Clinical Approach to Syncope in Children

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Pediatric syncope is one of the most common neurological problems in the pediatric population in both the office setting and in the emergency department. The abrupt brief loss of consciousness is usually dramatic and alarming to patients, family, onlookers, and providers. The differential diagnosis of syncope is wide but most cases are benign. A comprehensive but focused history and a thorough clinical examination are usually the cornerstones in the diagnosis of high-risk patients. It should be noted that the evaluation of syncope in children is costly and testing provides a low diagnostic yield. This chapter reviews the various types of syncope and provides a succinct clinical approach to the diagnosis, investigation, and management of 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.

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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