In this post, I link to and excerpt from Sudden Death in the Young: Information for the Primary Care Provider: FROM THE AMERICAN ACADEMY OF PEDIATRICS| POLICY STATEMENT| JULY 01 2021 [PubMed Abstract] [Full-Text HTML] [Full-Text PDF]. Pediatrics. 2021 Jul;148(1):e2021052044.
All that follows is from the above excellent resource.
There are multiple conditions that can make children prone to having a sudden cardiac arrest (SCA) or sudden cardiac death (SCD). Efforts have been made by multiple organizations to screen children for cardiac conditions, but the emphasis has been on screening before athletic competition. This article is an update of the previous American Academy of Pediatrics policy statement of 2012 that addresses prevention of SCA and SCD. This update includes a comprehensive review of conditions that should prompt more attention and cardiology evaluation. The role of the primary care provider is of paramount importance in the evaluation of children, particularly as they enter middle school or junior high. There is discussion about whether screening should find any cardiac condition or just those that are associated with SCA and SCD. This update reviews the 4 main screening questions that are recommended, not just for athletes, but for all children. There is also discussion about how to handle post-SCA and SCD situations as well as discussion about genetic testing. It is the goal of this policy statement update to provide the primary care provider more assistance in how to screen for life-threatening conditions, regardless of athletic status.
It Is Recommended That the Focus of Screening Should Be on Sudden Death Prevention and Identification of Those at Risk for SCA and SCD
In a 2012 policy statement, the American Academy of Pediatrics (AAP) recommended 4 questions directed toward SCA and SCD detection for which a positive response suggested an increased risk for SCA and SCD.8 Similar to the AHA screening question tool, the 4 questions in the AAP policy statement are based on expert opinion. In contrast to the AHA tool, the AAP tool is intended to be used in all children regardless of athletic participation. Modifications have been made to these 4 questions with wording that can be directly applied to a family questionnaire. PCPs, at their discretion, may find a positive response to be a significant cue to perform a cardiovascular evaluation. The fifth edition of the AAP publication Preparticipation Physical Evaluation noted the AAP recommends an annual comprehensive health supervision visit from ages 6 to 21 years by physicians, nurse practitioners, or physician assistants with the clinical training outlined by state law. The goal of integrating the PPE into the health care home may be more easily achieved if the PPE portion of the examination is addressed every 2 to 3 years, rather than annually, to allow a different focus for evolving child and adolescent risk at each visit.34 It is recommended that SCA and SCD screening should be performed for all children (athlete or not) at the same time as the PPE examination or at a minimum of every 3 years or on entry into middle or junior high school and into high school. Depending on family and PCP concerns, more frequent screening may be appropriate. The modified 4 questions, also based on expert opinion, are as follows:
- Have you ever fainted, passed out, or had an unexplained seizure suddenly and without warning, especially during exercise or in response to sudden loud noises, such as doorbells, alarm clocks, and ringing telephones?
- Have you ever had exercise-related chest pain or shortness of breath?
- Has anyone in your immediate family (parents, grandparents, siblings) or other, more distant relatives (aunts, uncles, cousins) died of heart problems or had an unexpected sudden death before age 50? This would include unexpected drownings, unexplained auto crashes in which the relative was driving, or SIDS.
- Are you related to anyone with HCM or hypertrophic obstructive cardiomyopathy, Marfan syndrome, ACM, LQTS, short QT syndrome, BrS, or CPVT or anyone younger than 50 years with a pacemaker or implantable defibrillator?
What Should Be Done With the Child Who Has a Positive Finding on a Screening Examination or Whose Parents Sought ECG Screening and Were Found to Have an ECG Abnormality?
A positive response from the 4 questions above or an abnormal ECG should prompt further investigation that may include referral to a pediatric cardiologist or pediatric electrophysiologist. A pediatric electrophysiologist will have better insight for suspected channelopathies or arrhythmia issues and will recommend studies as needed. Ideally, the child with a positive response to these questions should be held out of athletic participation until the cardiovascular evaluation is complete.