Comprehensive Care for Children with POTS with Jillian Myers, MSN, APRN-NP, CPNP-PC and Brittany Holst, MS, CEP, EIM

A disorder called Postural orthostatic tachycardia syndrome, or what is commonly referred to as POTS, has been on the rise in recent years in both adults and children. While surgery is not required, for children with cardiovascular symptoms of POTS, the Lurie Children's Heart Center team has taken a forward-thinking approach to treating the condition. Expanding its resources to meet increased demands, Lurie Children’s POTS program has become one of the few comprehensive programs for pediatric cases of POTS. In this episode, Jillian Myers, director of the POTS Program and Brittany Holst, Lead POTS Clinical Exercise Physiologist, discuss POTS in children, its ties to COVID-19 and other viral illnesses and treatment options that emphasize exercise and hydration.

“POTS can be triggered by a variety of conditions, including viral or bacterial infections. And so we're seeing that correlation between coronavirus and we think it's now becoming a trigger for POTS. We've seen definitely an increased number of patients who are presenting with symptoms after COVID-19. And these symptoms are POTS-like symptoms, so they are tachycardia, that's postural in origin, lightheadedness, dizziness, fatigue.”

Jillian Myers, MSN, APRN-NP, CPNP-PC
Director, POTS Program, Lurie Children’s
Advanced Practice Provider, Cardiology, Lurie Children’s

“Consistency and that gradual change is what helps patients get back to that activity or that level that they were at before the increase in their symptoms, a little easier. I try to enforce with all of my patients ‘be kind to yourself.’I know that seems so straightforward, but it's okay to have a more symptomatic day. It's going to happen. And I kind of call them our hills and valleys. So, you may have a day where your symptoms are feeling great, and we want to push ourselves and be more active, but keeping it consistent day-to-day helps reduce those valleys or those more symptomatic days. We try to create a nice plateau to help manage symptoms.”

Brittany Holst, MS, CEP, EIM
Lead POTS Clinical Exercise Physiologist

Show Notes

• POTS is a clinical syndrome of orthostatic intolerance, characterized by a sustained and marked increase in heart rate with little to no change in blood pressure during position changes, plus chronic symptoms of orthostatic intolerance.
• POTS is one of the most common disorders of the autonomic nervous system, with an estimated prevalence of about 0.1 to 1% of the patient population. Children are typically diagnosed between ages 12 and 15, with a prevalence in young girls.
• Normally, when a person stands up, the body counteracts gravity that pulls blood down to the lower extremities by shooting it back up through circulation. However, with POTS, the blood sinks to the lower extremities and stays there. The heart then races to try and compensate for the pooling.
• To remedy this, increased hydration and salt intake build up the circulating blood volume and help the blood return to the heart.
• POTS is a diagnosis of exclusion, and because symptoms mimic many other conditions, it can be hard to receive a diagnosis.
• POTS can interfere with the quality of life of children, preventing them from having the stamina to enjoy normal activities. Stress can also exacerbate symptoms. Luckily, the majority of pediatric patients outgrow POTS somewhere between ages 20 to 21.
• Cases have jumped since COVID-19, presumably because POTS is often triggered by a viral infection. This increase led to the expansion of POTS support at Lurie Children’s, where it is now one of the only comprehensive programs for pediatric POTS.
• Central to its treatment protocols, the POTS program includes a mandatory exercise program catered to individual needs of patients. The exercise plans focus on gradual improvement in both strength training and cardiovascular health.
• Depending on symptoms, exercise routines can begin with supine or laying down exercises, and then gradually transition to seated and standing exercises. Since POTS symptoms are postural, the idea is that patients will gradually be able to tolerate more and more upright activities.
• Providing both online and in-person exercise training, the program not only provides accountability, coaching, and guidance but also empowers patients to learn how to manage their symptoms at home with techniques they can implement in everyday life. 

Transcript

[00:00:00] Erin Spain, MS: This is Precision: Perspectives on Children's Surgery from Ann and Robert H. Lurie Children's Hospital of Chicago. I'm your host, Erin Spain. On this podcast, we introduce you to surgeons at one of the country's most renowned children's hospitals to find out how they are transforming pediatric medicine. A disorder called Postural Orthostatic Tachycardia Syndrome, or what is commonly referred to as POTS, has been on the rise in recent years in both adults and children, leading to the expansion of support for POTS patients here at Lurie Children's. Children diagnosed with POTS typically experience daily cardiovascular symptoms that affect their quality of life and require specialized care to help combat episodes of dizziness, lightheadedness, exercise intolerance, and near fainting. While surgery is not required, Lurie Children's Heart Center team has taken a forward-thinking approach in treating the condition. Joining me to discuss POTS and its ties to COVID-19 and other viral illnesses is Jillian Myers, director of the POTS Program, and Brittany Holst, a senior exercise physiologist at Lurie Children's. We'll start today with Jillian Myers. Welcome to the show, Jillian.

[00:01:19] Jillian Myers, MSN, APRN-NP, CPNP-PC: Thank you so much for having me.

[00:01:21] Erin Spain, MS: Well, let's first start off with the basics. POTS is a condition characterized by what's called orthostatic intolerance. Tell me what that means. How do you explain POTS to your patients and families that come in?

[00:01:35] Jillian Myers, MSN, APRN-NP, CPNP-PC: Postural orthostatic tachycardia syndrome, or POTS, is a clinical syndrome of orthostatic intolerance, characterized by a sustained and marked increase in heart rate with little to no change in blood pressure during position changes, plus chronic symptoms of orthostatic intolerance. It is one of the most common disorders of the autonomic nervous system with an estimated prevalence of about 0.1 to 1% of the patient population. So we typically say every time you change position, gravity pulls about 20% of your blood volume to your feet. The typical response is for your blood vessels to squeeze and shunt that blood back up to your heart, which recirculates to the rest of your body. With POTS, there's some dysfunction within the autonomic nervous system. So when patients stand up, all that blood volume goes down to their feet and it stays down there. So the hallmark of POTS is that blood pooling and the blood vessels are not squeezing appropriately and not communicating with the rest of their body. So to compensate for all that blood that's pooling in the lower extremities, we see some compensatory tachycardia come in and as soon as they're standing, their heart starts to really race and beat fast, and then bring that blood volume back up to their heart so they can recirculate to their rest of their body.

[00:02:48] Erin Spain, MS: You mentioned that this is a common condition, but it's very hard to diagnose. Tell me about that and how challenging this is for families who are dealing with these difficult symptoms, but might not have a clear path to diagnosis. And how do they typically end up coming to you? How do they find their way to getting a diagnosis?

[00:03:07] Jillian Myers, MSN, APRN-NP, CPNP-PC: Great question. So it's really, really tough to get a diagnosis for POTS. I would say that most of our patients do see about seven providers before they actually end up in our clinic. And the average time until diagnosis is about four years for patients. And that's a long time, especially these pediatric patients. We see most of our patients present somewhere between 12 to 15 years of age. So that is their teenage years. And I would say that most of our patients tend to be female. About 85 to 90% of our patients are actually female. POTS is such a chronic multi-symptom disorder, and it involves a broad array of symptoms. So we see dizziness, we see lightheadedness, we see a fast heartbeat. We see patients who feel like they're gonna pass out or do pass out. Chest discomfort, shortness of breath, fatigue, headache, stomach complaints, difficulty concentrating. And those are so multi-symptom that we really have to focus on what is the most bothersome symptom to the patient. And this may differ from patient to patient. The other thing that we see a lot is more than half of our cases are preceded by some sort of acute viral illness. And that can definitely be COVID and we've seen a lot of patients post-COVID vaccine as well, presenting with symptoms. Other triggers that we see are concussion. So an injury, surgery, puberty is a big trigger for a lot of our patients. Definitely there's a correlation between having your menstrual cycle and having increased symptoms. And then growth spurts can also be another trigger that we see.

[00:04:32] Erin Spain, MS: Going back to what you said about COVID-19, this has actually been a topic that's been in the news quite a bit, and you mentioned that POTS is showing up more often, not only after Covid infection, but after vaccination as well. I'm sure that this is a topic that you get asked about quite a bit. So why don't you set the record straight for me? What do we know right now about POTS and its prevalence after vaccination or infection?

[00:04:56] Jillian Myers, MSN, APRN-NP, CPNP-PC: So as previously mentioned, POTS can be triggered by a variety of conditions, including viral or bacterial infections. And so we're seeing that correlation between coronavirus and we think it's now becoming a trigger for POTS. We've seen definitely an increased number of patients who are presenting with symptoms after COVID-19. And these symptoms are POTS-like symptoms, so they are tachycardia, that's postural in origin, lightheadedness, dizziness, fatigue. So definitely falling into the same category.

[00:05:25] Erin Spain, MS: When it comes to diagnosis, there are other conditions that are often comorbid with POTS, and there are other conditions that can also mimic POTS symptoms. Tell me about that and how that impacts your ability to diagnose this condition.

[00:05:39] Jillian Myers, MSN, APRN-NP, CPNP-PC: POTS has been associated with other disorders, including hypermobile Ehlers-Danlos syndrome, hypermobile spectrum disorder, chronic fatigue syndrome fibromyalgia, autoimmune disorders, mast cell activation syndrome, celiac disease, and thyroid abnormalities. And then in terms of different diagnoses that mimic POTS, for us, POTS is a diagnosis of exclusion. Therefore, to make a diagnosis of POTS, patients must meet that strict criteria as previously discussed, and have the absence of another etiology for their symptoms. We do see that several disorders can be misdiagnosed as POTS, which is why it's so important for the provider to do a really detailed history in a physical exam for the patient. Within cardiology, we prioritize obviously that there's no underlying arrhythmias, structural abnormalities within the heart, cardiomyopathy, coronary abnormalities, or pulmonary hypertension. And all of our patients do undergo cardiac testing with the visit, which I'll talk about a little bit. Other conditions that mimic POTS include acute dehydration, deconditioning, autoimmune disorders, anxiety, anemia, thyroid disorders, and inappropriate sinus tachycardia. There are also several medications and medications with side effects that mimic POTS. So that's something that we look at as well. Are there medications that are potentially contributing to their symptoms or causing their symptoms?

[00:07:07] Erin Spain, MS: The symptoms can have a major impact on the quality of life of the children affected. Tell me about that and the long term outlook for kids with POTS.

[00:07:17] Jillian Myers, MSN, APRN-NP, CPNP-PC: When we see kids in our first visit, we say, you know, we're gonna do a lot of things that can help manage your symptoms. We're gonna be here to kind of guide you and we are gonna be your support system. If you decide to do nothing, you're likely gonna outgrow this by the time you're in your early twenties. So we see the majority of our patients do outgrow this somewhere between 20 to 21, if they do nothing. If they start working on these kind of lifestyle modifications that we're gonna talk about later, they can have improvement in symptoms potentially within a few months, which is a huge change for these patients. You know, this is the time where kids just wanna be kids, and it's really tough when you just can't be a kid. Another thing that we see with these patients too is often symptoms can flare up. So they'll have periods where they will get another viral illness or undergo a surgery and symptoms can flare up after that. A lot of our college age kids will say around midterms and finals, they see a flare up of symptoms just because they're more stressed, they're not sleeping as well. So we know that these certain things can flare up symptoms and that's something that we address with our patients as well. POTS is really, it's an invisible illness and it can be difficult for family, friends, and others to really understand symptoms because when they look at these patients, they look well. So we always do recommend that patients find a support group, whether it's peers or family support, and school support. Just educate them about POTS and how they can assist and advocate for the patient when they're not feeling well. Another important thing too is POTS as a chronic illness, and I always tell patients it feels lousy to feel lousy, so we always advocate for patients to see a therapist or counselor who can really help them develop coping mechanisms and provides support for a chronic illness like POTS.

[00:08:53] Erin Spain, MS: Can you walk me through what families can expect when they come to Lurie Children's, for a possible diagnosis of POTS.

[00:09:00] Jillian Myers, MSN, APRN-NP, CPNP-PC: POTS is a chronic illness that doesn't really have a cure. So our treatment goals include symptom suppression, improved physical conditioning, enhanced quality of life, and ongoing patient education. Our treatment approach usually involves both non-pharmacological and pharmacological approaches with non-pharmacological approaches as a first line of therapy. In terms of the visit, patients will come in, they will obtain just baseline vital signs. Next, they will go and have an EKG done, and EKG is one of the simplest and fastest procedures to evaluate the heart, and it's particularly useful to us if we're looking to diagnose an abnormal heart rhythm or abnormal heartbeat. Next, the patients will have their active stand test. This is a simple and non-invasive test that we use to diagnose and manage POTS. We call it kind of our bedside tilt table test. During this test, the patient will lie down in an exam table for at least 10 minutes, and we do that just to allow their heart rate and blood pressure to stabilize. Then the patient will stand up quickly and remain standing for 10 minutes, and our team will monitor both heart rate and blood pressure at regular intervals during the test and evaluate their symptoms. And with that test, we're looking for that exaggerated heart rate response that's both sustained while standing. Next the patient will see the POTS provider. And if the patients are meeting criteria for POTS, we will develop an individualized care plan for the patient. Next, the patient will undergo a functional capacity assessment with the exercise team and complete some surveys. And then the patients will go home with an exercise prescription. Patients will also receive some sort of cardiac monitoring before leaving the clinic. As I mentioned previously, it's important to rule out other things that can mimic pots, and one of the most common things that we do pick up is abnormal heart rhythms. So patients usually go home with a 24 hour monitor or a 30 day monitor to document their symptoms And then we also do blood work with the initial visit. As mentioned previously, there are a lot of things that can contribute to symptoms or potentially cause symptoms. So we look for thyroid abnormalities, anemia, vitamin deficiencies and a few other labs that may affect the autonomic nervous system and contribute to POTS.

[00:11:16] Erin Spain, MS: One thing that I want to point out is that your program is nestled within the heart center at Lurie Children's. Tell me how important it is to be part of the heart center and how that helps you give the very best care to your patients.

[00:11:30] Jillian Myers, MSN, APRN-NP, CPNP-PC: Within the Heart Center, again, we kind of focus on cardiovascular symptoms of POTS. So we really do address, you know, palpitations, tachycardia, dizziness, lightheadedness, and we really focus on the whole picture for the patient. The Heart Center has been a great resource for the program. And they realize this is a large patient population and that patients need a home, a home base, and they are definitely giving us the resources that we need to move this program forward.

[00:12:00] Erin Spain, MS: Tell me about the volume that you are seeing, especially now that you've been able to expand the program and with this recent uptick in cases since COVID-19, how many children and families are you seeing through your doors?

[00:12:11] Jillian Myers, MSN, APRN-NP, CPNP-PC: Currently, our clinics are filled through the rest of the year. I would say I'm seeing about 60 patients a month on average. So over 700 patients a year. We utilize both in-person visits and then telemedicine when appropriate. Telemedicine has been a great avenue to really get patients in and follow up with patients, especially patients who can't make it downtown into the city. That's been wonderful. But our volumes are high. We just incorporated another provider into our clinic. With both of us, we should be seeing about over a thousand patients a year. We are fully booked through 2024 and we have a very long wait list into 2025.

[00:12:46] Erin Spain, MS: And one of the reasons for this demand is because Lurie Children's has one of the only comprehensive programs to support pediatric patients. Tell me about the goals of the program.

[00:12:57] Jillian Myers, MSN, APRN-NP, CPNP-PC: The goal of our program is essentially to reduce symptoms and increase overall quality of life. And something that we incorporated within the past few years is our exercise program. We know that exercise is essential for these patients and many pediatric patients, they avoid exercise altogether because it makes them feel awful when they do it. If you think about it, these patients just standing, many of these patients, their heart rate goes up to 1 40, 1 50. We see that exaggerated heart rate response. So when they try to do exercise, their heart rate may increase to, you know, 150 to 180, where somebody else who doesn't have POTS, they may see a heart rate increase up to 120. So it's really uncomfortable for many of these patients and they're not really able to kind of stick with an exercise program. So to address this, we incorporated a clinical exercise physiologist into all of our POTS clinics to really highlight the benefit of symptom management with a daily exercise program, which has been a huge positive change for the program and for patients. I think we've really pivoted to look at the total picture and really make sure that we are working with families and patients so that they can really hit the goal of a daily exercise program.

[00:14:07] Erin Spain, MS: Another important part of this program is hydration and salt intake. Why is it so important to keep these patients well hydrated and a diet full of salt and sodium?

[00:14:19] Jillian Myers, MSN, APRN-NP, CPNP-PC: So with the increased hydration, increased salt, it builds up the circulating blood volume By increasing that blood volume, it'll both increase the amount of blood circulating in their body and help that return to their heart. So it doesn't have to work as hard to get that blood back to the heart.

[00:14:31] Erin Spain, MS: Well, now's a good time to bring in Brittany Holst. She is the lead POTS clinical exercise physiologist, and she's doing some innovative programming to help children within the program. Start this exercising program and maintain an exercise routine. Welcome to the show, Brittany.

[00:14:47] Brittany Holst, MS, CEP, EIM: Thanks.

[00:14:47] Erin Spain, MS: This is something that's a big differentiator for the POTS program at Lurie Children's. It's exercise and what you're able to offer these patients is really interesting. You are not only giving them a prescription for exercise, but you were following up with them and holding them accountable to making sure that they're able to do this work. Tell me about this aspect of the program and what you're able to offer patients.

[00:15:10] Brittany Holst, MS, CEP, EIM: So my role in clinic, I come in and do a one-on-one consultation. With that, I do some functional assessments to kind of get our baseline and we talk about the majority of what their symptoms are. We really focus on any barriers that they're having. I go through how many days they're being limited by their symptoms, and we kind of take a step back and I ask point blank, what do we like and what don't we like about exercise? Because coming up with an exercise program for anyone can be challenging, but when we incorporate in their symptoms too, we wanna make sure it's a realistic plan for them and something they're going to be able to adhere to.

[00:15:46] Erin Spain, MS: So how is this different, the exercise program, than maybe other programs that are available?

[00:15:52] Brittany Holst, MS, CEP, EIM: I think one of the things you see across the board with POTS exercise programs are a focus primarily on cardiovascular exercise and some focus on strength or resistance exercises. With our program, what I did when we first started was saw what was out there and decided what was going to be realistic for these patients. These patients struggle with their heart rate, right? So if I give them a heart rate and say, you can't go past this, I'm kind of limiting them. So if I take away the heart rate component and we say we're gonna focus on gradual increases in cardiovascular exercise that will be realistic, we end up having more buy-in with the patients. Secondly, I focus probably half to three quarters of our program on strength and lower resistance exercises. We start with, depending on where the patients are symptom wise, with supine or laying down exercises, and then gradually transition them to more seated exercises and more standing exercises. The reason behind that is the majority of their symptoms are postural and when they're changing position. So if we're able to gradually build their strength and their lower extremities from that laying down to seated to standing, the concept being that they'll gradually be able to tolerate more and more upright activities.

[00:17:08] Erin Spain, MS: Another interesting aspect of the exercise program is that it's mandatory.

[00:17:12] Brittany Holst, MS, CEP, EIM: Most definitely. I think, you know, that's something that across the board when you hear about POTS and you hear about lifestyle modifications and treatments, exercise is always in there, right? They talk about hydration and nutrition and all the salt you can get. But then exercise is just, you should be exercising. Jillian and I sat down and we said, how do we make this mandatory, right? Because they need it. But having me incorporated directly into the clinic and then following with these patients, it definitely makes a difference in terms of that accountability, having me as a support and just saying, I get that sometimes it's not gonna happen, and that's being realistic, but how can I help it happen more consistently?

[00:17:52] Erin Spain, MS: And you're doing a lot of this work virtually. So what do these virtual sessions look like?

[00:17:56] Brittany Holst, MS, CEP, EIM: So we've kind of designed levels within our exercise program. One that would be all in person because we feel that that's gonna be the most beneficial for these patients, that they need a little extra assistance into establishing a program and maybe their symptoms are more significant. So they do need a little extra assistance. And then, the next level would be kind of a mix where some of those sessions you can do at home and be on a telemedicine visit with me, and I'm coaching you through, I'm looking at your heart rates, I'm having you take your blood pressures, making sure everything is correlating how we expect, and I'm able to coach you through those exercises. It's also giving you that autonomy, right? It's making these patients feel like, okay, I can do this. I understand what I'm saying, rather than just sending them home with a program saying. Okay, now go do it. And then kind of that third option is all virtual. And what that is is maybe two, three sessions a week where I am there to coach them through.

[00:18:51] Erin Spain, MS: What could some of those exercises look like, especially for the newly diagnosed and the folks who are really struggling to exercise.

[00:18:58] Brittany Holst, MS, CEP, EIM: I would say newly diagnosed and struggling to exercise, they may be all seated exercises, so thinking of what we call full knee extensions. So both feet flat on the ground, you're bringing a leg out in front of you, holding it for a second, back down, even seated marching, right? So we bring a knee up, we hold for a second, back down. It seems like simplified exercises, but things where we're focusing on lower extremities, right? We know that with those position changes, what can happen is we have blood pooling. So the concept being if we can strengthen lower extremities to help counteract any of that blood pooling, that's where my main focus is for seated exercises. But also, if patients don't have cardiovascular equipment at home, we focus primarily just on those strength exercises. And then I think finally anyone that's been newly diagnosed with POTS can benefit from are what we call counter pressure maneuvers to help counteract any blood pulling that's happened. So let's say that you're sitting in class, it might be 30 minutes, it maybe 45. So something we can do throughout that duration is calf raises or where we're just kind of lifting up onto our toes and back down. We're doing those little marching where you're bringing a foot up and down thigh squeezes where you're literally squeezing your thigh for a second and relax. So, pretty simple, straightforward. Those are just some examples. But what it does is help, like I said, counteract any of that blood pooling. I like to say it sends a signal up to our brain to say, Hey, we're ready to move. That way when we do that position change from that seated up to standing, we're not necessarily getting that quick increase in those symptoms. We're trying to counteract any of those symptoms that may happen.

[00:20:34] Erin Spain, MS: And for some of these kids, they may have been a multi-sport athletes. Exercising may have been a huge part of their life and playing and just being outdoors and exercising. So how does this help some of those kids kind of get that part of their life back again?

[00:20:49] Brittany Holst, MS, CEP, EIM: Yeah, I think, that's a huge part of the patient population that we do see are those varsity athletes. Those can be some of the most challenging patients to get back exercising 'cause they're so used to being in that competitive sport. The big, I would say, concept with exercise and POTS is a gradual change, and having those gradual day-to-day changes and being able to understand that depending on your symptoms that day, you may have to adjust slightly, right? So if we said, I want you to walk for 15 minutes today, understanding that if you're having a more symptomatic day, it's okay to say, I'm gonna do 10 minutes, or I'm having a terrible symptom day, I'm gonna do five minutes. But that consistency and that gradual change is what helps patients get back to that activity or that level that they were at before the increase in their symptoms, a little easier. I try to enforce with all of my patients be kind to yourself. I know that seems so straightforward, but it's okay to have a more symptomatic day. It's going to happen. And I kind of call them our hills and valleys. So you may have a day where your symptoms are feeling great, and we wanna push ourselves and be more active, but keeping it consistent from day to day helps reduce those valleys or those more symptomatic days. We try to create a nice plateau to help manage symptoms.

[00:22:06] Erin Spain, MS: And so you've had a firsthand seat really to watch the progression of how this treatment can really help people. How gratifying that is to see these little maneuvers and the exercising really make an impact on the day-to-day life of these children.

[00:22:20] Brittany Holst, MS, CEP, EIM: Most definitely, I think from my perspective exercise for everyone can be challenging developing routine. If you had someone meeting with you routinely and saying, I'm here for your support or meeting a few times a week, right? You're gonna be more accountable. And for me, being in that position and seeing these patients that even more so are struggling to get to school because of their symptoms or just struggling to go out with their friends and walk around and all of a sudden after meeting with me for a month, two months, they're coming back and saying, Brit, guess what I did this weekend? I was able to go out and I did a two mile walk with my friends. I only had to take a few breaks, but I was able to do it. For me, just hearing that change in their quality of life and feeling like they can get out with their friends again, that's huge. Right. Especially since the majority of our patient population are high school to college age, we want them to have a normal high school and adolescent experience, right? So being able to be a part of that has been so rewarding.

[00:23:17] Erin Spain, MS: Well, thank you so much, Brittany, for sharing those success stories and more information about the exercise aspect of the program. I'm going to bring back Jillian Meyers and Jillian, as we wrap up the episode today, what advice would you like to give to people who may suspect that their child has POTS? What would you like them to know?

[00:23:36] Jillian Myers, MSN, APRN-NP, CPNP-PC: I think early referral is key. I think if you're suspecting POTS or have concerns about POTS, definitely having the patient see their primary care provider or pediatrician for that extensive evaluation, and if they think they are meeting criteria, then referring them early. We know there's definitely a correlation between getting patients in the door and starting these lifestyle modifications and how symptoms kind of trend overall. A lot of pediatricians can work on improved hydration, getting them started on a walking program. It doesn't have to be a structured exercise program to start. We say let's start with a 10 minute or a 15 minute walk every day. Just start there. So really get these patients moving. Looking at their diet, make sure they're not skipping breakfast, not skipping lunch, eating healthy meals. I also want to reinforce that, you know, medications are band-aids. They may help manage symptoms, but they're not gonna fix everything overall. So don't start medications early and don't start medications until lifestyle modifications have been initiated and maintained. We see many patients in clinic who are on medications and it just doesn't make them feel better. If anything, they feel worse because of the side effects of the medication.

[00:24:44] Erin Spain, MS: Well, thank you very much Jillian Myers, director of the POTS program here at Lurie children's and Brittany Holst, the lead POTS clinical exercise physiologist. This was a very enlightening episode. So thank you both for sharing your expertise today.

[00:24:58] Brittany Holst, MS, CEP, EIM: Thanks.

[00:24:59] Jillian Myers, MSN, APRN-NP, CPNP-PC: Thank you so much for having us.

[00:25:05] Erin Spain, MS: For more information, including how to make a referral or an appointment, visit luriechildrens.org.