Syncope

Introduction

Children and teenagers commonly experience lightheadedness, and as many as 15% of children have 1 episode of syncope (fainting) before their 18th birthday. [Kanjwal: 2015] Lightheadedness and fainting usually result from not enough blood getting to the brain. Syncope is rarely caused by a serious medical problem.
For children and adolescents, syncope is more common in girls and peak incidence occurs between the ages of 15 and 19 years. Lightheadedness and fainting are more likely to occur when the child or adolescent:
  • Is dehydrated or drinks too little
  • Skips meals
  • Stands up too fast
  • Stands for too long without moving around
  • Is having hair brushed or combed while standing
  • Becomes too hot – including from hot showers and hot tubs
  • Breath-holds
  • Has low red blood counts (anemia)
Simple techniques can be taught to help prevent and alleviate lightheadedness.

The temporary decrease in blood flow to the brain that causes syncope may also cause some jerking activity; this is not a seizure/epilepsy and the jerking does not respond to antiepileptic medication.
Syncope that occurs with exercise or with a history of sudden unexpected death in family members or other historical factors (listed below under Medical History) is also likely to be simple syncope, though further evaluation is needed.

Other Names

Blackout
Fainting
Lightheadedness
Near-syncope
Syncope
Vaso-vagal syncope

ICD-10 Coding

R55, Syncope and collapse
ICD-10 for Syncope and Collapse (ICD10Data.com) provides further coding details.

Pearls & Alerts

Workup for fainting
All children/adolescents with fainting episodes should have an EKG to rule out long QTc syndrome and other arrhythmias. If the EKG is normal and there are no risk factors, no further workup is needed.
Hair combing
Events that occur when hair is being combed, even if accompanied by jerking, are almost certainly “hair-grooming syncope” and not seizures.

Clinical Assessment

Differential Diagnoses

The primary consideration in the differential is seizure, which is usually ruled out by a detailed history of the event. If appropriate, see the Portal’s Seizures/Epilepsy, Initial Diagnosis for further information.

Medical History

Ask about more serious causes for fainting:
  • Was CPR needed after fainting?
  • Did fainting occur with exercise?
  • Was the faint triggered by fright or sound/noise?
  • Did chest pounding or chest pain/pressure precede the faint?
  • Did anyone witness posturing or jerking for 1 minute or more with the faint?
  • Is there a history of an abnormal heart or neurologic examination?
  • Has there been an abnormal electrocardiogram?
  • Do any close family members have a history of unexplained sudden death, heart rhythm problems or cardiomyopathy, or seizures?
  • Is there a history of brain or cardiac injury or disease?
  • Is there any underlying metabolic or kidney disease?
  • Has peripheral or autonomic neuropathy been found?
  • Is there significant developmental delay?

Physical Examination

Assess for any significant injury resulting from a faint.

Testing

Unless other risk factors are identified, the only tests recommended to be done routinely are an electrocardiogram (ECG) and measurement of orthostatic blood pressures:
  • Orthostatics: Heart rate and blood pressure while sitting and then after standing for 2 minutes
    • Abnormal: Systolic blood pressure falls >20 mmHg and/or pulse increases >40 beats per minute
  • ECG: Obtain if a normal ECG is not available from the previous 90 days.
    • Abnormal QTc: Boys and prepubertal girls >450 msec; adolescent and older girls >470 msec
Criteria for cardiology evaluation/echocardiogram:
  • Abnormal ECG
  • Abnormal cardiovascular examination
  • Family history of cardiomyopathy
  • Family history of unexplained sudden death
  • History suggestive of acute myocarditis
  • Syncope during exertion
  • Suspected central nervous system (CNS) disease
Criteria for neurology evaluation/EEG:
  • Clinical diagnosis of seizure disorder
Criteria for brain MRI:
  • Abnormal neurological examination
  • Suspected CNS disease
Criteria for laboratory testing:
  • Abnormal orthostatic evaluation (electrolytes, kidney function)
  • Suspected anemia (hemoglobin/hematocrit)
Criteria for tilt-table testing
  • Tilt-table testing is of limited utility in the evaluation of syncope in children. [Batra: 2008] [Shen: 2017]

Management

Unless the medical history or physical exam suggests the need, children and adolescents who present with syncope do not need an evaluation beyond an EKG or a referral to a specialist. Focus on prevention (details below). Children and adolescents will also sometimes need a letter asking the school for a 504 accommodation to allow the child to drink water in class and use the bathroom as necessary. For a sample letter, see .Sample Letter Requesting a 504 Plan for Fainting (Medical Home Portal) (PDF Document 139 KB). For a more detailed explanation of this civil rights law, see Section 504 of the Rehabilitation Act.

Prevention

Advise families and patients to follow preventive actions known to be effective:
  • Drink more water (urine should be clear).
  • Increase salt intake.
  • Eat healthy meals often enough to avoid getting too hungry.
  • Avoid caffeine.
  • Avoid standing in one position for a long time.
  • Stand up slowly after sitting or lying down.
  • Avoid getting too hot from hot tubs or standing too long in a hot shower.
  • Sit when having hair brushed or combed by someone else (and get up slowly afterward).
  • Boys who are prone to fainting should sit on the toilet to urinate, especially first thing in the morning.

Immediate Self-Treatment

Educate about the best methods for getting more blood to the individual's brain when the child or adolescent is feeling lightheaded or faint:
  • Lay down and raise the legs above the level of the head.
  • Cross legs and squeeze the leg muscles until the lightheaded feeling goes away.
  • Grip hands and try to pull them apart and down.

Subspecialist Collaboration

Pediatric Neurology (see all Pediatric Neurology services providers (6) in our database)
Refer if seizures are suspected, but keep in mind that children and adolescents often jerk with syncope, which does not need a workup by neurology,
Pediatric Cardiology (see all Pediatric Cardiology services providers (3) in our database)
Refer if there are abnormal items in the medical history, such as a family history of prolonged QTc syndrome or sudden unexplained death. Even though vasovagal syncope is the likely reason why some children faint while exercising, these children should still receive testing for a rare cardiac electrical or structural cause.

Resources

Information & Support

For Parents and Patients

Fainting (Nemours)
Explains the reasons that people faint and how to prevent it, how to help someone who faints, and when to see a doctor.

Practice Guidelines

Shen WK, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, Grubb BP, Hamdan MH, Krahn AD, Link MS, Olshansky B, Raj SR, Sandhu RK, Sorajja D, Sun BC, Yancy CW.
2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society.
Heart Rhythm. 2017;14(8):e155-e217. PubMed abstract

Patient Education

Lightheadedness & Fainting (Intermountain Healthcare) (PDF Document 897 KB)
A pamphlet that explains some of the causes of fainting and what to do if your child or adolescent becomes lightheaded or faints.

Tools

Sample Letter Requesting a 504 Plan for Fainting (Medical Home Portal) (PDF Document 139 KB)
A sample of a short letter requesting that school personnel allow the child to carry a water bottle and drink from it throughout the day, use the bathroom when necessary, and sit down or lie down if feeling faint.

Services

Pediatric Cardiology

See all Pediatric Cardiology services providers (3) in our database.

Pediatric Neurology

See all Pediatric Neurology services providers (6) in our database.

For other services related to this condition, browse our Services categories or search our database.

Helpful Articles

Wieling W, Ganzeboom KS, Saul JP.
Reflex syncope in children and adolescents.
Heart. 2004;90(9):1094-100. PubMed abstract / Full Text

Authors & Reviewers

Initial Publication: April 2018;
Current Authors and Reviewers (click on name for bio):
Senior Author: Lynne M. Kerr, MD, PhD
Reviewer: Collin Cowley, MD
Authoring history
(Limited detail is available on authoring dates before 2014.)
AAuthor; CAContributing Author; SASenior Author; RReviewer

Page Bibliography

Batra AS, Balaji S.
Usefulness of tilt testing in children with syncope: a survey of pediatric electrophysiologists.
Indian Pacing Electrophysiol J. 2008;8(4):242-6. PubMed abstract / Full Text

Kanjwal K, Calkins H.
Syncope in children and adolescents.
Cardiac Electrophysiology, Johns Hopkins University. 2015;33(3). PubMed abstract

Shen WK, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, Grubb BP, Hamdan MH, Krahn AD, Link MS, Olshansky B, Raj SR, Sandhu RK, Sorajja D, Sun BC, Yancy CW.
2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society.
Heart Rhythm. 2017;14(8):e155-e217. PubMed abstract