Although most pediatric syncope cases are benign, general providers should be able to distinguish red-flag symptoms and refer patients as necessary.

“Providers should differentiate syncope from cardiac conditions, seizures, metabolic disturbances or psychogenic causes,” said Delwyn E. McOmber, M.D., pediatric cardiologist with Norton Children’s Heart Institute, affiliated with the UofL School of Medicine.

By taking a detailed history, performing thorough physical exams and knowing when to refer, providers can ensure appropriate care while offering families reassurance.

History is key

Syncope, characterized by a loss of consciousness with loss of postural tone, is followed by spontaneous recovery, with common preceding symptoms that can include tunnel vision, nausea, sweating, tingling and palpitations.

Patient history is a critical component in determining the cause of syncope. Key questions for patients include:

1. • • Was there a prodrome (symptoms such as dizziness, nausea, etc.)?
     • Did the patient experience palpitations or chest pain?
     • Were they exercising at the time of the episode?
     • What was their hydration status or environment (standing, hot or crowded setting)?
     • Do you or your family have a history of cardiac issues?

Providers should order an electrocardiogram (ECG) for all syncope patients to help guide next steps.

“Even if the ECG is normal, if they’re fainting while exertion is taking place, then they need an echocardiogram, and potentially a stress test to be sure of what’s going on,” Dr. McOmber said.

Types of syncope
Differentiating the type of syncope reveals underlying causes. Types of syncope include:

Cardiac syncope: Caused by arrhythmias, structural heart disease or obstructive cardiac lesions

Neurally mediated (reflex) syncope: Includes vasovagal syncope (sudden drop in blood pressure due to vagus nerve overstimulation from emotional stress, pain, blood draws or prolonged standing) and situational syncope (occurring with specific activities such as coughing, urination or swallowing)

Orthostatic hypotension syncope: Caused by a drop in blood pressure upon standing

Neurologic syncope: Caused by seizures, strokes or transient ischemic attacks (TIAs) affecting cerebral perfusion

Postural orthostatic tachycardia syndrome (POTS): A dysautonomic condition that may cause syncope or presyncope when transitioning from standing up and lying down

When to refer a patient

Referral to cardiology is always recommended for the following red-flag symptoms:

• Syncope during exercise or any physical exertion
• Absence of a prodrome or no warning signs preceding the episode
• Prolonged loss of consciousness or reports of being unresponsive for an extended period of time
• Abnormal ECG findings
• Family history of unexplained sudden cardiac death or significant cardiac conditions
• Recurring syncope episodes that are unexplained despite initial evaluation
• Signs of seizure activity, such as convulsions or post-ictal state

In cases where a headache precedes the fainting episode or convulsions occur during one, referral to neurology in conjunction with cardiology is appropriate.