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When Children Faint _ Non-cardiovascular Syncope: Causes&Treatment

Online Health Chat with Dr. Manikum Moodley

September 29, 2011


Introduction

Cleveland_Clinic_Host: Syncope -- also called fainting, blacking out, or passing out -- is a sudden loss of consciousness, followed by a fall from a standing or sitting position. It is a condition that is caused by a decrease in blood flow to the brain. Blood contains oxygen, so when blood flow to the brain decreases, oxygen to the brain also decreases.

Certain heart or brain conditions and a sudden change in position may cause syncope. Signs and symptoms include light-headedness, dizziness, cold sweaty skin, and feeling more tired than usual.

There are different types of non-cardiovascular syncope, which include neurological syncope usually caused by seizure disorders, such as epilepsy, and other problems of the nervous system, including stroke, transient ischemic attack (TIA) or other rare causes including migraines and normal pressure hydrocephalus; orthostatic hypotension, an inability to maintain normal blood pressure while standing, is often due to disorders of the autonomous nervous system (ANS), which regulates most "automatic" bodily functions. It may occur in otherwise healthy people as a result of standing for long periods, exercise, overheating, or other forms of stress.

Syncope affects people of all ages, from toddlers to the elderly. More than 100,000 adults and children visit a doctor each year with complaints of fainting spells.

Dr. Moodley is a staff member of the Cleveland Clinic Neurological Institute’s Center for Pediatric Neurology. At Cleveland Clinic, he is involved in neonatal neurology and in the clinical management of patients with pediatric multiple sclerosis and white-matter disorders, pediatric neuromuscular disorders, neurofibromatosis, syncope and autonomic disorders, and neurodevelopmental disorders.

Cleveland_Clinic_Host: To make an appointment with Manikum Moodley, MBChB, or any of the specialists in the Neurological Institute’s Center for Pediatric Neurology at Cleveland Clinic, please call 866.588.2264. You can also visit us online at www.clevelandclinic.org/pediatricneurology

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Manikum Moodley, MBChB. We are thrilled to have him here today for this chat. Let’s begin with some of your questions.

stay_cool: Does my child have a type of seizure?

Dr__Manikum_Moodley: When a child goes to the doctor or to the emergency room with what looks like syncope, one of our differential diagnoses -- something we need to rule out -- would be a seizure disorder.

So, how does one differentiate a seizure from syncope? A seizure does not have symptoms ahead of time, such as lightheadedness, visual changes (e.g., blurriness), nausea, vomiting, etc. These symptoms are common in syncope. Furthermore, patients with seizures may lose consciousness for a much longer period of time than with syncope.

Patients with seizures also have convulsive movements, and these movements can be clonic or myoclonic. Also, patients with seizures have a prolonged postictal phase during which time their level of consciousness is still altered. In patients with syncope, the altered level of consciousness lasts only a few seconds and not more than a minute. Also, in patients with seizures, associated signs may include: urinary incontinence, tongue biting, eye deviation, and sometimes fecal incontinence.


Causes

jelly_beans: What are the causes of syncope and how common is it?

Dr__Manikum_Moodley: Syncope has numerous causes; but in children, the most common cause is a simple faint, which is also called 'vasovagal syncope,' 'vasodepressive syncope,' or 'neurocardiogenic syncope.'

Other causes of syncope include: cardiovascular mediated syncope, situational syncope, drug-induced syncope, reflex syncope (similar to vasovagal syncope), psychogenic syncope and – rarely -- syncope due to metabolic disorders.

While vasovagal syncope is the most common in children, cardiovascular mediated syncope is also important to rule out in the emergency department.

In the pediatric emergency room, 1 percent to 3 percent of admissions will be secondary to syncope.

jigg: What triggers fainting and how can we prevent fainting?

Dr__Manikum_Moodley: Triggers of syncope in kids include:

  • prolonged upright posture
  • prolonged standing
  • change in posture (orthostasis)
  • crowding
  • heat
  • fatigue
  • hunger
  • a concurrent illness

Emotional or stress factors -- such as venipunctures, public speaking, pain, and fear -- are commonly associated triggers for fainting in children.


Types of syncope

Kat72: What is psychogenic syncope?

Dr__Manikum_Moodley: One of the most important causes of syncope in pediatric patients, in particular adolescents, is psychogenic syncope. Several features will help a physician to distinguish psychogenic from neurocardiogenic syncope.

  • The episodes are extremely frequent (sometimes several per day).
  • The episodes are not associated with injury. There are usually no precipitating or triggering factors.
  • Patients experience syncope in the supine position.
  • Patients fail to regain consciousness rapidly after a fainting attack (usually takes several hours).
  • Patients show remarkable indifference to their syncope. During tilt table testing, these patients may suddenly faint without any changes in heart rate or blood pressure.

A detailed psychosocial history may be enlightening about possible mechanisms involved. Many patients have conversion reactions, most often secondary to sexual abuse. Appropriate referral to a behavioral psychologist or pediatric psychiatrist for further evaluation and management is recommended.


Symptoms

playdoh: My child often gets dizzy and lightheaded. When this happens, I just give him something to eat. Does he need to see a doctor?

Dr__Manikum_Moodley: Dizziness in children can have several causes. It could be a pre-syncopal symptom; it could occur prior to a migraine; it could be related to an inner ear problem (for example, labrynthitis from a viral infection); or it could be due to a cardiac lesion.

Occasionally metabolic disorders such as hypoglycemia may result in dizziness.

If your child is better with eating, he may have mild hypoglycemia. Drinking extra water may be a simple way of treating vasovagal or reflex syncope.

vallieds: Sometimes, we know my son is about to faint because he gets very lightheaded. Are there any other signs we should look for?

Dr__Manikum_Moodley: An episode of fainting is typically preceded by a period called a prodrome that can last from several seconds to one to two minutes. This period usually has distinctive warning features such as:

  • Nausea
  • Blurred or tunnel vision
  • Muffled hearing
  • Dizziness
  • Lightheadedness
  • Sweating
  • Hyperventilation
  • Palpitations
  • Pallor
  • Cold and clammy skin
  • Weakness

These symptoms may occur in any combination or be variably present in any given patient from one episode to the next. If the prodrome period lasts long enough, a child -- like your son -- can learn to recognize the signs that he or she is about to faint and can lie down or relax to relieve the symptoms.


Diagnosis

sonja: If my child is fainting, does he have a serious heart condition? Will he die if he has another attack?

Dr__Manikum_Moodley: If a child presents with syncope, the first thing to look for would be a cardiac cause. However, it is less common than vasovagal syncope.

So what is important in the assessment of a child presenting with syncope is a comprehensive but focused history, a comprehensive but focused clinical examination, and an EKG. In combination, the chance these three together can yield the diagnosis is 50 percent.

Patients who have vasovagal syncope may have frequent attacks, but these attacks are benign. However, if a patient has a fainting attack from a cardiac cause, and if it is not treated, the prognosis can be serious.

lilybelle: How does a ‘history’ help you make a diagnosis of syncope?

Dr__Manikum_Moodley: The patient history is the cornerstone on which the diagnosis of syncope is made. Important points in the history include:

  • Hydration status – Was your child dehydrated before he fainted?
  • Environmental conditions – Where was he and what was the environment like?
  • Activity immediately before the syncopal event – What was going on and what was your child doing?
  • Frequency and duration of the episode – How often does your child faint and how long does the syncopal event last?
  • Any symptoms preceding the fainting (prodromal) – What symptoms does your child experience before he or she faints?
  • Historical data from witnesses – Have you or anyone else seen it when your child faints? What happens?
  • A complete drug history (patient) – What medications does your child take?

From the family, it is important to obtain the following history:

  • Family history of syncope or cardiac disease
  • Sudden unexplained death in children or young adults
  • Family history of seizures
  • Family history of deafness

brady: What tests will my child have to find the cause of her fainting attacks?

Dr__Manikum_Moodley: The doctor can use certain diagnostic tests for a child with frequent fainting attacks. Before diagnosing syncope, it is important to rule out other causes, such as seizure disorders or cardiac problems as the reason for the fainting.

  • They will do blood tests -- including a complete blood count, complete metabolic panel and a pregnancy test in children who are menstruating.
  • An EKG should be obtained on all patients with recurrent syncope or if the syncope occurs with exercise.
  • Also to differentiate a simple faint from a seizure disorder, one can obtain an EEG or a video EEG. All patients with recurrent syncope, family history of syncope or sudden unexplained death should be referred to cardiology for further evaluation. Testing may include echocardiography, and a Holter or event monitor.
  • In patients with recurrent syncope, autonomic testing in the form of a tilt table may be performed to rule out autonomic dysfunction, including postural orthostatic tachycardia syndrome (POTS). However, it should be noted that experience with tilt table testing with pediatric patients is limited.

olivia1: What happens during a tilt table test?

Dr__Manikum_Moodley: The test is done by positioning the patient head upright at an angle of 60-80 degrees for 15 to 60 minutes on a tilt table with a supporting footboard. The test is positive when the symptoms of syncope or pre-syncope are reproduced.

Again, I want to point out that more controlled studies are necessary to validate and standardize this test as a safe, practical, and useful tool for diagnosing neurogenic syncope in children.


Treatment

calm_seas: What is the treatment of syncope?

Dr__Manikum_Moodley: Once a diagnosis of neurocardiogenic or vasovagal syncope is confirmed, treatment requires:

  • Counseling of the patient (when appropriate) and his/her parents - The benign nature of these events should be explained to the patient and parent to allay anxiety about epilepsy or sudden death from this condition.

    Most patients presenting after a single uncomplicated syncopal event require: simple reassurance, education about the disease, advice on recognizing prodromal symptoms and how to avoid triggers. These triggers are: prolonged standing, sudden changes in posture, dehydration, and irregular meal times. If a prodromal phase is consistently present, a patient may be taught to recline or sit to avoid injury from a fall.
  • Supplemental fluids and electrolytes may be beneficial (Gatorade) for adolescents: 1.5-2.5 liters of fluid are recommended.
  • Patient should be instructed to increase dietary salt given either as salt tablets or liberal use of salt with meals.
  • Physical counter maneuvers can be done, including leg crossing, squatting, or buttocks tensing.
  • Elastic stockings worn below knee with pressure of 2-30 mm mercury
  • Abdominal binders
  • Psychological counseling.

Medications for treatment of recurrent retractable cardiogenic syncope include:

  • beta blockers
  • anticholinergics
  • alpha agonists
  • serotonin uptake inhibitors
  • mineral corticoids (fludrocortisone)

General Questions

dipanfp: Will a child have this problem all his life?

Dr__Manikum_Moodley: The prognosis for recovery is excellent in neurocardiogenic syncope. Most patients show spontaneous recovery of their syncope and presyncope in the first year after onset. Five percent to 10 percent, will, however, continue to show symptoms over an extended period of time, often up to five years.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Manikum Moodley is now over. Thank you again, Dr. Moodley for taking the time to answer our questions about When Children Faint – Non-cardiovascular Syncope: Causes and Treatment.

Dr__Manikum_Moodley: Thank you very much.


More Information

To make an appointment with Manikum Moodley, MBChB, or any of the specialists in the Neurological Institute’s Center for Pediatric Neurology at Cleveland Clinic, please call 866.588.2264. You can also visit us online at www.clevelandclinic.org/pediatricneurology.

A remote second opinion may also be requested from Cleveland Clinic through the secure eCleveland Clinic MyConsult Web site. To request a remote second opinion, visit www.eclevelandclinic.org/myConsult.

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This chat occurred on 9/29/2011

This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. ©Copyright 1995-2011 The Cleveland Clinic Foundation. All rights reserved.