OCCASIONAL REVIEW
Approach to the pre-
school child with sudden
loss of consciousness
Pradeep Naganna
Niha Mariam Hussain
Nahin Hussain
Abstract
There are several causes for sudden loss of consciousness in pre-
school children. These include Transient Loss of Consciousness (T-
LOC), which encompasses a group of disorders with the following
characteristics: abnormal motor control, loss of responsiveness,
amnesia for the period of unconsciousness, and a short duration.
There are three main categories of T-LOC in pre-school children: syn-
cope, resulting from a sudden and reversible lack of oxygenated blood
supplied to the brain, often caused by transient impairment of cardiac
output or systemic arterial hypotension. Secondly, epileptic seizures
due to excessive and hypersynchronous cortico-neuronal electrical
activity in the brain, and thirdly, “unexplained T-LOC,” which includes
cases not yet diagnosed fully, and those for which a pathophysiolog-
ical mechanism has not yet been identified, despite thorough investi-
gations. Reflex Anoxic Seizures (RAS) are important in the differential
diagnosis of non-epileptic paroxysmal events in infants and pre-
school children. Parents and carers who witness these episodes are
understandably anxious, and the mainstay of management is ensuring
that the correct diagnosis is made, reassurance is given, and both the
patient and parents are educated about the condition. Diagnosis can
be made based off a detailed history, including an eyewitness account
of the episode, as well as clinical examinations. This review aims to
describe an approach to the diagnosis and management of T-LOC
in pre-school children.
Keywords ECG; epileptic seizures; reflex asystolic syncope; syn-
cope; transient loss of consciousness
Introduction
A sudden loss of consciousness in a child can cause anxiety
amongst both parents and clinicians. It presents in various forms,
such as ‘fainting,’ ‘black outs,’ ‘collapse,’ and ‘passing out.’
Pradeep Naganna MBBS MRCPCH, Specialist Registrar Department of
Paediatric Neurology, Leicester Royal Infirmary, University Hospitals
of Leicester NHS Trust, Leicester, UK. Conflicts of interest: none
declared.
Niha Mariam Hussain, Medical Student College of Medical and
Dental Sciences, University of Birmingham, Birmingham, UK.
Conflicts of interest: none declared.
Nahin Hussain MBBS FRCPCH, Consultant Paediatric Neurologist
Department of Paediatric Neurology, Leicester Royal Infirmary,
University Hospitals of Leicester NHS Trust, Leicester, UK. Conflicts
of interest: none declared.
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Please cite this article as: Naganna P et al., Approach to the pre-school child with sudden loss of consciousness, Paediatrics and Child Health,
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According to the European Society of Cardiology, syncope is
defined as a transient loss of consciousness due to cerebral
hypoperfusion. It is characterized by a rapid onset, short dura-
tion, and spontaneous complete recovery. Syncope shares clin-
ical features with disorders that may be mistaken for one
another, forming the group of disorders labelled as ‘transient loss
of consciousness’ (T-LOC). T-LOC is formally defined as a real or
apparent transient loss of consciousness, expressed through all
four of the following qualifiers: abnormal motor control, loss of
responsiveness, amnesia for the period of unconsciousness, and
a short duration.
Epidemiology
TLOC is a common symptom in all age groups, affecting up to
50% of the population; 47% of females and 31% of males will
have fainted at least once in their lives. In addition, around 1% of
toddlers may have a form of vasovagal syncope, their risk
increasing with age and peaking at around 15 years old.
The incidence of syncope requiring medical attention is 125/
100,000. It accounts for 3% of Emergency Department atten-
dances, and 1% of all hospital admissions.
Although syncope is a relatively common condition with a
good prognosis, in some cases it has the potential to become life-
threatening. Diagnosis can be incredibly challenging, and the rate
of recurrence in children who were misdiagnosed following
hospital admission are high.
Classification and pathophysiology
The two main groups of TLOC are ‘TLOC due to head trauma’
and ‘non-traumatic TLOC’. Traumatic TLOC is outside the scope
of this article and will therefore not be mentioned further;
however, non-traumatic TLOC disorders may be further classi-
fied based on history and pathophysiology. Approximately 50%
of paediatric syncope are non-cardiovascular, 20e30% are car-
diovascular, and a further 20e30% are of unknown aetiology.
See Figure 1.
Neurally mediated/reflex syncope
The reflex syncope is the most common cause of syncope. It
occurs due to an abnormal response between sympathetic and
parasympathetic reflexes; it is characterised by peripheral vaso-
dilation, a fall in blood pressure and bradycardia, resulting in
global cerebral hypoperfusion.
Sudden cessation of blood pressure for even 6e8 seconds has
been known to cause a complete loss of consciousness. Systemic
blood pressure is the product of cardiac output and peripheral
vascular resistance. Any event which results in a fall of either
factor (or both) can subsequently lead to syncope.
Vasovagal syncope
Vasovagal syncope is the most common cause of reflex syncope
seen in day-to-day practice. It is triggered by several factors:
emotional stress, prolonged standing, standing up suddenly,
tiredness, hunger or dehydration, the sight of blood, fear,
anaemia, as well as post-exercise are included.
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 OCCASIONAL REVIEW

Figure 1 A summary of the various causes of TLOC. PNES, psychogenic non-epileptic seizures; PPS, psychogenic pseudosyncope; VVS,
vasovagal syncope; CSS, carotid sinus syndrome; TIA, transient ischaemic attack. Adapted from Brignole et al., 2018.

Reflex asystolic syncope (RAS)/reflex anoxic seizures
Reflex Asystolic Syncope (RAS) is a paroxysmal disorder which
typically occurs in a neurodevelopmentally intact pre-school
child. Any unexpected stimulus, such as pain, shock or fright,
causes the heart and breathing to stop.
Presentation of RAS may involve an extremely pale dis-
colouration; the child is often blue around the mouth and under
the eyes (reflecting central cyanosis). Furthermore, their eyes
may roll up, their jaw may clench, and the body would stiffen,
sometimes alongside the jerking of the limbs. Episodes tend to
last approximately 30 seconds, after which the body relaxes and
the heart and breathing resume, leaving the person unconscious
in a post-ictal state. One or two minutes later the person may
regain consciousness; however, the child may remain uncon-
scious or sleepy for well over an hour. During recovery the
person may be emotional and look extremely pale. RAS attacks
rarely occur several times per day, per week, or per month (more
common), or per year. These attacks appear to cluster.
Expiratory apnoea syncope (EAS)
EAS is a common cause of reflex syncope in toddlers and infants.
It is also known as cyanotic breath-holding spells. It typically
starts with the child becoming upset and crying, resulting in the
child becoming apnoeic in expiration. This leads to a loss of tone
and consciousness. Sometimes a dramatic extensor spasm as
described in RAS may occur. RAS can sometimes be indistin-
guishable on history or video record from EAS.
Orthostatic syncope
Orthostatic syncope is due to an impairment of reflexes during
standing, resulting in fall in blood pressure and/or tachycardia.
Accompanying symptoms include dizziness, light headedness,
nausea, fatigue, blackouts and palpitations.
Causes of orthostatic syncope include:
 Orthostatic hypotension due to impaired in venous return
during exercise, post-prandial etc;
 Volume depletion, caused by haemorrhage, profound
anaemia, gastroenteritis, Addison’s disease etc;
 Anaphylaxis
 Septic shock
 Valsalva manoeuvres
 micturition (post-micturition)
Orthostatic hypotension (OH) is defined as a decrease in
systolic blood pressure of 20 mmHg or a decrease in diastolic
blood pressure of 10 mmHg, occurring within three minutes of
standing up from a sitting/supine position. The incidence of
syncope in children is unknown but studies estimate it is <5% in
people under the age of 50.

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 OCCASIONAL REVIEW

Cardiopulmonary syncope Other causes

Cardiac syncope is relatively less common in children; none- Metabolic causes and hypoglycaemia
theless, thorough evaluation is recommended to rule out any Certain metabolic condition may present with either a loss/
other life-threatening diagnoses. decreased levels of consciousness. These may present in children
Causes may be subdivided, shown in Table 1. with development delay or failure to thrive. Additionally, meta-
bolic conditions may cause hypoglycaemia and subsequently
Non-syncopal seizures neuroglycopenia. This results in a gradual loss of cognitive
functions causing slower reaction times, blurred speech, seizures
Febrile seizure
and loss of consciousness.
A simple febrile seizure is defined by the International League
Against Epilepsy (ILAE) as a short, generalized seizure, not Benign paroxysmal vertigo of childhood (BPVC)
recurring within 24 h and not caused by an acute disease of the BPVC is a common cause of recurrent episodes of dizziness in
nervous system. It occurs in children aged 6 months-5 years, children aged 3e4 years. Episodes have a rapid onset and may
with no neurologic deficits. last several minutes; children will recover completely after the
episode. At this young age, children usually cannot express their
Epileptic seizure
symptoms, but will often panic from loss of control and may
Epilepsy is a neurological condition, characterised by recurrent
cling to an adult until the episode resolves.
epileptic seizures. Seizures are due to abnormal hyperexcitation
of the cortical neurons; they are often confused with syncope. Raised intracranial pressure (ICP) and hydrocephalus
Absence seizures may present as staring/vacant episodes, lasting Infections of the brain, including meningitis and encephalitis, can
only for a few seconds, occurring several times a day. Complex increase ICP, leading to an altered level of consciousness. Pa-
partial seizures typically last longer than absence seizures (>60 tients usually have a fever and other common signs of infection
seconds), may present with a preceding aura, and have a post- as well. Rare structural abnormalities in the brain may present
ictal phase. with hydrocephalus; these include Arnold-Chiari malformations,
congenital aqueduct stenosis and tumours.
Psychogenic causes
Psychogenic TLOC episodes may last anywhere from minutes to History and examination
hours. It can present in two forms: Psychogenic non-epileptic It is crucial to take a detailed history directly from the patient and
seizures (PNES) and Psychogenic pseudosyncope (PPS). PNES their parent/witness. Witnesses should be encouraged to clarify
are group of disorders resembling epileptic seizures associated any terms used by the clinician (especially medical terminology)
with motor component, but without the epileptic electrical dis- and should describe the event chronologically. If possible, video
charges. PPS differs from PNES due to a lack of motor move- recordings of the event should be shown.
ments. These disorders are manifestations of psychogenic The history taking must include the following:
distress.  Circumstances prior to the event
 Precipitating factors
 Where the child was, what they were doing & patient’s po-
sition at onset
 Past medical history, including drug history and
investigations
 Family history to elicit for cardiac disorders
A table outlining the different types of cardiopulmonary o Any sudden unexplained deaths
syncope o Any fitting of pacemakers or defibrillator
o Any arrythmias
Cardiac rhythm problems Cardiac structural  Family history of neurological disorder
abnormalities o Epilepsy
o Strokes
Sinus node dysfunction Valvular disease
o Arterial dissection
Brady/tachyarrhythmia Acute myocardial infarction/
o Aneurysms
ischaemia
 History suggestive of neurocutaneous disorders
Atrioventricular conduction system Obstructive cardiomyopathy
 Sleep history (if narcolepsy with cataplexy indicated)
disease
 History of any psychological or psychiatric Illness
Inherited syndromes, e.g. long QT Pericardial disease/tamponade
 Social history
syndrome
From a detailed history, syncope can be differentiated from
Implanted device malfunction, e.g. Pulmonary embolus
other forms of TLOC in 60% of cases. Studies have shown that 30
pacemaker, ICD
e40% of children diagnosed with epilepsy were wrongly diag-
Drug-induced arrhythmia Pulmonary hypertension
nosed; the children were most likely to have syncope instead.
Vascular steal syndromes
The evaluation should answer these key questions:
1. Was the event TLOC?
Table 1

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2. Is the TLOC of syncopal or non-syncopal origin?  Presence of a short PR interval, a wide QRS complex with
3. In case of suspected syncope, is there a clear aetiological a slurred onset of the QRS waveform (delta wave) and
diagnosis? secondary ST-T wave changes in Wolff-Parkinson-White
4. Is there evidence to suggest a high risk of cardiovascular syndrome.
events or death?  Voltage criteria for obstructive left or right ventricular
Table 2 outlines the differential diagnoses for sudden loss of hypertrophic cardiomyopathies (HCM) or
consciousness/awareness. cardiomyopathies.
2. Cardiac Echocardiogram: for suspected structural cardiac
Examination disease
 Examination covering vital signs of blood pressure and heart 3. Blood tests: Haemoglobin/haematocrit, blood gas for
rate anaemias
 Cardiac examination for: 4. Blood sugar: for hypoglycaemia
o murmurs 5. Blood pressure: Sitting and standing blood pressure for
o irregular pulse postural hypotension, POTS.
o carotid bruit 6. EEG: only to support if clinical suspicion of epilepsy. EEG must
 Neurological system examination for: not to be done on suspected syncope as it may show non-
o cranial or motor neurological deficits specific inter-ictal epileptiform discharges.
o sensory deficits 7. Head-up tilt tests are the gold standard for diagnosing and
 Neuro-cutaneous syndromes such as cafe au lait marks categorising neurally-mediated syncope (NMS). It is not used
 Plot growth parameters on appropriate growth charts routinely due to difficulties in conducting the test without the
 Head circumference necessary equipment. It is used in cases of diagnostic uncer-
 Signs for trauma tainty, such as in cases with frequent, or atypical, or treatment
 Fundi examination resistant TLOC.

Investigations Red flag signs and symptoms

1. ECG: A standard 12 lead ECG should be included in all cases. If
cardiac pathology is suspected, then further investigation such
as continuous or exercise ECG may be necessary.
 Emphasis should be placed on the QT interval and T wave
for evidence of long QT syndrome.
Careful consideration should be given to red flag signs and
symptoms. If present, patients must be evaluated and managed
as per the clinical indication, after seeking a relevant specialist’s
opinion. Red flag signs and symptoms include:
 Little or no prodromal symptoms

A table outlining the differential diagnoses for sudden loss of consciousness/awareness

Differential diagnoses Clues from history

Neurally mediated syncope C Usually have a trigger

C Pre-syncope symptoms include dizziness,
light headedness, visual/auditory distor-
tions, nausea, flushing and sweating.
C History of visual disturbance and feeling of
becoming distant, and then losing balance
and falling/slumping on to floor.
Cardiac arrythmia C Sudden and brief TLOC with collapse and
an immediate recovery
Typical generalised epileptic seizure C Tonic, clonic, tonic-clonic movements with
or without impaired loss of consciousness
and impaired breathing
C Associated with cyanosis, incontinence,
tongue biting
C Followed by drowsiness or sleepiness
Psychogenic TLOC C Lack of witnesses
C long standing history of psycho-somatic
symptoms
C TLOC occurs in supine positions with
absence of neurological deficits.

Table 2

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 OCCASIONAL REVIEW
 Prolonged loss of consciousness (longer than 5 min)
 Exercise induced syncope
 Chest pain or palpitations
 History of cardiac disease
 Familial history of cardiac conditions/arrythmias
 Family history of sudden deaths, genetic conditions and
metabolic conditions
 History or family history of migraine
 Neurological signs or symptoms
o focal neurological deficits
o ataxia
o dysarthria
Treatment and general advice
The most common reflex or neurally mediated syncope (NMS)
rarely needs medication or treatment. Upon diagnosis of NMS, a
standardised approach of reassurance, general education and
lifestyle modification advice should be given. The patient needs
to be reminded that they can still lead a normal life without any
restrictions. General education and awareness for patients and
carers involves spotting and avoiding potential triggering factors
such as a hot environment, prolonged standing, dehydration,
fatigue and stress. Prompt recognition of prodromal symptoms
and proactive steps should be encouraged to treat these, such as
sitting, lying down or raising the legs above the body.
Clinicians should stress the importance of taking enough
fluids (indicated by colourless urine), optimising salt intake and
regularly exercising. It should be noted that caution should be
exercised on fluid and salt intake if the patient has any under-
lying cardiac conditions or hypertension. Patients and carers
should also be further directed towards information resources
such as the NHS (https://www.nhs.uk/conditions/breath-
holding-in-babies-and-children/) or STARS websites (https://
www.heartrhythmalliance.org/stars/uk).
Some children with RAS benefit from medical treatment with
atropine or fluoxetine. Rarely in recurrent/resistant NMS, or
when lifestyle changes have failed, there are number of medi-
cations can be tried, such as alpha blockers, beta blockers, flu-
drocortisone and midodrine; however, the evidence for their
effectiveness is limited and must only be used under specialist
advice. Note that a permanent cardiac pacemaker is indicated if
asystole is a feature of reflex syncope.
Conclusions
TLOC is the common problem in paediatric practice and though
there are several causes, most cases are of neurally mediated
syncope, which has excellent prognosis. The diagnosis can be
made confidently via a history, physical examination, and in-
vestigations such as an ECG. In most cases, extensive in-
vestigations are not necessary; however, an ECG must be
performed, and the patient must be referred for a cardiologist
opinion if there are any red flags. If it has failed to be recognised
and managed with reassurance, education and lifestyle modifi-
cations, TLOC can have a significant impact on children and their
families.
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