Causes of syncope in children and adolescents
- Jack C Salerno, MD
Jack C Salerno, MD
- Associate Professor, Department of Pediatrics, Division of Cardiology, Arrhythmia and Pacing Services
- University of Washington School of Medicine
- Brian Coleman, MD, MSE
Brian Coleman, MD, MSE
- Attending Physician, Georgia Emergency Physician Specialists
- Memorial Health University Medical Center
- Section Editors
- George A Woodward, MD
George A Woodward, MD
- Section Editor — Pediatric Signs and Symptoms
- Professor of Pediatrics
- University of Washington School of Medicine
- John K Triedman, MD
John K Triedman, MD
- Section Editor — Pediatric Cardiology
- Professor of Pediatrics
- Harvard Medical School
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — Adult and Pediatric Emergency Medicine
- Senior Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
This topic will review the serious and benign causes of syncope. A discussion of the emergent evaluation and algorithmic approach to children and adolescents with syncope is presented separately (algorithm 1). The evaluation of adults with syncope is also discussed elsewhere. (See "Emergent evaluation of syncope in children and adolescents" and "Evaluation of syncope in adults".)
Syncope is a sudden, brief loss of consciousness associated with loss of postural tone from which recovery is spontaneous . Up to 15 percent of children experience a syncopal episode prior to the end of adolescence [2,3].
Although the etiology of syncopal events in children is most often benign, syncope can also occur as the result of more serious (usually cardiac) disease with the potential for sudden death. The vast majority of cases of syncope in the pediatric age group represent benign alterations in vasomotor tone [4,5]. Life-threatening causes of syncope generally have a cardiac etiology (table 1).
Life-threatening cardiac conditions cause syncope as the result of an abrupt decrease in cardiac output, either from an arrhythmia or related to structural heart disease . Arrhythmias are typically tachyarrhythmias. In children, syncope caused by isolated bradycardia (ie, complete AV block) is uncommon . (See "Bradycardia in children", section on 'Clinical presentation'.)
Primary electrical disturbances can occur in patients with structurally normal hearts. These arrhythmias may be related to exogenous factors (ie, a metabolic disturbance or drug ingestion) or an inherited electrophysiologic abnormality (ie, congenital long QT syndrome). Arrhythmias may also develop as the result of structural heart disease, such as myocarditis or repaired congenital heart disease. Finally, syncope can occur in conditions such as aortic stenosis and hypertrophic cardiomyopathy (HCM) as the result of left ventricular outflow tract obstruction and compromised systemic blood flow, particularly during exercise.
- Kapoor WN. Syncope. N Engl J Med 2000; 343:1856.
- Lewis DA, Dhala A. Syncope in the pediatric patient. The cardiologist's perspective. Pediatr Clin North Am 1999; 46:205.
- Friedman KG, Alexander ME. Chest pain and syncope in children: a practical approach to the diagnosis of cardiac disease. J Pediatr 2013; 163:896.
- Pratt JL, Fleisher GR. Syncope in children and adolescents. Pediatr Emerg Care 1989; 5:80.
- Massin MM, Bourguignont A, Coremans C, et al. Syncope in pediatric patients presenting to an emergency department. J Pediatr 2004; 145:223.
- Gillette PC, Garson A Jr. Sudden cardiac death in the pediatric population. Circulation 1992; 85:I64.
- Strickberger SA, Benson DW, Biaggioni I, et al. AHA/ACCF Scientific Statement on the evaluation of syncope: from the American Heart Association Councils on Clinical Cardiology, Cardiovascular Nursing, Cardiovascular Disease in the Young, and Stroke, and the Quality of Care and Outcomes Research Interdisciplinary Working Group; and the American College of Cardiology Foundation: in collaboration with the Heart Rhythm Society: endorsed by the American Autonomic Society. Circulation 2006; 113:316.
- Alexander ME, Berul CI. Ventricular arrhythmias: when to worry. Pediatr Cardiol 2000; 21:532.
- Mivelaz Y, Di Bernardo S, Pruvot E, et al. Brugada syndrome in childhood: a potential fatal arrhythmia not always recognised by paediatricians. A case report and review of the literature. Eur J Pediatr 2006; 165:507.
- Probst V, Evain S, Gournay V, et al. Monomorphic ventricular tachycardia due to Brugada syndrome successfully treated by hydroquinidine therapy in a 3-year-old child. J Cardiovasc Electrophysiol 2006; 17:97.
- Probst V, Denjoy I, Meregalli PG, et al. Clinical aspects and prognosis of Brugada syndrome in children. Circulation 2007; 115:2042.
- Skinner JR, Chung SK, Nel CA, et al. Brugada syndrome masquerading as febrile seizures. Pediatrics 2007; 119:e1206.
- Basso C, Corrado D, Rossi L, Thiene G. Ventricular preexcitation in children and young adults: atrial myocarditis as a possible trigger of sudden death. Circulation 2001; 103:269.
- Schimpf R, Wolpert C, Gaita F, et al. Short QT syndrome. Cardiovasc Res 2005; 67:357.
- Maron BJ. Sudden death in young athletes. N Engl J Med 2003; 349:1064.
- Garson A Jr, Smith RT, Moak JP, et al. Ventricular arrhythmias and sudden death in children. J Am Coll Cardiol 1985; 5:130B.
- Rocchini AP, Chun PO, Dick M. Ventricular tachycardia in children. Am J Cardiol 1981; 47:1091.
- Garson A Jr. Arrhythmias in pediatric patients. Med Clin North Am 1984; 68:1171.
- Driscoll DJ, Jacobsen SJ, Porter CJ, Wollan PC. Syncope in children and adolescents. J Am Coll Cardiol 1997; 29:1039.
- Keane JF, Driscoll DJ, Gersony WM, et al. Second natural history study of congenital heart defects. Results of treatment of patients with aortic valvar stenosis. Circulation 1993; 87:I16.
- Strieper MJ. Distinguishing benign syncope from life-threatening cardiac causes of syncope. Semin Pediatr Neurol 2005; 12:32.
- Igarashi M, Boehm RM Jr, May WN, Bornhofen JH. Syncope associated with hair-grooming. Brain Dev 1988; 10:249.
- DiMario FJ Jr. Prospective study of children with cyanotic and pallid breath-holding spells. Pediatrics 2001; 107:265.
- DiMario FJ Jr, Burleson JA. Autonomic nervous system function in severe breath-holding spells. Pediatr Neurol 1993; 9:268.
- DiMario FJ Jr, Bauer L, Baxter D. Respiratory sinus arrhythmia in children with severe cyanotic and pallid breath-holding spells. J Child Neurol 1998; 13:440.
- Onvlee-Dekker IM, De Vries AC, Ten Harkel AD. Carbon monoxide poisoning mimicking long-QT induced syncope. Arch Dis Child 2007; 92:244.
- Scott WA. Evaluating the child with syncope. Pediatr Ann 1991; 20:350.
- LIFE-THREATENING CONDITIONS
- Primary electrical disturbances
- - Long QT syndrome
- - Brugada syndrome
- - Catecholaminergic polymorphic ventricular tachycardia
- - Preexcitation syndrome
- - Congenital short QT syndrome
- Structural heart disease
- - Hypertrophic cardiomyopathy
- - Coronary artery anomalies
- - Arrhythmogenic right ventricular cardiomyopathy
- - Valvar aortic stenosis
- - Dilated cardiomyopathy
- - Pulmonary hypertension
- - Acute myocarditis
- Heat illness
- COMMON CONDITIONS
- Vasovagal syncope
- Breath holding spells
- Orthostatic hypotension
- Toxic exposure
- OTHER CONDITIONS
- CONDITIONS THAT MIMIC SYNCOPE