Postural orthostatic tachycardia syndrome (POTS) frequently begins during adolescence. Symptoms can disrupt everyday function including school, social functions, and daily routine. POTS is often mistaken for anxiety disorder but its clinical diagnosis involves abnormal cardiovascular and autonomic responses to rising to an upright position.
Diagnosis is often delayed and even if identified the condition and its treatment can be confusing. A July 2026 study in the journal Nursing (1) wrote: “POTS management is often misunderstood, which may lead to misdiagnosis and invalidation by health care professionals.”
A December 2022 study published in Clinical pediatrics (2) from Johns Hopkins All Children’s Hospital suggested that doctors should better understand the adolescent and their parents feelings towards the disease, the treatments and their doctors to help the young patient cope and recover. In this paper the researchers found four common themes among a small group of adolescent POTS patients and their parents.
- Concern 1: There was expressed concern about the reduced or negative changes in adolescents’ functioning,
- Concern 2: The feeling that the patient was not believed, their condition could not be validated and the accompanying “difficulties living with an invisible condition.”
- Concern 3: Patients and parents had difficulties with medical trust and advocacy, and
- Concern 4: The patients and parents felt there was a need for increased resources and understanding.
The conclusion of course is that these concerns greatly impacted the well being of the family. Doctors should explore providing POTS Specific treatment recommendations and possibly consider mental health counseling.
POTS is different for Adolescents
A November 2022 paper in the journal Medicine (3) found adolescents with POTS demonstrated several unique characteristics compared to adults with POTS and adolescents without POTS. POTS may be underrecognized among syncope and presyncope patients, among which 22.4% of these adolescent patients were diagnosed with the syndrome.
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The researchers write: Adolescent postural orthostatic tachycardia syndrome has distinguishing features, with significantly lower resting diastolic blood pressure and heart rate, and more rapid conversion to maximum heart rate than adolescents without the syndrome.
In August 2000, Julian Stewart, M.D., Ph.D. of the Department of Pediatrics, The Center for Pediatric Hypotension, New York Medical College wrote in the journal Pediatric research (4) of his work to determine the nature of autonomic and vasomotor changes in adolescent patients with orthostatic tachycardia associated with the chronic fatigue syndrome (CFS) and the postural orthostatic tachycardia syndrome (POTS). These are the summary findings:
Heart rate and blood pressure responses before and 3-5 min after head-up tilt in 22 adolescents with POTS and 14 adolescents with CFS, compared with control subjects comprising 10 healthy adolescents and 20 patients with simple faint.
- Two of 10 healthy controls and 14 of 20 simple faint patients experienced vasovagal syncope during head-up tilt.
- By design, all CFS and POTS patients experienced orthostatic tachycardia, often associated with hypotension.
- R-R interval and heart rate variability were decreased in CFS and POTS patients compared with control subjects and remained decreased with head-up tilt. (Heart rate variability (HRV) refers to the variability between successive heart beats, specifically the R-R intervals on an EKG recording. If a person has a heart rate of 60 beats per minute, the average R-R interval would be 1 second but some R-R intervals may be 0.8 seconds and others 1.2 seconds. The variability between successful beats determines the HRV level, as well as its subcomponents.)
- Low-frequency blood pressure variability reflecting vasomotion was increased in CFS and POTS patients compared with control subjects and increased further with head-up tilt. This was associated with depressed baroreflex transfer indicating baroreceptor attenuation through defective vagal efferent response.
- Loss of beat-to-beat heart rate control may contribute to a destabilized blood pressure resulting in orthostatic intolerance. The dysautonomia of orthostatic intolerance in POTS and in chronic fatigue are similar.
A July 2026 study in the journal Pediatric Cardiology (5) comparing 19 adolescents with POTS to 44 healthy controls found that those with POTS had reduced heart rate variability (HRV), lower parasympathetic (vagal) activity, and relatively higher sympathetic nervous system activity, reflecting autonomic dysfunction. The Parasympathetic Nervous System Index (PNSi) was the best marker for distinguishing POTS from healthy individuals. The researchers concluded that Holter monitor-derived HRV measurements may provide a simple, noninvasive way to identify and characterize autonomic dysfunction in adolescents with POTS.
One-fifth of patients under 18 with POTS had EDS and over one-third of patients had hypermobility spectrum disorder
A March 2021 study published in the journal Autonomic Neuroscience: Basic & Clinical (7) examined the prevalence of joint hypermobility syndromes in pediatric Postural Orthostatic Tachycardia Syndrome.
Here are some of the observations of this paper:
- Patients with Postural Orthostatic Tachycardia Syndrome (POTS) have been shown to exhibit comorbid joint hypermobility manifested as Ehlers-Danlos Syndrome (EDS) or hypermobility spectrum disorder (HSD).
- While the prevalence of EDS and HSD in POTS has been demonstrated in smaller studies combining adult and pediatric patients, this paper examined a large series of pediatric patients to determine their prevalence in children with POTS.
In this study:
- Patients 18 years old, or less.
- POTS was diagnosed based on at least six months of frequent debilitating symptoms of orthostatic intolerance, plus a consistent heart rate increase of at least 40 beats per minute without orthostatic hypotension on the standing test.
- Patients with a Beighton score of at least 5/9 plus other systemic findings suggestive of EDS were further evaluated in Connective Tissue Disorders clinics.
Incidence:
- There were 362 patients examined for this study
- 82 patients had EDS (22.7%) and
- 141 patients had HSD (39.0%).
The researchers concluded: “Our evaluation of a large series of pediatric patients with POTS revealed that over one-fifth of patients had EDS and over one-third of patients had HSD. The awareness of the prevalence of comorbidities such as hypermobility disorders may help inform providers diagnosing and caring for these patients.”
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References
1 Gerik DJ, Cadet MJ. How does postural orthostatic tachycardia syndrome (POTS) affect pediatric patients?. Nursing2026. 2026 Jul 1;56(7):36-9. [Google Scholar]
2 Frye WS, King CK, Schaefer MR, Decker J, Kuhn B. “You look perfectly healthy to me”: Living with postural orthostatic tachycardia syndrome through adolescents’ and parents’ eyes. Clinical pediatrics. 2023 Jun;62(6):622-32. [Google Scholar]
3 Kim DH, Park JY, Kim SY, Lee NM, Yi DY, Yun SW, Lim IS, Chae SA. Awareness of postural orthostatic tachycardia syndrome is required in adolescent syncope. Medicine. 2022 Nov 11;101(45):e31513. [Google Scholar]
4 Stewart JM. Autonomic nervous system dysfunction in adolescents with postural orthostatic tachycardia syndrome and chronic fatigue syndrome is characterized by attenuated vagal baroreflex and potentiated sympathetic vasomotion. Pediatric research. 2000 Aug;48(2):218-26. [Google Scholar]
5 Kakavand B, Ebadi A, Kakavand AA, Rueda-De-Leon E. Holter-Based Heart Rate Variability Distinguishes Adolescent Postural Orthostatic Tachycardia Syndrome from Healthy Controls. Pediatric Cardiology. 2026 Jul 1. [Google Scholar]