Podcast Summary:

The Pediatrician Next Door – Simple Advice on Parenting and Family Health
Episode: All in Your Head? POTS and the Diagnosis Doctors Miss
Host: Dr. Wendy Hunter
Guest: Dr. Jeff Boris (Pediatric Cardiologist & Autonomic Specialist)
Date: February 18, 2026

Overview

This episode explores Postural Orthostatic Tachycardia Syndrome (POTS)—a commonly misunderstood and underdiagnosed condition that affects the autonomic nervous system, especially in adolescents and young adults. Dr. Wendy Hunter, joined by Dr. Jeff Boris, delves into the clinical presentation, triggers, diagnosis, and management of POTS, highlighting why it so often goes unrecognized by both doctors and families.

Main Discussion Points & Key Insights

What is POTS & Why Is It So Often Misdiagnosed?

• Classic Patient Story:
  Dr. Hunter opens with an example of a healthy 15-year-old soccer player who becomes frequently dizzy, fatigued, and unable to function normally. Despite multiple tests, everything appears “normal,” and she’s told it's anxiety or stress (03:00–04:30).

• Dysautonomia Defined:
  Dr. Boris explains:

  "Dysautonomia is an umbrella term... Dysautonomia is not a diagnosis. It's a description of a problem. But an actual diagnosis would be more like syncope and POTS and orthostatic hypotension." (05:16–06:00)
  This underlies the confusion and frustration for patients and families.

• Invisible Symptoms and Gender Bias:
  Many POTS symptoms—lightheadedness, fatigue, cognitive dysfunction—are invisible, which leads to disbelief or dismissal, especially among female patients.

  "The symptomatology for a lot of this is invisible... And females, both girls, adolescent females and women, have been marginalized by the medical establishment for decades." (06:20–07:24)

• Prolonged Diagnostic Odyssey:

  "Half of patients saw at least seven providers before getting a diagnosis, and 23% saw at least 10 clinicians." (07:55–08:20)

What Causes POTS? (08:56–11:30)

• Post-Infectious and Other Triggers:
  Infection is "the number one trigger for POTS" (Dr. Boris, 09:06). It can follow various infections, including mono (Epstein-Barr virus), Lyme disease, or even COVID-19.

• Other Triggers:
  Concussion, surgery, trauma, growth spurts, menarche, and possibly (controversially) HPV vaccination can all act as triggers. (10:47–11:27)

• COVID-19 Connection:
  POTS cases have surged post-pandemic, with estimates rising from “1 to 3 million” to “3 to 8 million” in the US, possibly around 2% of the population.

  "Pre-pandemic estimates were about 1 to 3 million... Post-pandemic, probably more like 3 to 8 million. So at least 2% of the general population." (08:30–08:55)

Overlapping Diagnoses & Symptom Complexity

• Post-Concussion Syndromes:
  Dizziness, vertigo, and convergence (eye) disorders can mirror or coexist with POTS symptoms—making diagnosis and management trickier (11:27–12:34).

• Symptom Range:
  POTS is more than dizziness or rapid heart rate—symptoms cover cardiovascular, neurologic, and GI systems:

  • Lightheadedness, syncope
  • Fatigue, brain fog, insomnia
  • Nausea, constipation, abdominal pain
  • Muscle/joint pain, headaches, heat intolerance, sensory sensitivities (13:18–14:59)

How Is POTS Diagnosed? (13:18–16:00)

• Heart Rate Response is Key:
  In adolescents, a hallmark is an increase in heart rate of 40+ beats per minute within 10 minutes of standing, with no drop in blood pressure (16:00–17:00).
• Sustained & Reproducible:
  Must be consistent for at least three months and involve daily functional impairment—not just occasional dizziness.

Comorbidity and Complications (19:58–22:40)

• Presentation in Younger Kids:
  POTS can be seen in children as young as six (19:58–20:09).

• Common Co-conditions:

  • Joint Hypermobility: 75% of POTS patients (20:25–20:54)
  • Mast Cell Activation Syndrome (MCAS): Up to 70% may have MCAS, leading to symptoms like flushing, hives, headaches, GI issues.

• MCAS Treatments:

  "Entry level therapy for a lot of them. H1 and H2 blockade. So, you know, twice a day, Zyrtec, twice a day, Pepcid takes care of a lot of these patients..." (21:32–22:39)

Pathophysiology—What’s Gone Wrong? (23:12–24:59)

• Blood Pooling & Autonomic Response:
  Blood pools in the extremities and abdominal vessels, not returning to the heart. The brain senses this as low blood flow and ramps up heart rate (“the hypothalamus tries its best, but it just cranks up the heart rate and tries to crank up the blood pressure as best as possible. In a not particularly winning approach.” – Dr. Boris, 23:12–24:11)

• Analogy:
  Dr. Hunter: “Imagine you're trying to fill an empty bucket. If you move the bucket around too fast, it never fills all the way. When the heart races, it doesn't have enough time to fill with blood between the beats.” (24:11–24:59)

Memorable Quotes

• Dr. Boris:
  "The symptomatology for a lot of this is invisible. It's hard to demonstrate lightheadedness, fatigue, cognitive dysfunction, or brain fog, insomnia, nausea, those kind of things." (06:20)
• Dr. Hunter:
  “For a long time, kids with symptoms like this were told that maybe they were anxious or deconditioned. And now we're realizing that a lot of these kids weren't imagining anything.” (30:40)
• Dr. Boris:
  "It's a syndrome. We don't understand in 2026, we don't understand the underlying pathophysiology still. We think that for most, if not all patients, there's probably some aspect of autoimmunity, but, you know, haven't proven that yet." (06:30)

Timestamps for Key Segments

• [04:30] Introduction to case study and why doctors miss POTS
• [05:16–06:06] Dysautonomia and umbrella terms explained
• [06:20–08:55] The invisible nature of POTS, gender bias, and the diagnostic journey
• [08:56–10:47] Causes and triggers, including post-infectious onset and the pandemic
• [11:27–12:34] Overlap between concussion symptoms and POTS
• [13:18–14:59] Range of symptoms and diagnostic criteria for POTS
• [16:00–17:00] Heart rate change as diagnostic key (with no BP drop)
• [19:58–20:09] POTS seen in younger children
• [20:21–22:39] Comorbidities (joint hypermobility, MCAS), MCAS symptoms, & simple antihistamine therapy
• [23:12–24:59] What’s actually happening in the body, blood pooling analogy
• [25:27–28:17] Foundational and symptomatic treatments for POTS
• [28:17–29:07] Exercise protocol specifics and physical therapy insight
• [29:27–30:40] Individualized meds and the link to long COVID

Treatment Approaches

Foundational, Non-Pharmacological (25:27–28:17)

• Hydration & Salt: 80–120 oz fluid/day, 8–10g sodium daily.
• Head of Bed Elevation: 6–8 inches for early morning symptoms.
• Abdominal Binders: Prevent blood pooling in the belly.
• Cooling Vests: For patients with heat intolerance.
• Exercise Protocol:
  • Start “low and slow,” recumbent exercises first (bike, row, swim).
  • Transition upright around month 4.
  • Dysautonomia International’s "Dallas CHOP POTS protocol" recommended (searchable online).

Pharmacological

• Symptom-Targeted Meds:
  Medications are chosen based on top patient complaints (e.g., heart rate, GI issues, brain fog).
• MCAS Management:
  H1/H2 blockers (Zyrtec, Pepcid) for allergy-type symptoms.

"Non-pharmacologic therapies are foundational. So you gotta do those... My goal is to allow them to do their activities... and to exercise, because consistent and progressive exercise really does help." (25:27–27:15)

The Long COVID Connection

• COVID-19 has “given us a clearer window” into POTS after viral infections, and about 30% of long COVID cases may actually be POTS (29:54–30:36).
• Treatments for long COVID with an autonomic/pots-like pattern are largely similar.

Call to Action & Closing Thoughts

• Share knowledge about POTS—especially for misunderstood children, teens, and young adults.
• If a young person has unexplained dizziness, rapid heart, profound fatigue, or brain fog, consider POTS.
• For clinicians: “Stay curious. These are the patients that medicine missed for a long time. We're not done learning, and we are moving in the right direction.” (30:40–31:10)

Resource Mentioned:

• Dallas CHOP POTS Exercise Protocol — Available via Dysautonomia International.