PoTS treatment in Children and Adolescents

Postural tachycardia syndrome, or PoTS, is in my experience one of the most common reasons children and teenagers are referred to a paediatric cardiologist. Many parents arrive at the appointment feeling confused, worried, and unsure of what to expect. This page tries to explain how PoTS is treated, in a language that is straightforward and easy to follow.

Treatment works in steps. Most children begin with changes to how they drink, eat, and support their body through the day. Medication are used later when those first steps have been tried and are not enough on their own. Both approaches matter, and both are explained here.

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Why POTS needs treatment

PoTS affects the body's automatic control of heart rate when a person stands up. Occasionally children and teenagers can have symptoms also while sitting upright. The nervous system does not respond quickly enough, blood pools in the legs, and the heart races to try to compensate. This leads to dizziness, fatigue, headaches, and sometimes fainting. Some children describe chest tightness. Most children with PoTS improve significantly with the right treatment. Many (up to 80%) recover fully over time, particularly during or after the teenage years, as the nervous system matures. Starting treatment early and staying consistent makes a real difference. Read more about PoTS in children and teenagers.

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The building blocks of POTS treatment

Before any actual medication is discussed, there are some practical steps that represent the foundation of every treatment plan. These may seem trivial but are in my experience and based on consensus extremely important. They work, and they work well. Many children see major improvement from these measures alone.

Salt and Fluids

The body needs enough fluid and salt to keep blood volume stable. Without enough of either, blood pressure may fall when standing and the heart rate spikes to compensate. Children and teenagers with PoTS are usually advised to drink two to three litres of fluid every day. Water is ideal and fizzy drinks should be avoided. Adding an electrolyte drink sachet can help combine salt and fluid in one step. Two to three litres sounds like a lot. Spreading it across the whole day, rather than drinking large amounts in one go, makes it much more manageable. Increasing salt intake through food is often the recommended starting point but in my experience is not sufficient as the guidance of just "consume more salt" is too general and open to interpretation.

Sodium Tablets

When dietary salt alone does not raise blood volume enough, sodium chloride tablets are prescribed. In the UK we have Slow Sodium (slow release 600 mg tablets). These are a concentrated and reliable way to deliver the salt the body needs. Additionally they offer the benefit of allowing slow release and absorption around the 24 hours. A typical starting dose is 1.8 grams two times daily, adjusted depending on the child's size, symptoms, and blood pressure. Dr Giardini reviews sodium intake at every clinic visit. Monitoring matters even though increased salt intake rarely causes a raised blood pressure in some children.

Compression Stockings

Compression stockings are tight-fitting socks or tights that apply gentle, firm pressure to the legs. In the UK it is recommended to use compression level 2 or 3 to apply enough compression. This pressure stops blood from pooling in the lower legs and feet when standing, which is one of the main physical triggers for the fast heart rate in PoTS. Teenagers often push back against wearing them. That is very understandable as for practical purposes they resemble a wetsuit. The evidence that they help is solid. Medical-grade compression stockings, usually described as class 2, are the most commonly recommended. They provide around 23 to 32 mmHg of pressure. Putting them on before getting out of bed in the morning, before blood has had a chance to pool, gives the best result. Waist-high compression tights work better and I generally do not recommend knee-high stockings. Blood also pools in the thighs and lower abdomen, and waist-high garments address this more completely. Getting the correct fit is important, and a specialist nurse or physiotherapist can help with this.

When medication is needed

Some children improve fully with the measures above. Others need additional help, especially when symptoms are severe enough to affect school attendance or daily life. Adding medication does not mean the non-pharmacological measures have failed. It means that extra support is needed on top of non medical remedies while the body gradually adjusts. Most medications used in paediatric PoTS were not originally developed for this specific purpose in children and not licensed. Doctors call this "off-label" use. This sounds more worrying than it is. These medications have been used safely for many years, and there is a growing body of research supporting their use in PoTS. Dr Giardini assesses each child individually before recommending any medication and he has extensive experience in the use of all the medications listed below. Heart rate recordings, blood pressure measurements, symptom patterns, and any other health conditions all inform the decision as well as the results of an active standing test that is usually performed at the time of the first appointment.

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Medications used in paediatric POTS

Fludrocortisone

Fludrocortisone is a synthetic steroid that helps the kidneys hold onto more salt and water. This increases the total volume of blood in the body, making it easier to maintain stable blood pressure when standing. It is taken once daily at a low dose. It is usually taken in the morning. Side effects at the doses used in PoTS are usually mild, but headaches and raised blood pressure can occur. Regular monitoring is needed in the first few weeks of treatment and this includes having a blood test after 4-6 weeks of treatment.

Beta-blockers

Beta-blockers, most often propranolol or atenolol, slow the heart rate by blocking the effect of adrenaline. They are among the most widely used medications in paediatric PoTS. Fatigue is the side effect to watch for most closely and some children will already fel low energy and fatigue. Some young people find that a low dose taken before school or a demanding activity suits their lifestyle better than a fixed daily dose.

Ivabradine

Ivabradine slows the heart rate by acting on a specific channel in the sinus node. Unlike beta-blockers, it does not lower blood pressure. This makes it a good option for children who cannot tolerate beta-blockers, or those who already have low blood pressure. Children with chronic fatigue also tend to respond better to Ivabradine. Dr Giardini has prescribed ivabradine in children and teenagers where palpitations and fatigue on standing are the most limiting symptoms.

Midodrine

Midodrine gently narrows the blood vessels, which helps push blood upward back to the heart when standing. It is particularly useful when low blood pressure on standing is a prominent feature. Midodrine works only for about 4 hours after being taken and so to cover the 12 hours of a normal day 3 separate doses have to be taken (usually 08.00, 12.00 and 16.00). Midodrine can affect sleep so the last dose of the day should not be taken after 16.00 so that the medication is out of the system by night time. As the dose of Midodrine is increased it can affect the blood pressure and so Dr. Giardini instructs parents to measure the blood pressure when recumbent in bed after 1 hour from the administration. Specific age-related upper limits of acceptable exist and will be shared by Dr. Giardini when required. A tingling or crawling sensation on the scalp shortly after taking it is a recognised and harmless side effect.

Pyridostigmine

Pyridostigmine boosts signals in part of the autonomic nervous system that help blood vessels respond correctly to standing. It is less commonly used but can be helpful for teenagers with persistent symptoms who have not responded to other treatments. Stomach cramps and loose stools are the most common side effects, which usually improve with a gradual increase in dose.

Desmopressin

Desmopressin helps the kidneys hold onto water, temporarily increasing blood volume. It is usually reserved for specific situations rather than daily use, for example before a long school day or an important event. It must not be taken alongside excess fluid, because it can cause the salt level in the blood to drop. Dr Giardini gives clear guidance on this whenever the medication is prescribed.

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How treatment decisions are made

In my experience no two children with PoTS are exactly alike, and there is no single treatment that works for everyone everytime. A single medication at a low dose is the usual starting point, with a review after four to six weeks. Two medications together are sometimes needed for children with more severe or persistent PoTS, always planned carefully to avoid overlapping side effects, especially for children who are already on other medications.

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What parents find hardest

Many parents who come to clinic have already been through months or years of not knowing what was wrong. Some were told their child had anxiety. Others watched their child miss school, lose friendships, and fall behind, while being told the tests all looked normal. That experience has been shared by many families.

PoTS is an invisible illness. Children with PoTS often look completely well. That gap, between how they look and how they actually feel, creates real practical problems. Teachers question whether the absences are genuine. Extended family members suggest the child needs to push through. Getting schools involved early, with a formal medical letter where necessary, makes a real difference.

PoTS UK, the leading UK charity, notes that children with PoTS crave having more energy, and that over-reliance on the condition as a reason to avoid activity is far less common than parents tend to fear. Depression and anxiety are genuinely common in young people with PoTS, not because PoTS is caused by anxiety, but because living with an unpredictable chronic illness is hard at a young age. Treating the PoTS tends to reduce the anxiety considerably. Post-COVID PoTS is a recognised and increasingly common presentation. Many parents first notice symptoms in a child who seemed to have recovered from COVID-19 but then remained persistently unwell weeks or months later.

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Frequently Asked Questions

• Will my child need medication forever? Most children do not. PoTS often improves as the nervous system matures, and many young people reduce or stop medication by their late teens or early twenties.
• Are these medications safe for teenagers? Yes, when prescribed and monitored by a specialist. Most medications used for PoTS have been in clinical use for many years at doses considerably lower than those used in adults.
• My child refuses to wear compression stockings. What can we do? Sports compression socks are sometimes more acceptable to teenagers. They provide slightly less compression but still help. Wearing them during the school day only can be a practical starting point.
• Can my child still go to school during treatment? Yes, and keeping up with school is an important part of recovery. Practical adjustments such as sitting near the front of the classroom and access to water can make attendance much more manageable.
• What if the medication does not seem to work? Treatment often takes several weeks to show benefit. Dr Giardini will review the dose, adherence to non-pharmacological measures, and whether a different medication or combination is more appropriate.
• Our GP said it was probably anxiety. Could it still be PoTS? Yes. PoTS symptoms are triggered by standing and improve with lying down. A simple active standing test is usually enough to raise suspicion. Asking for a cardiology referral is entirely reasonable if symptoms are not explained.
• My child looks completely fine. How do I explain this to the school? A formal letter from a specialist carries far more weight than a parent explanation. Dr Giardini provides clinic letters that can be shared directly with schools, specifying the adjustments needed without disclosing more than necessary.
• Can my child do sport with PoTS? Exercise is one of the best long-term treatments. Swimming, rowing, and recumbent cycling are recommended first. Most young people return to their usual activities in time.
• My daughter's symptoms get much worse around her period. Is this related? Yes. Hormonal changes affect blood volume and autonomic tone, and many young women with PoTS notice a clear cyclical pattern. This can influence the choice of treatment.
• We tried salt and fluids for weeks and nothing changed. Does that mean medication is needed? Not automatically. Check that the recommended levels are genuinely being met. If consistent non-pharmacological management over six to eight weeks has not helped, medication is usually the sensible next step.
• My child is better now. Can we stop the medication? Always gradually and under specialist supervision. Reducing the dose slowly over several weeks, while continuing non-pharmacological measures, is the safest approach.
• Is PoTS the same as anxiety? No. PoTS is a physical condition. Some children also experience anxiety, which is understandable. Treating PoTS tends to reduce the anxiety. The reverse is not usually true.
• Could post-COVID be causing my child's PoTS? Yes. Post-COVID PoTS is well recognised in children and teenagers. The treatment approach and prognosis are the same as for other forms of paediatric PoTS.
• My child seems really low in mood since the diagnosis. Is that part of PoTS? Low mood is common. It often improves as physical symptoms come under control. Psychological support can be a valuable part of the treatment plan if it persists.
• My child wants to keep their diagnosis private at school. Should we respect that? Yes. PoTS UK notes that medical details belong to the child. A formal letter can secure the adjustments needed without sharing more clinical detail than the child is comfortable with.

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References and further reading

1. Raj SR, Fedorowski A, Sheldon RS. CMAJ. 2022;194(10):E378-E385.

2. Sheldon RS et al. Heart Rhythm Society consensus. Heart Rhythm. 2015;12(6):e41-e63.

3. Kizilbash SJ et al. Pediatric Clinics of North America. 2014;61(2):229-239.

4. Boris JR. Autonomic Neuroscience. 2018;215:97-101.

5. Barzilai M et al. Cardiology in the Young. 2020;30(2):259-263.

6. Raj SR et al. Circulation. 2009;120(9):725-734.

7. Fischer PR et al. Clinical Pediatrics. 2012;51(8):735-742.

8. PoTS UK. www.potsuk.org

‍9. Dysautonomia International. www.dysautonomiainternational.org

‍10. NHS. www.nhs.uk‍

11. European Society of Cardiology. European Heart Journal. 2018;39(21):1883-1948.

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Author: Dr. Alessandro Giardini, MD, PhD

Written 07/05/2026