Decreased milk drinking causing flecainide toxicity in an older child.

Flecainide is a class IC antiarrhythmic agent, used frequently in all age groups for the treatment of tachyarrhythmias. Flecainide blocks the voltage-gated sodium channel in the myocardium, leading to prolongation of depolarisation resulting in slowed conduction velocity. Within a paediatric population, flecainide is indicated primarily for supraventricular tachycardia resulting from atrioventricular nodal re-entry and accessory pathway mediated re-entry. It can be considered for use in patients with atrial tachycardia, fascicular ventricular tachycardia, benign right ventricular outflow tract tachycardia and paroxysmal atrial fibrillation. It is well documented to cause paradoxical proarryhthmia in children, with evidence that milk can reduce absorption in infants. The authors present the case of an older child whose flecainide levels were persistently subtherapeutic until he reduced his milk intake. At this time he developed symptoms of severe flecainide toxicity associated with increased levels.