AREAS OF FOCUS
Dysautonomia and POTS
Dysautonomia is when abnormal regulation of the autonomic nervous system causes symptoms. The autonomic nervous system controls functions we rarely think about: heart rate, blood pressure, digestion, and temperature. Postural orthostatic tachycardia syndrome, or POTS, is the form most often seen in teenagers. Its signature is simple to describe but hard to live with. When a young person with POTS abruptly stands up from a seated or lying down position, their heart races, and the adjustment in blood flow circulation is not fast enough to keep up. They feel dizzy, have grainy vision, hearing becomes muffled, and they sense that they might pass out. Tests that measure the heart itself usually come back normal, which is part of what makes the condition so easy to miss and so frustrating for families living with it.
Why positional change causes problems
In a healthy body, standing up triggers an automatic set of adjustments. Blood vessels constrict, other blood vessels dilate, the heart adjusts, and blood continues to flow evenly to the brain. In POTS, that automatic response does not work as it should. When a teenager with dysautonomia stands up abruptly, adjustment in blood circulation is sluggish, and the heart compensates by beating much faster, in some patients by thirty to forty beats per minute above its resting rate. The racing heart is not a disease itself; it is the body’s attempt to make up for a circulatory system that is not regulating itself well. The organs are healthy. The signaling that coordinates them has become unbalanced.
The symptoms, and why they cluster
POTS rarely presents with a single symptom, which is one reason it takes so long to diagnose. The hallmark is dizziness, faintness, or exhaustion upon standing, but it usually comes with others: a pounding or racing heart, fatigue that sleep does not relieve, brain fog, headaches, nausea, and difficulty tolerating heat or prolonged standing. Symptoms often ease when lying down and return upon standing. For a teenager, this can turn ordinary days, a full class schedule, a shower, or a wait in line into a real struggle, even though they look perfectly well from the outside.
Building tolerance back
Treatment helps more than families often expect, though it is not a quick fix. Because blood volume and circulation are central to POTS, treatment is steady and physical: more fluids, more salt and electrolytes under a doctor’s guidance, and a carefully graded exercise program that rebuilds aerobic capacity and blood flow regulation. Compression wear, better sleep, and attention to triggers such as heat also help. Medication is sometimes added when those measures are insufficient. Most teenagers improve with time and a consistent plan, and many find that the condition eases as they move into adulthood.
How Dr. Shulman approaches it
Dr. Shulman is a pediatric rheumatologist who cares for young people with dysautonomia and POTS, conditions that often accompany the chronic pain he treats and writes about in his forthcoming book, Cramp: A Doctor’s Notes on Pain. His approach begins with taking symptoms seriously, because these patients have often been told, incorrectly, that nothing is wrong. An accurate diagnosis matters, but the real work is helping a young person rebuild a functional daily life, which depends as much on being believed as on any prescription.
Frequently Asked Questions
Is POTS a real medical condition, or is my child just anxious?
POTS is a real medical condition. POTS and dysautonomia are clinical diagnoses, made from the pattern of symptoms rather than by ruling out other causes until only anxiety remains, and some patients also show a significant, measurable rise in heart rate when they change position. This overlap causes real confusion because a racing heart and lightheadedness can resemble anxiety, and living with an unpredictable illness can certainly cause worry. But the underlying problem is a nervous system that is not regulating circulation properly, and treating it as anxiety alone tends to leave the child no better off.
Why does my child feel fine lying down but sick when standing?
This is the defining feature of POTS. Lying down keeps blood evenly distributed, so the circulatory system is not under strain. Standing and physical activity require the body to move blood circulation against gravity, and in POTS that adjustment is sluggish, so the brain receives less blood than it needs. The heart races to compensate, producing dizziness, palpitations, and fatigue. The pattern of feeling better lying down and worse standing is not imagination, and it is the condition itself.
Why are all the heart tests normal if my child’s heart is racing?
Standard heart tests, such as an EKG or an echocardiogram, assess the heart’s structure and electrical function, and in POTS, those are usually normal. The heart is healthy. The problem lies in how the autonomic nervous system regulates heart rate and blood flow when a person changes position, which those tests are not designed to capture. POTS and dysautonomia are identified by the symptom characteristics. Measuring how the heart rate responds to positional change can be a helpful test.
Can teenagers grow out of POTS?
Many improve significantly. POTS that begins in the teenage years, sometimes after an illness, a growth spurt, or a period of prolonged inactivity, often improves with a consistent treatment plan, and a meaningful number of young people see their symptoms fade as they reach adulthood. Recovery is gradual and rarely a straight line, but the outlook is encouraging, especially when the condition is recognized early and managed with fluids, salt, and a steady return to activity.
What should I do if I think my child has POTS?
A useful first step is to clearly describe the pattern to a doctor: lightheadedness, a racing heart, and fatigue that occur when standing and ease when lying down. From there, families often work with a clinician familiar with autonomic conditions who can confirm the diagnosis and develop a plan. The most important early steps are to have the pattern recognized rather than dismissed, to start the fluid, salt, and graded-activity measures that form the foundation of care, and to avoid prolonged bed rest, which tends to make POTS worse rather than better.
Does POTS affect adults differently than teenagers?
The underlying mechanism, an autonomic nervous system that struggles to regulate circulation with positional change and physical activity, is the same at any age. The difference often lies in the trajectory. Teenagers frequently work through the symptoms of dysautonomia and POTS as they mature, whereas adults are more likely to have a longer course and other conditions alongside it. Dr. Shulman specializes in treating children and adolescents. Adults who recognize these symptoms can discuss them with their own physician or request a referral to a specialist in autonomic disorders, where the same principles of fluids, conditioning, and careful management apply.
For appointments or clinical questions, please contact Rady Children’s Health Orange County (formerly CHOC).