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Indian Pediatr 2021;58:134-136 |
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Clinico-Etiological
Profile of Pediatric Syncope: A Single Center Experience
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Sweta Mohanty, 1
C P Ravi Kumar2
and Sowmyashree Mayur Kaku3
From Department of 1Pediatric Cardiology, 2Neurology,
and 3Clinical Neurosciences and Child and Adolescent
Psychiatry, Aster CMI Hospital, Bengaluru, Karnataka, India.
Correspondence to: Dr Sweta Mohanty, Valmark Apas,
Bangalore 560 076, Karnataka, India.
Email: [email protected]
Received: July 23, 2020;
Initial review: August 31, 2020;
Accepted: November 17, 2020.
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Objective: To describe the clinical profile of
children with syncope. Methods: Hospital records were reviewed
for clinical and laboratory details of childrenpresenting withreal or
apparent syncope. Five diagnostic categories were identified:
neurocardiogenic syncope (NCS), psychogenic pseudosyncope (PPS),
cardiac, neurological and indeterminate.
Results: 30 children (aged 4 to 17 years)were included. The
commonest cause of syncope was NCS (63.3%), followed by PPS (13.3%),
cardiac (10%), neurological (10%) and indeterminate (3.3%). Exercise,
loud noise or emotional triggers and family history were associated with
cardiac etiology, and electrocardiogram (ECG) was diagnostic in the
majority. Children with PPS and cardiacsyncope had frequent episodes
when compared with other groups. Indiscriminate antiepileptic use was
found in 5 children, including two cardiac cases.Conclusion:
Frequent recurrences of syncope may suggest PPS or cardiac cause.
Cardiac etiology may be readily identified on history and ECG alone.
Keywords: Neurocardiogenic syncope, Psychogenic pseudosyncope,
Head-up tilt table test, Management.
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S
yncope is defined as a transient loss of
consciousness due to transient global cerebral hypo-perfusion,
and is characterized by rapid onset, short duration and
spontaneous complete recovery [1]. Syncope is commonest in
adolescent age group with a peak in incidence between 15 to 19
years [2].
Various classification systems broadly
categorize syncope as neurocardiogenic (NCS), cardiac,
neurologic, or psychogenic pseudosyncope (PPS) [2],the commonest
cause being benign NCS [2,3]. Although cardiac causes of syncope
are rare, they can be potentially life-threatening [4]. Even a
benign syncopal event can generate extreme anxiety. As a result,
syncope evaluation often leads to a battery of expensive
low-yield tests [4].
We performed this study to document common
etiologies and identify clinical features that may assist in
differentiating between various diagnostic categories.
METHODS
We reviewed records of patients aged 1 to 18
years presenting to our center with syncope, over a 14-month
period from January, 2019 to February, 2020. Outpatient visits
as well as inpatient hospitalizations of the first presentations
were included. For the purpose of this study, syncope was
defined as a sudden and transient (<2 hours) loss of
consciousness and postural tone, with spontaneous recovery
[5,6]. Children with dizziness without loss of consciousness
were excluded. Those with clinical presentation of seizure,
focal neurological deficit or established causes of pathological
syncope like cardiac disorder or trauma were excluded. The
electronic medical records were retrospectively reviewed for
demographic and clinical data and results of electrocardiography
(ECG) or any additional testing.
Patients were classified into five diagnostic
categories [1,2] viz., neurocardiogenic syncope (NCS), cardiac
syncope, psychogenic pseudosyncope (PPS), neurological disorder
and indeterminate cause. NCS was diagnosed by typical history,
such as precipitating factors or prodromal symptoms, with
supportive evidence on orthostatic vital testing or Head-up tilt
table (HUTT) test in some cases. A confirmatory diagnosis of
cardiac syncope was made based on ECG abnormalities and
supplemental tests such as exercise stress test or 24-hour ECG
monitoring (Holter). All cases of neurological disorder had
abnormal electroencephalogram (EEG) with or without abnormal
neuroimaging findings. Syncope was classified as indeterminate
in absence of a clearly definable cause for an objective
clinical manifestation. A diagnosis of PPS was made after the
exclusion of other causes, and evaluation by a child
psychiatrist.
Our pediatric syncope team follows a
standardized clinical assessment and management plan to evaluate
syncope patients. A standard 12-lead ECG is done in all
patients. Orthostatic vital sign testing in the clinic is
considered positive when there is a drop in systolic blood
pressure of greater than 20 mm Hg [7] or a rise in heart rate of
more than 40 beats per minute on standing for 3 minutes [4].
Standard views for echocardiograms and standardized protocols
for HUTT[8] and exercise stress testing[9] are followed. Holter
monitoring consists of digital recording over 24 hours, analyzed
using Digitrack (GE) software system with manual reviewing of
all data. Psychological evaluation is done by the child
psychiatrist, as indicated.
RESULTS
A total of 30 patients, aged 4 to 17 years,
presented with syncope. Seven of these patients required
hospitali-zation; the remaining were evaluated and managed on
outpatient basis. Of the 30 patients, 19 (63.3%) were diagnosed
to have NCS, 4 (13.3%) had PPS, 3 (10%) had a cardiac cause, 3
(10%) had a neurological cause and 1 (3.3%) was of indeterminate
etiology. Two patients with NCS had convulsive syncope, where
tonic clonic move-ments were observed following the loss of
conscious-ness (EEG was normal in both).
Sixteen (53.3%) children had a history of
recurrent episodes of syncope. All cases of PPS presented with
multiple episodes in a week, with complete disappearance during
hospital observation. Postural changes (15, 84%) or accompanying
acute febrile illnesses (6, 31%) were the predominant
precipitating factors for NCS (Table I). Exercise was
precipitating event for a child with NCS, but syncope in this
case was post-exertional (occurring a minute after cessation of
exercise). Only two (10.5%) patients of NCS had a positive
orthostatic exam.
Table I Demographic Features and Precipitating Events in Different Etiological Categories of Pediatric Syncope (N=30)
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Cardiac |
NCS |
PPS |
Neurologic |
|
(n=3) |
(n=19) |
(n=4) |
(n=3) |
| Age (y)a |
13.7 |
10.3 |
12.5 |
10 |
|
(1.1) |
(3.5) |
(1.7) |
(2.6) |
| Females |
1 |
9 |
1 |
2 |
| Recurrent syncope |
2 |
8 |
4 |
2 |
| Family history |
2 |
0 |
0 |
0 |
| Precipitating event |
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| Exercise |
2 |
1 |
0 |
0 |
| Loud noise/emotion |
1 |
0 |
0 |
0 |
| Postural factors |
1 |
15 |
3 |
2 |
| Fever/acute illness |
0 |
6 |
0 |
0 |
| Accompanying symptoms |
|
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| Nausea/sweating |
0 |
3 |
0 |
1 |
| Palpitation/chest pain |
1 |
0 |
1 |
0 |
| Headache |
1 |
2 |
3 |
2 |
| Visual change |
0 |
2 |
2 |
0 |
| Injury during fall |
0 |
2 |
1 |
0 |
| Urination |
0 |
0 |
0 |
1 |
| Vomiting on awakening |
1 |
3 |
0 |
1 |
| NCS:
Neurocardiogenic syncope; PPS: Psychogenic pseudosyncope;
Values in numbers except amean (SD). |
Web Table I shows the investigations
performed with their diagnostic yield. ECG was performed in all
children and revealed a cardiac diagnosis in three children
(long QT syndrome, 2; sinus node dysfunction, 1). One child with
sinus node dysfunction had significantbradycardia
onholtermonitoring andrequired electrophysiology refer-ral. EEG
confirmed a diagnosis of idiopathic epilepsy in three patients,
all of whom were started on antiepileptic medications. Lastly, a
child with syncope following epistaxis,with similar parental
history, was classified as indeterminate, after baseline
investigations, including holter monitoring, revealed no
abnormality.
All children with NCS were reassured, advised
to increase fluid and salt intake and advised behavioral
modifications on experiencing prodromal symptoms. The two
siblings with long QT syndrome were started on beta-blockers and
showed no recurrence on follow up at 3 months. For children with
PPS, underlying stressors were identified, and two cases
required psychotropic medi-cations.Unindicated antiepileptic
medications were being administered in five patients, with
recurrent episodes (including children with cardiac syncope),
and were discontinued.
DISCUSSION
In this retrospective study, the commonest
diagnosis in children presenting with syncopewasneurocardiogenic,
followed by psychogenic pseudosyncope. Specific features on
history that suggested a cardiac etiology, as reported
previously [1,10], included syncope associated with exercise,
loud noise or fright, and syncope preceded by chest pain or
palpitations in the absence of prodromal symptoms.
The frequency of episodes tends to be
significantly higher in cardiac causes as compared to
non-cardiac [11], with the exception of PPS. In a patient with
unusual loss of consciousness occurring multiple times per day,
un-related to posture, with varying presentations, or with
events lasting longer than 3 minutes, conversion disorder should
be considered [7].
ECG is an essential component of evaluation
of all children who present with syncope [5] and clinched the
diagnosis for the cardiac cases in this cohort.
Echocardio-gramwas found to be non-contributory, as also
reported earlier [12]. HUTT is useful to differentiate NCS from
PPS by the reproduction of symptoms during tilt testing in the
absence of haemodynamic abnormalities in the latter [13].
However, as HUTT is time-consuming and not without risk [7], we
selectively advised the test only when it was expected to bring
about a change in management. EEG may be helpful in
differentiating convulsive syncope, wherein extremity jerking
usually occurs after loss of consciousness, from myoclonic
jerks. It is common for syncope to be misdiagnosed and
erroneously treated as an epileptic condition [14].
This study has the limitation of being a
retrospective study, with a small sample size. However, our
findings underscore that a detailed history is of paramount
impor-tance in making the diagnosis in syncope, and cases of
syncope need an ECG to rule out potentially life-threaten-ing
cardiac causes.
Ethics clearance: Institutional ethics
committee; Aster CMI Hospital; No IEC/033/2019-20, dated March
16, 2019.
Contributors: SM: drafting of manuscript,
analysis of data, review of literature; RK: acquisition and
interpretation of data, final approval of paper; SMK:
interpretation of data, critical revision of paper.
Funding: None; Competing interests:
None stated.
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WHAT THIS STUDY ADDS?
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Detailed history of precipitating factors and
accompanying symptoms and a baseline electrocardiogram
helps identify the cause of syncope in most cases.
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