMed] [Read by QxMD]

Szwast A1, Hanna B, Shah M. Atrial fibrillation and pulmonary embolism. Pediatr Emerg Care. 2007 Nov;23(11):826-8. PMID: 18007216. [PubMed] [Read by QxMD]

Koul PB1, Sussmane JB, Cunill-De Sautu B, Minarik M. Atrial fibrillation associated with alcohol ingestion in adolescence: holiday heart in pediatrics. Pediatr Emerg Care. 2005 Jan;21(1):38-9. PMID: 15643323. [PubMed] [Read by QxMD]

Zachary CH1, Cyran SE. Spontaneous-onset atrial fibrillation in a toddler with review of mechanisms and etiologies. Clin Pediatr (Phila). 2000 Aug;39(8):453-9. PMID: 10961817. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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1 Response

  1. February 12, 2018

    […] review of atrial fibrillation in kids is a must-read, if only for Sean Fox’s reminder that pediatric exceptionalism “engenders fear […]

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