Current approaches to the clinical assessment of syncope in pediatric population

Pediatric Syncope: Is the Diagnostic Guideline Implemented and Adhered to?

BACKGROUND

We sought to investigate adherence to the current pediatric syncope guideline in the emergency department and its impact on the frequency of missed or unnecessary diagnostic measures. For the first time, in 2014 updated guideline defines indispensable basic diagnostic measures and a consecutive algorithm for safe clinical decision making.

PATIENTS AND METHOD

We analyzed retrospectively 314 pediatric patients, 166 were presented before and 148 after publication of this guideline update.

RESULTS

After guideline publication, 54 patients (36.5%) were not treated in accordance with the guideline and 2 (0.63%) cases caused by epileptic seizures were initially misdiagnosed as reflex syncope. Among these 54 patients, 32 (59.3%) inpatient admissions were inappropriate, as well as 11 (20.4%) electroencephalographies, 4 (7.4%) sleep-deprivation EEGs, 2 (3.7%) magnetic resonance imaging, 5 (9.3%) urine diagnostics and 32 (59.3%) blood tests. In 21 cases (38.9%), the medical history was insufficient. ECG was missed in 42 patients (77.8%). There was no significant difference between the pre- and post-guideline groups concerning diagnostic work-up (p=0,12).

DISCUSSION

This non-compliance with the guideline did not cause a large number of misdiagnosed epileptic seizures (1.4%) or adverse outcomes but led to waste of resources in healthcare system and undue burdens on patients and their families.

CONCLUSION

In addition to establishment of clinical guidelines, the need for additional measures and strategies to promote their implementation seems obvious.

Geçici Bilinç Kaybıyla Başvuran Çocuk Olguların Retrospektif Değerlendirilmesi

Amaç: Çalışmamızın amacı , geçici bilinç kaybı (GBK) yakınması ile başvuran çocuk olguların tanılarının aydınlatılması, anamnez, etiyoloji, özgeçmiş ve soygeçmiş, fizik muayene ve laboratuvar bulgularının, tedavilerinin retrospektif değerlendirilmesidir. Gereç ve Yöntemler: Çalışmaya Süleymen Demirel Üniversitesi Tıp Fakültesi Hastanesine GBK yakınmasıyla 1 Ağustos 2017-1 Şubat 2020 tarihleri arasında çocuk polikliniklerine başvuran hastalar dahil edildi, kaydedilen anamnezleri, fizik muayene bulguları detaylı olarak geriye dönük incelendi. Yapılan biyokimyasal laboratuvar incelemeleri, elektrokardiyografi (EKG), transtorasik ekokardiyografi (EKO), 24 saatlik ritm holter EKG, kraniyal manyetik rezonans (MR) görüntüleme, elektroensefalografi (EEG) retrospektif olarak tanıya ve tedaviye yönelik değerlendirildi. Bulgular: Hastaların 110’u (%68.8) kız, 50’si (%31.2) erkek idi. Hastaların ortalama yaşı 11.4 (±4.8) idi. Hastaların geçirdikleri ortalama GBK sayısı 1.6 (±1.2) idi. Çalışmamızdaki hastaların %33’ü tekrarlayan GBK atakları ile başvurmuştu. Çalışmamızda GBK tanısına yönelik yapılan ileri incelemelerde en sık neden vazovagal senkop (VVS) (51 hasta, %31.9), ikinci olarak epilepsi/FK/AFK (febril konvülzyon/afebril konvülzyon) (41 hasta, %25.6), üçüncü olarak psikojenik senkop (28 hasta, %17.5 ) olarak saptanmıştır. Diğer nedenler de sırasıyla durumsal, katılma nöbeti, OH (ortostatik hipotansiyon), migren/SVO (serebrovasküler olay), kardiyojenik, BPPV (benign paroksizmal pozisyonel vertigo) olarak bulunmuştur. Hastalara yapılan biyokimyasal tetkikler, EKG, EKO, 24 saatlik ritm holter EKG, EEG, kraniyal MR incelemeleri analiz edildi ve değerlendirildi. Sonuç: GBK yakınmasıyla başvuran her hastadan ayrıntılı anamnez alınmalı, tam sistemik muayene yapılmalı ve EKG çekilmelidir. Kan testleri, EEG, EKO, nörogörüntüleme, 24 saatlik ritm holter EKG değerlendirmeleri ön tanıya yönelik istenmelidir.

Prognostic Value of Biomarkers in Children and Adolescents With Orthostatic Intolerance

Orthostatic intolerance (OI) refers to a series of symptoms that occur during upright standing, which can be relieved when returned to the supine position. OI is a common cause of syncope in children and adolescents. In recent years, more and more studies have been carried out to assess the prognosis of OI by using biomarkers, among which, flow-mediated vasodilation, left ventricular ejection fraction and fractional shortening, hemodynamic change during head-up tilt test, detection of 24-h urinary sodium excretion, body mass index, midregional pro-adrenomedullin, and erythrocytic H2S producing rate are relatively stable, inexpensive, and easy to obtain. With the help of biomarkers, individualized treatment can be carried out to improve the long-term prognosis of children and adolescents with OI. This article reviews the prognostic value of biomarkers in children and adolescents with OI.

Outcomes of Implantable Loop Monitoring in Patients <21 Years of Age

Rhythm-symptom correlation in pediatric patients with syncope/palpitations or at risk cohorts can be difficult, but important given potential associations with treatable or malignant arrhythmia. We sought to evaluate the use, efficacy and outcomes of implantable loop recorders (ILR) in pediatrics. We conducted a retrospective study of pediatric patients (<21 years) with implanted ILR. Patient/historical characteristics and ILR indication were obtained. Outcomes including symptom documentation, arrhythmia detection and ILR based changes in medical care were identified. Comparison of outcomes were performed based on implant indication. Additional sub-analyses were performed in syncope-indication patients comparing those with and without changes in clinical management. A total of 116 patients with ILR implant were identified (79 syncope/37 other). Symptoms were documented 58% of patients (syncope 68% vs nonsyncope 35%; p = 0.002). A total of 37% of patients had a documented clinically significant arrhythmia and 25% of patients had a resultant change in clinical management independent of implant indication. Arrhythmia type was dependent on implant indication with nonsyncope patients having more ventricular arrhythmias. Pacemaker/defibrillator implantation and mediation management were the majority of the clinical changes. In conclusion, IRL utilization in selected pediatric populations is associated with high efficacy and supports clinical management. ILR efficacy is similar regardless of indication although patients with nonsyncope indications had a higher frequency of ventricular arrhythmias as opposed to asystole and heart block in syncope indications. The majority of arrhythmic findings occurred in the first 12 months, and new technology that would allow for less invasive monitoring for 6 to 12 months may be of value.

Management of Neurological Emergencies in Children: An Updated Overview

Neurological emergencies account for about one-third of the highest severity codes attributed in emergency pediatric departments. About 75% of children with acute neurological symptoms presents with seizures, headache, or other paroxysmal events. Life-threatening conditions involve a minor proportion of patients (e.g., less than 15% of children with headache and less than 5% of children with febrile seizures). This review highlights updated insights about clinical features, diagnostic workup, and therapeutic management of pediatric neurological emergencies. Particularly, details will be provided about the most recent insights about headache, febrile seizures, status epilepticus, altered levels of consciousness, acute motor impairment, acute movement disorders, and functional disorders, as well as the role of diagnostic tools (e.g., neuroimaging, lumbar puncture, and electroencephalography), in the emergency setting. Moreover, the impact of the current novel coronavirus disease2019 (COVID-19) pandemic on the evaluation of pediatric neurologic emergencies will also be analyzed.

The Psychopathology, Depression, and Anxiety Levels of Children and Adolescents With Vasovagal Syncope: A Case-Control Study

ABSTRACT

Vasovagal syncope constitutes 61% to 80% of syncope cases in the pediatric age group. Syncope is frequently associated with psychopathologies such as depressive disorders, anxiety disorders, somatization disorders, etc. Our study aims to evaluate vasovagal syncope cases in terms of additional psychopathologies, depression, and anxiety levels with a control group. A total of 97 people were included in the study (47 cases and 50 controls). After conducting a cardiological examination, the participants were evaluated for psychopathologies using Kiddie-Sads-Present and Lifetime Version, Child Depression Inventory, and Screen for Child Anxiety Related Emotional Disorders. The case group had a higher rate of psychopathology compared with the control group. Depression, social anxiety disorder, generalized anxiety disorder, separation anxiety, and conversion disorder were significantly higher in the case group than in the control group. Syncope in children can be an underlying psychopathology or the clinical manifestation of a psychosomatic condition. Psychological assessment, which could offer beneficial contributions to the diagnosis and treatment of syncope, was considered necessary for a holistic evaluation of patients.

Investigation on the Incidence of Syncope in Children and Adolescents Aged 2-18 Years in Changsha

Objectives: Syncope is a common clinical symptom, while there are less relevant literature and targeted research on childhood morbidity. This article makes a cross-section survey on the incidence of syncope in children and adolescents aged 2-18 years in Changsha. Materials and Methods: There were 4,352 children and adolescents aged 2-18 years randomly selected from six primary and secondary schools and three kindergartens in Changsha from March 2018 to November 2018. There were 4,916 standardized questionnaires issued, and 4,352 (88.53%) valid questionnaires were recovered. Results: (1) Incidence: 17.37% of children and adolescents aged 2-18 years who had at least more than one syncope; the incidence in the adolescence (28.85%) was higher than that in the school age (8.32%) and in the preschool age (2.71%) (P < 0.01). (2) Age at onset: 13.9 ± 3.1 years old, with a peak age of 16 years. (3) Gender difference: The incidence in adolescent females was higher than that in males (31.72 vs. 26.25%, P < 0.05). In inducements, females had higher rates than males in sweltering environment (P < 0.01), whereas males had higher rates than females in urination (P < 0.05). Dizziness, nausea, sweating, and facial pallor were higher in females than in males in presyncope (P < 0.05). Conclusions: The incidence of syncope in children and adolescents aged 2-18 years in Changsha is 17.37%. The incidence of syncope is different between males and females in different age groups; there are gender differences in syncope inducements and presyncope.

Non epileptic paroxysmal events in childhood

Non epileptic paroxysmal events are recurrent movement disorders with acute onset and ending, which may mimic epilepsy. The duration, place, timing of the attacks, and state of conciousness may confuse pediatricians about the diagnosis of epilepsy and non epileptic paroxysmal events. The key point in the diagnosis is taking an accurate and detailed history. Wrong diagnosis can give rise to anxiety of both the family and the child, interruptions in the child's education, limitations in career planning, and irreversible damages in the long term. The diagnosis can prevent unnecessary drug use and psychological damage. This review aims to discuss the clinical findings, treatment, and differential diagnoses of non epileptic paroxysmal events, and to increase awareness about non epileptic paroxysmal events among pediatricians.