Check out the Fits, Faints and Funny Turns – referral pathway (1) resource provided by Bristol Royal Hospital for Children.

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All children who experience a syncopal episode should undergo a thorough history and examination (1)

An in-depth review of the incident provides crucial information to uncover the cause of syncope and direct further investigations. It is recommended to gather details such as:

• Health: Was the child healthy at the time of the event?
• Prodromal symptoms: Any warning signs before syncope?
• Triggers: Specific factors leading to syncope?
• Duration: How long did the episode last?
• Nature of movements: Description of any movements.
• Truncal and limb tone: Any changes in trunk and limb muscle tone.
• Focal symptoms: Any signs of focal abnormalities.
• Recovery: Post-syncope symptoms and recovery time.
• Relevant context prior to the event (infections, pain, headaches, vomiting, etc.).

Examination

A complete assessment, including neurological and cardiovascular evaluations, should be conducted to identify signs of injury or non-accidental causes.

Investigation

• Children with loss of consciousness need Glucose, ECG, and Blood Pressure tests.
• Children experiencing syncope require lying and standing blood pressure assessments in addition to the above tests.
• Additional tests such as echocardiogram, Holter monitoring, and exercise stress tests may be considered depending on individual cases.

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Ordinarily, non-urgent ECGs for children are performed in primary care settings.

No specific ECG service for children exists in secondary care, with adult ECG services accepting referrals for patients aged 16 and above only.

If interpretation of an ECG from primary care is needed, consider seeking pediatric advice and guidance.

For urgent interpretations, refer to the Urgent Care Referrals page or consult with an on-call pediatric cardiologist.

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Criteria for referral to General Pediatrics clinic through eRS:
• Children under 8 years with unexplained syncopal episodes
• Any other concerning undiagnosed episodes

Criteria for Cardiology Referral through eRS or immediate discussion for red flag cases:
• Syncope during exercise or when lying down
• Family history of sudden death, prolonged QT syndrome, or hypertrophic cardiomyopathy
• Syncope following palpitations
• Syncope in a child with known heart defects
• Heart murmur or other cardiovascular abnormalities on examination or ECG

Additional information:
• It is important to note that syncopal episodes can be caused by a wide range of factors, including cardiac issues, neurological conditions, dehydration, or simply standing up too quickly.
• Detailed history-taking and thorough physical examination are crucial in evaluating a child with syncope.
• In cases of uncertain diagnosis or persistent symptoms, further investigations such as Holter monitoring, echocardiogram, or tilt table testing may be necessary.
• Collaboration between General Pediatrics and Cardiology teams is essential for comprehensive care and management of pediatric syncope.

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NICE guidelines

While every effort is made to ensure the accuracy and compliance of these guidelines, BNSSG ICB does not guarantee it. These guidelines do not replace healthcare professionals’ individual judgment or decisions made in consultation with patients or guardians, as well as in accordance with the law and drug characteristics. Practitioners must fulfill their duties according to legal requirements, and adherence to those duties takes precedence over this guidance.

Information from Remedy is regularly updated, so printed materials may become outdated quickly.

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In children, syncope is commonly neurally mediated and typically resolves on its own. This paper aims to differentiate severe causes of syncope from benign neurally mediated episodes and identify patients who could benefit from medical intervention.

Keywords: Evaluation, Syncope

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Generally, syncope in children is neurally mediated and tends to resolve spontaneously. This condition involves a temporary loss of consciousness due to a reversible disruption of cerebral function. Proper differentiation allows for the identification of neurally mediated syncope patients who may benefit from medication, distinguishing them from more common non-cardiac episodes in childhood.

It is important for healthcare providers to conduct a thorough evaluation of children who experience syncope to rule out underlying cardiac conditions that may require further intervention. While neurally mediated syncope is mostly benign, being vigilant and seeking medical advice can help ensure the safety and well-being of young patients. Parents and caregivers should also be educated on recognizing warning signs and how to respond in case of a syncope episode.

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Syncope can be categorized into three groups: NMS, cardiovascular syncope, and non-cardiovascular syncope (Table 1). The second category presents the most concern due to potentially life-threatening causes.

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Causes of syncope

NMS, also known as vasovagal syncope, is a common cause of syncope in young individuals, linked to hypersensitive receptors triggering an efferent response.

NMS presents with warning signs followed by unconsciousness, often triggered by stress or dehydration. Cardiovascular syncope, although less frequent, requires a comprehensive assessment for accurate diagnosis and prognosis, involving both primary cardiac anomalies and various arrhythmias.

Risk factors pointing to cardiac syncope include no prodrome, prolonged unconsciousness, syncope during physical activity, chest pain, past heart conditions, or family history of heart diseases.

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A thorough clinical examination is essential for distinguishing between cardiac, noncardiac, and NMS syncope. ECG and additional tests aid in determining the underlying cause, particularly in suspected arrhythmia cases.

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Treatment for NMS initially focuses on lifestyle changes, such as avoiding triggers and increasing blood volume. Medical intervention may include beta-blockers, with further measures rarely necessary. It is also important for patients with NMS to stay well-hydrated and to maintain a balanced diet to support overall health and well-being.

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Conservative measures are recommended for NMS, with gradual improvement anticipated over time. Avoiding dehydrating factors and maintaining regular routines may help manage symptoms. Medication could be considered if lifestyle modifications are ineffective, with pacemaker intervention seldom required.

For cardiac syncope, treatment options depend on the cause, such as beta-blockers for long QT syndrome, medical therapy for cardiomyopathy, surgical procedures for heart obstructive lesions, and pacemaker therapy for heart block or sick sinus syndrome. Implantable defibrillators are rarely necessary.

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In children, syncope typically stems from neurally mediated causes and resolves naturally. Initially, conservative approaches should be attempted before considering pharmacological intervention. Suspecting cardiac syncope requires a comprehensive evaluation involving history, physical examination, and ECG.

It is important to differentiate between neurally mediated syncope and cardiac syncope in children as the treatment approaches differ. Neurally mediated syncope is usually benign and can often be managed with lifestyle modifications, such as increasing fluid intake and avoiding triggers. On the other hand, cardiac syncope may require further testing, such as echocardiograms or Holter monitoring, to determine the underlying cause.

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• Manolis AS. Evaluation of patients with syncope: Focus on age-related differences.
• Calkins H, Seifert M, Morady F. Clinical presentation and long-term follow-up of athletes with exercise-induced vasodepressor syncope.
• Wolff GS. Unexplained syncope: Clinical management.
• Braden DS, Gaymes CH. The diagnosis and management of syncope in children and adolescents.
• Tanel RE, Walsh EP. Syncope in the pediatric patient.
• Brignole M, Menozzi C, Gianfranchi L, et al. A controlled trial of acute and long-term medical therapy in tilt-induced neurally-mediated syncope.
• Lewis AL, Zlotocha J, Henke L, Anwer Dhala. Specificity of head-up tilt testing in adolescents.
• Found FM, Sitthisook S, Vanerio G, et al. Sensitivity and specificity of the tilt table test in young patients with unexplained syncope.
• Lerman-Sagie T, Rechavia E, Strasberg B, Sagie A, Blieden L, Mimouni M. Head-up tilt for the evaluation of syncope of unknown origin in children.
• Luckstead EF. Cardiovascular evaluation of the young athlete.
• Morillo CA, Leitch JW, Yee R, Klein GJ. A placebo-controlled trial of intravenous and oral disopyramide for prevention of neurally-mediated syncope induced by head-up tilt.

Articles from Paediatrics & Child Health are provided here courtesy of Oxford University Press

Key factors from medical history and physical examination can help identify cardiac syncope in children. Consider involving pediatric cardiologists for further assessment.

Occurs in a child below 8 years old

In young children, a thorough history can help distinguish between syncope and breath-holding spells.

Occurs during physical activity

If syncope happens during exercise, it may indicate the need for further investigation into conditions like hypertrophic cardiomyopathy.

Is preceded by chest discomfort

Chest pain before a syncopal episode is unusual and could point to a different underlying issue.

Results in significant physical harm

If syncope leads to severe injuries, it might suggest a more serious hidden condition.

Results in near drowning

Although rare, syncope that leads to near drowning is concerning due to the risk of oxygen deprivation.

Is accompanied by seizure activity and post-seizure state

Seizure activity following syncope could indicate a longer recovery period and necessitate further evaluation.

Shows focal neurologic findings post-syncopal event

Unusual neurologic findings after syncope require a comprehensive assessment to rule out other potential conditions.

A family history of heart conditions like cardiomyopathy, sudden death, arrhythmias, or young relatives with pacemakers/defibrillators should raise suspicions of cardiac syncope.

Cardiomyopathy

Cardiomyopathy is a cardiac muscle disease affecting the heart’s ability to pump blood. There are various types, each contributing to different cardiac complications.

Sudden death in individuals under 50 years old

Early sudden deaths within the family could suggest underlying cardiac problems that require investigation.

A relative under 50 with a pacemaker or defibrillator

The presence of pacemakers or defibrillators in young family members might indicate hereditary heart conditions.

QTc interval >470 msec

A prolonged QTc interval can lead to syncope and sudden cardiac death. It warrants a referral to a cardiologist.

Pre-excitation

Patients with pre-excitation have an extra pathway bypassing the AV node. Features include Wolff-Parkinson-White syndrome with pre-excitation on EKG and tachycardia episodes. Key EKG characteristics of pre-excitation are:

• PR interval
• “Delta wave” with slurring of the initial QRS portion
• QRS prolongation >110ms
• ST Segment and T wave discordant changes
• Pseudo-infarction pattern in up to 70% of patients

Brugada pattern

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Brugada pattern resembles a pseudo-right bundle branch block with persistent ST segment elevation in leads V1-V3. ST segment elevation >2mm followed by a negative T wave. It is caused by a genetic sodium channel mutation and is more prevalent in Southeast Asia.

Abnormal voltage levels and intervals

Consult age/gender-specific norms to calculate peaks and intervals for patient safety and potentially refer to a Cardiologist. Signs of ventricular hypertrophy can include abnormal LVH, upright T wave in V1, or First degree AV block with PR interval >250 msec.

Pathological ST segment alterations

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In healthy adolescents, ST segment upsloping after QRS complex, known as “J-point elevation”, may be present. Benign early depolarization is common in young hearts. Notching of the J-point in lead V4 gives a “fish hook” appearance. The prominence can vary with heart rate, necessitating good EKG interpretation skills.

Specific signs such as systolic ejection murmur in aortic stenosis, differences in pulse quality in coarctation of the aorta, or murmurs in hypertrophic cardiomyopathy may diminish with increased venous return. Other indicators include rales, friction rub, gallop, LOUD S2, and hepatosplenomegaly in cases of heart failure.

References:

• Evans WN, Acherman RJ et al. Simplified pediatric electrocardiogram interpretation.
• Friedman KG, Alexander ME et al. Diagnosis of cardiac disease in children with chest pain and syncope.
• Healey JS, Toff WD et al. Cardiovascular outcomes in atrial vs ventricular pacing.
• Hurst D, Hirsh DA et al. Predicting cardiac disease in pediatric syncope cases.
• Gillette PC, Garson A Jr. Sudden cardiac death in pediatrics.