Sorting Through Dizziness and Fainting in Children and Teens

Fainting in adolescents is common, but distinguishing benign events from those that warrant further evaluation remains a frequent challenge for pediatricians.

“Up to half of teens will have a syncopal event at some point,” says Cleveland Clinic pediatric cardiologist Gary Butchko, MD. “Many of these patients don’t need ongoing cardiac care, but they do need help identifying the source of their symptoms and getting connected to the right resources.”

Cleveland Clinic’s Pediatric Syncope Clinic provides expertise for children and adolescents who have experienced fainting, dizziness or other symptoms of dysautonomia. While the clinic is led by a pediatric cardiology team, its approach is multidisciplinary — coordinating care with neurology, psychology, gastroenterology, rheumatology and pain management.

“There wasn’t a medical home for kids with recurrent syncope and dysautonomia,” Dr. Butchko explains. “We developed this clinic to assess for significant medical problems and address them so the symptoms don’t recur. That may involve cardiovascular care, but it often does not.”

Referring routine and complex cases

The Pediatric Syncope Clinic sees two main categories of patients:

• Those with recurring episodes of dizziness, chest pain, heart palpitations, syncope or presyncope despite seeing one or more providers
• Those with a shorter history of symptoms, such as only one syncopal event

“While we started the clinic for the first type of patient, we actually see more of the second type,” says pediatric cardiology nurse practitioner Shannon Pignatiello, CNP.

Most patients present between ages 15 and 19. There is a 36% increase for syncope in female patients, notes Dr. Butchko.

Uncovering causes: Lifestyle factors or disease?

Many factors can contribute to adolescent syncope and dysautonomia, including:

• Increased fluid, nutritional and caloric needs during growth
• Irregular or heavy menstrual bleeding
• Iron deficiency or endocrine conditions
• Inadequate sleep
• Deconditioning
• Mental health concerns that may coexist with, result from or intensify physical symptoms

“Primary cardiovascular disease causes only about 2% to 6% of syncope cases in adolescents, making it one of the rarest causes,” Dr. Butchko says. “But if there truly is a cardiovascular condition — such as valve narrowing, pulmonary hypertension, arrhythmia, coronary artery anomalies and heart muscle abnormalities — there’s a high risk it could be lethal. Shannon and I focus on assessing the heart, and if it’s healthy, we move on to educating patients about lifestyle factors and improving their lifestyle to minimize symptoms. We may also refer them to other specialties.”

Patient-guided workup

The clinic’s evaluation emphasizes direct input from patients, encouraging them to describe their symptoms while parents or other caregivers provide additional context.

Workup may include:

• Detailed symptom and family history
• Physical examination
• Orthostatic vital signs
• Baseline laboratory testing
• Electrocardiogram
• Ambulatory monitoring for palpitations or racing heartbeat
• Echocardiography or exercise testing as indicated by symptoms, age or clinical findings

For example, evaluating heart structure may be emphasized in younger patients while more advanced cardiac testing may be required for a teen with exercise intolerance. If cardiovascular disease is ruled out, patients may be referred to nutrition, psychology or another pediatric specialty rather than undergoing further cardiac studies.

“That’s what distinguishes a visit to our clinic from a standard cardiology visit,” says Pignatiello. “These patients can have a complex disorder that crosses multiple organ systems. In most cases, the cardiovascular symptoms are secondary to something else. Our job is uncovering that secondary issue.”

Red flags that warrant further evaluation

Not all syncope warrants specialty evaluation, but several features are red flags for a cardiac or other serious cause:

• Symptoms during exertion. Syncope, presyncope or palpitations during exercise are more concerning than symptoms after exercise, during recovery.
• Sudden events with limited warning. A paroxysmal episode is a greater cardiovascular concern. The presence, absence and nature of prodromal symptoms can help guide the differential diagnosis.
• Heart palpitations. Patients may describe the feeling as heart racing, pounding, fluttering, flip-flopping or skipping in the chest, throat or neck.
• Concerning family history. Even without a syncopal event, patients should be evaluated if they have a family history of sudden cardiac death, congenital heart disease, or myocardial infarction or stroke in a first-degree relative younger than age 50.
• Younger age or atypical presentation. Children younger than the onset of puberty, or those with unusual presentations, often need more extensive evaluation.

“Noncardiac concerns such as thyroid disease, iron deficiency, nutritional deficiencies, and depression or anxiety may also require prompt attention,” Dr. Butchko adds. “There can be serious conditions at play outside the cardiovascular system, so that’s when we bring in other pediatric subspecialists.”

Don’t dismiss symptoms as ‘just anxiety’

Dysautonomia symptoms may contribute to anxiety or depression and vice versa. However, physical symptoms should not be dismissed as anxiety-driven, notes Pignatiello.

“It doesn’t matter if syncope triggers anxiety or anxiety triggers syncope,” she says. “Both deserve our attention. We reassure these patients that their symptoms are real, not just ‘in their head,’ and we connect them with providers who can help, even if not a cardiologist.”

First-line management for typical symptoms

For patients with typical vasovagal or orthostatic symptoms, general pediatricians can begin care by recommending lifestyle changes:

• Increase fluid intake to at least 64-80 ounces per day, avoiding caffeinated beverages
• Increase salt intake to 3-5 grams per day, when clinically appropriate
• Eat frequent, smaller meals and avoid skipping meals
• Gradually increase physical activity based on conditioning
• Strengthen the core and legs
• Get adequate sleep

“These basics can be overlooked, especially in teens, and many patients improve with these measures,” Dr. Butchko says. “If symptoms persist despite consistently following these recommendations, or if you spot any red flags, our Pediatric Syncope Clinic is ready to help.”