Clinical Approach to Syncope in Children
Introduction
Syncope is defined as the abrupt loss of consciousness and postural tone resulting from transient global cerebral hypoperfusion followed by spontaneous complete recovery.1 Presyncope is the feeling that one is about to pass out but remains conscious with a transient loss of postural tone.2
In the young patient, syncope often results from a fall in systolic pressure below 70 mmHg or a mean arterial pressure of 30-40 mmHg.3, 4 The syncopal event is typically preceded by a prodrome lasting from several seconds to 1-2 minutes characterized by distinctive premonitory features such as nausea, epigastric discomfort, blurred or tunnel vision, muffled hearing, dizziness, light-headedness, diaphoresis, hyperventilation, palpitations, pallor, cold and clammy skin, or weakness.4 These symptoms may occur in any combination or be variably present in any given patient from 1 episode to the next.4 Most cases of pediatric syncope are benign but an evaluation must exclude a rare life-threatening cardiac or noncardiac disorder. Furthermore, the term syncope may have different meanings to different people, therefore specific questions should be asked to help differentiate cardiac from neurologic, psychogenic, and metabolic conditions.
Section snippets
Epidemiology
Syncope is a common pediatric problem, affecting 15%-25% of the children and adolescents.4 The incidence peaks between the ages of 15 and 19 years for both sexes but there appears to be a female predominance.5 Before age 6, syncope is unusual except in the setting of seizures, breath-holding spells, and cardiac arrythmias.1 In contrast to adults, neurocardiogenic syncope or vasovagal syncope or vasodepressor syncope is the most frequent cause of pediatric syncope (61%-80%).6 Syncope secondary
Etiology
A detailed history of the event followed by a comprehensive physical examination will help in categorizing syncope into the 3 major categories:
- (a)
Neurally mediated syncope
- (b)
Cardiovascular mediated syncope
- (c)
Noncardiovascular syncope.
Neurally mediated syncope and cardiovascular-mediated syncope, each accounts for about 50% of the cases of syncope in adults but in children cardiovascular-mediated syncope is less frequent than it is in adults.8 The differential diagnosis of syncope is given in Table 1.
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Treatment
The objective of treatment for neurocardiogenic syncope is to prevent recurrent syncope which leads to impaired quality of life, psychological distress, and substantial morbidity including frequent absence from school. The mainstay of treatment of neurocardiogenic syncope is education and counseling of the patient and his or her parents.4 The benign nature of these events should be explained to the patient and the parents and they should be reassured that these episodes would not result in
Conclusion
Syncope is a common presenting problem in children with a wide differential diagnosis. Most causes of syncope are benign but rarely may be the first warning sign of a serious underlying cardiac or noncardiac disease. The key to identifying high-risk patients is a detailed history and a comprehensive physical examination. This approach will guide practitioners in choosing the diagnostic tests that are appropriate for a given patient. Key features in the history and physical examination that
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Evaluation of changes in physician behavior after introduction of pediatric syncope approach protocol in the emergency department
2022, American Journal of Emergency MedicineCitation Excerpt :Therefore, detailed history and physical examination are important parts of the assessment in syncope patients. It is recommended that the characteristics of syncope (prodromal findings, predisposing factors, association with exercise) and the history of sudden death in the family be inquired, and cardiac, neurological and ECG warning signs should be evaluated in all patients [3,4]. Syncope patients create a significant burden in terms of resource use, length of stay and cost in the PED.
Demographic and clinical features of pediatric patients with orthostatic intolerance and an abnormal head-up tilt table test; A retrospective descriptive study
2020, Pediatrics and NeonatologyCitation Excerpt :Patients with OI receive diagnoses such as, but not limited to postural tachycardia syndrome (POTS), neurocardiogenic syncope, orthostatic hypotension, vasovagal syncope, etc.2,3 A comprehensive history, physical examination, bedside orthostatic testing, and an electrocardiogram (ECG) are appropriate for diagnosis. Preventive measures for postural intolerance and reassurance are adequate in most cases.4–6 However, many patients with OI have limitations of daily activities with reduced school attendance and impaired quality of life.7
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2018, Cardiac Electrophysiology: From Cell to Bedside: Seventh EditionSyncope and Dizziness
2018, Nelson Pediatric Symptom-Based DiagnosisThe Use of Echocardiography for Pediatric Patients Presenting with Syncope
2017, Journal of PediatricsSyncope and Dizziness
2017, Nelson Pediatric Symptom-Based Diagnosis