Chapter 2 Index

A. Evaluation by system:

1. General

2. HEENT

3. Cardiopulmonary
--Heart Murmurs: When to Refer
--How to Feed Infants with Heart Disease

Syncope in the Pediatric Age-Group

Introduction: Syncope, the loss of consciousness usually due to decreased cerebral blood flow, is most often seen after the age of 10-12 years, and can be difficult to distinguish from epilepsy. Typically, teenaged girls come into the office after having had a syncopal attack, and it is your job to determine the extent of the workup needed.

Symptoms of Syncope: Children will say they feel hot, perspire, and are nauseated before they pass out. About half of the patients with syncope have their eyes roll back in their heads, and even make brief tonic-clonic motions. It is important to remember that these symptoms do not imply seizure activity: there is no postictal state, and, if an EEG is obtained, it will be normal.

Differential Diagnosis of Syncope: The exact etiology of syncope is found in about 25% of cases. The rest are considered to be vasovagal reactions.

• As with all patients, a careful history and physical examination is helpful in identifying the cause of syncope more than laboratory testing.
• All syncope associated with exercise must be considered dangerous and, after an EKG is obtained, the patient should be referred to a cardiologist.

A. Cardiac Causes:

• Arrythmias : dysrhythmias -Wolff-Parkinson-White syndrome, heart block, and long QT intervals (>0.48 seconds).  Prolonged QT can be secondary to heart disease, or be congenital.
• Hypertrophic cardiomyopathies, myocarditis. Diagnosis: EKG.  Tilt table testing may be indicated.

B. Neurological Causes: Migraines are an unusual cause for syncope.

C. Metabolic Causes:

Hypoglycemia: particularly common in teenaged girls who skip breakfast, go on long  diets and even fasts. Treatment: encourage patient to eat regularly. Diagnosis: check blood sugar during visit; consider doing a glucose tolerance test on patient if syncopal attacks continue: if hypoglycemic, sugar levels will plateau in the 60’s to 70’s during this test.

D. Vaso-Vagal: By far the most common cause of syncope. Tilt test is used but of questionable value. If syncope is recurrent in these children, consider treatment with oral beta adrenergic blocking meds, and salt ingestion and Fluorinef if other therapy ineffective.

Workup to be done on most children with first syncopal attack:

1. Careful history and physical.  Particular detail should be paid to past medical history, medications taken, dietary history, and actual symptoms prior to event. Blood pressures lying and sitting and standing should be obtained; underlying cardiac conditions sought eg Hypertrophic cardiomyopathy, long QT interval.
2. EKG: A complete 12 lead EKG to evaluate for dysrhythmia, long QT (see in multiple leads) and chamber enlargement.
3. Blood sugar: easily done test.  If normal, and suspect hypoglycemia, have patient return for a fasting blood sugar the next morning. May need to do abbreviated glucose tolerance test.

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Department of Pediatrics  |  Medical College of Georgia
Please email comments, suggestions or questions to:
John T.  Benjamin M.D.,  jbenj@mcg.edu

February 27, 2004