Syncope for the General Pediatrician

Abstract

Pediatric syncope is a common complaint in the primary care, emergency department, and specialty care setting and is often unsettling to patients and providers alike as a symptom of conditions causing sudden death. In all cases, syncope should be thought of as a symptom rather than a diagnosis and explored with a thorough history and physical. Thankfully, the majority of syncope in children and adolescents is not cardiac in origin and carries no increased risk or association with sudden cardiac death. The majority of life-threatening or cardiac causes of syncope can be differentiated on the basis of history alone. Most concerning symptoms associated with cardiogenic syncope are identified at the time of presentation without extensive testing or referral to specialists. Physical examination and ancillary testing are usually of limited benefit in the initial diagnosis; however, cases with concerning symptoms or uncertainty require further investigation, typically through referral to cardiologists. The majority of pediatric syncope is caused by benign common fainting, also referred to as reflex, vasovagal, or neurocardiogenic syncope, which can and should be treated with reassurance and mild lifestyle modifications only. A minority of syncope is cardiogenic and occurs from three general mechanisms: outflow obstruction, arrhythmia, and myocardial dysfunction. Cardiac causes of syncope are potentially life-threatening and must be excluded during the evaluation. The goal of the primary care evaluation of syncope should be to discriminate common fainting, which almost never requires specialty care, from cardiogenic syncope.