Adderall use in children and adolescents
On February 10, 2005, Health Canada suspended sales of Adderall, a drug commonly prescribed for attention deficit hyperactivity disorder (ADHD), from the Canadian market based on U.S. reports of 20 deaths—14 in adolescents and children. Six of those patients had underlying heart disease that put them at risk for sudden death. In the remaining patients, the deaths may have had causes completely unrelated to Adderall use. While the United States Food and Drug Administration (FDA) is not removing Adderall from the market, this widely reported decision has triggered some concern among patients and providers, prompting an ad-hoc committee of the Pharmacy and Therapeutics Committee at Children's Hospital Boston to carefully review available data.
There are specific features of the stimulants prescribed for ADHD (dextroamphetamines and methylphenidates) that may make one of them more or less effective for individual patients. Specific guidelines may be coming from the FDA over the coming months, but in the interim these are our recommendations.
No role for routine ECG screening
While there have been suggestions that routine electrocardiogram (ECG) screening is warranted in patients on stimulant therapy, it is not our recommendation. This topic was reviewed by a select committee for the American Heart Association and the American Academy of Pediatrics in 1998 with no specific monitoring recommended at that time. The ECG, while relatively inexpensive, is problematic because a large number of normal children test positively for left ventricular hypertrophy or borderline QT intervals in the absence of any disease. On the other hand, some patients with serious diseases, like anomalous coronary artery, have completely normal ECGs. Hence, for the cardiovascularly asymptomatic patient with a reassuring family history and normal physical examination, routine ECG screening is likely to increase anxiety without significant benefit. For the patient with known or potential heart disease, the ECG is a routine part of the evaluation. There may be a limited number of situations when the ECG helps the primary care provider determine the importance of a cardiology referral.
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Patients without known heart disease deserve the level of screening given during pre-participation sports physicals in evaluating for potential familial heart disease or other occult disease. We believe that when examining for cardiac symptoms, a family history and a physical examination represents the most effective screening test. During the discussion with patient and family, the following questions must be included in the assessment:
Does the patient have:
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A past or current personal history of syncope, fainting or palpitations?
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A past or current personal history of significant heart disease?
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A family history of either cardiomyopathy or sudden death earlier than age 40?
Patients and/or family members who answer yes to any of those questions or whose examination suggests significant heart disease should be referred to a cardiologist.
For patients with known heart disease there continue to be valid reasons to be prudent about the use of any of these ADHD drugs. The current labeling of both the amphetamine-based and methylphenidate-based agents includes cautions about their use in patients with high blood pressure, heart failure or those diseases where increasing blood pressure could be dangerous. Similar precautions are made for atomoxetine (Strattera). Decisions regarding individual patients with heart disease should entail a standard risk/benefit discussion that is best managed among the family and responsible providers.
A publication for pediatric caregivers from Children's Hospital Boston 
