Vasovagal fainting in children and teenagers

W. Wieling
Department of Internal Medicine, Academic Medical Center, University of Amsterdam, (The Netherlands)

A 14 year old boy was referred to our syncope unit for analysis of an unexplained episode of transient loss of consciousness. The episode occurred while standing still during a soccer competition game after a run. The patient denied prodromal symptoms. The duration of the loss of consciousness was short (< 1 min).

The general health of the patient was excellent. Evaluations by two pediatricians, a pediatric cardiologist and a pediatric neurologist including several EKG, an echocardiogram, a 24 hours Holter, an exercise test and blood examinations were unremarkable. He was advised to restrain from playing soccer.

Additional history taking revealed that three addditional episodes of transient loss of consciousness had occurred. One while standing still on a warm day during a vacation with his parents in Paris while a street artist was making a drawing of him. The other episodes occurred also standing motionless while a girlfriend of his mother was giving him a haircut. During this episodes he was reported to be pale and sweating. Nausea was present during one of the episodes. Based on the historical findings reflex vasovagal syncope was diagnosed. The mechanism underlying the episodes were explained to the patient and his parents. The young patient and his parents were reassured and informed about life style measures. He started to play soccer again. No more syncopal episodes occurred.

Editor's comments

By far the most common cause of transient loss of consciousness in young subjects is a reflex syncopal event and in particular a vasovagal faint [1,2]. A variety of triggers have been identified [Table 1].

Table 1. Classification of syncope based on triggers

A) Reflex mediated Vasovagal syncope emotionally induced e,g., venipunctures, immunizations, sight of blood) (central type) orthostatic induced (peripheral type) Ocular syncope Gastro-intestinal swallow syncope esophageal stimulation gastrointestinal tract instrumentation rectal / vaginal examination defecation syncope Urogenital (post)-micturition syncope urogenital tract instrumentation pulmonary airway instrumentation B) Mechanical/hydraulic factors Initial orthostatic hypotension Increased intrathoracic pressure: cough and sneeeze syncope wind instrument player's syncope weight lifter's syncope mess trick and fainting lark stretch syncope

References

1. Estruch R, Ros E, and Martínez-González MA. Mediterranean diet for primary prevention of cardiovascular disease. N Engl J Med. 2013 Aug 15;369(7):676-7. DOI:10.1056/NEJMc1306659 |