Faints, fits and funny turns
- Are very common in children and adolescents
- 1 in 3 teenagers have had vasovagal syncope
- Breath holding causing reflex anoxic seizures is as common as 1 in 20 infants / toddlers
- < 25% of children referred will have epilepsy
- Cardiac syncope is a rare cause, 1 in 30,000
- Taking an accurate and detailed clinical history is the key to diagnosis
This document does not cover the management of conditions such as epilepsy in secondary care.
Do not routinely refer - see management section
- A child / adolescent with vasovagal syncope and / or pre-syncope
- A baby with benign neonatal myoclonus of sleep
- A toddler with breath-holding attacks or reflex anoxic seizures
- A child with night terrors
- A child with tics or a motor stereotypy
- An adolescent with non-epileptic attacks (dissociative seizures)
Assessment
History- An accurate first-hand witness account of an event is crucial. Ask about:
- Situation - What was the child doing at the time?
- Warning symptoms – Dizziness, changes to vision, sweating, palpitations etc.
- The event - duration, ask about pallor / cyanosis, tone, describe movement and other associated movements (atuomatisms) such as tongue biting.
- Duration of event (often inaccurate)
- Post event – time to recover, headaches, confusion or weakness.
please ask witnesses to complete the Event Evaluation sheet
- Encourage witnesses / carers to video events on their mobile phone
- PMHx of other funny turns, family history of cardiac disease, epilepsy or sudden unexpected death in childhood / young adulthood
Examination:
- Vital signs, lying and standing blood pressure (latter if cardiac or vasovagal syncope suspected), heart sounds and signs of heart failure
- Centiles and head circumference
- Full neurological exam including fundoscopy
- Skin examination looking for birthmarks, pale patches or multiple café-au-lait patches
- Developmental exam
Investigations
- If available perform a 12-lead ECG for any episode of collapse, blackout or convulsive episode. Red flags on the ECG include:
- Conduction abnormality (for example, complete right or left bundle branch block or any degree of heart block)
- Evidence of a long or short QT interval. The normal range for QTc is 350 – 450ms. A QTc greater than or equal to 0.47 seconds is suggestive of a long QT syndrome (LQTS), although a QTc above 0.44 seconds may be considered 'borderline'.
- Any ST segment or T wave abnormalities.
If a 12-lead ECG with automated interpretation is not available, take a manual 12-lead ECG reading and have this reviewed by a healthcare professional competent in identifying ECG abnormalities.
Do not refer for an EEG to 'rule in' or 'rule out' epilepsy.
Diagnosis:
Information regarding specific disorders:
Hypnogogic jerks- myoclonic jerks as falling asleep, extremely common and benign.
Benign neonatal sleep myoclonus -Non epileptic myoclonic jerks of limbs. Jerks can be synchronous/asynchronous, unilateral / bilateral and can occur in clusters. Stops on arousal and holding. Baby otherwise well. Stops by 6 months of age. Do NOT occur when aware. Does not need investigation.
Breath holding- (6months-2yrs). Triggered by fright/frustration/minor injury. The child cries and becomes apnoeic then turns ‘blue’ with loss of consciousness and jerking/posturing. Usually lasts < 1minute, terminates with a gasp and promptly awakens. Can be associated with anaemia. Prognosis is excellent. Parents should continue to set boundaries for their child.
Reflex anoxic seizures- common in young children but can be any age. Triggered by unexpected bump/ fright/ seeing blood leading to severe bradycardia, asystole, transient syncope and anoxic seizure. Education and reassurance is mainstay of treatment. Treatment is not usually required.
Infantile spasms–(3-6 months of age). Clusters of attacks usually on awakening: eyes rolling, stiffening and collapsing forward for 1-3seconds. These are associated with halted development.Needs urgent referral/ admission.
Night terrors- (3-12yrs), usually occurs in first 90mins of sleep, does not recur. Sudden partial arousal leading to sitting upright, walking, running, talking incoherently. Wide eyed, breathing fast, sweating, confused. Complete amnesia of the event in the morning. Reassure parents that these are benign and self limiting.
Myoclonic epileptic seizures- very fast single or multiple jerks of limbs, often associated with other seizures types. Early morning jerks in a teenager think juvenile myoclonic epilepsy (JME). Refer for a Paediatric review.
Daydreaming / sensory pauses / inattention– Commonest cause of blank spells. Usually noticed at school in children with learning difficulties or with sensory processing issues. Child becomes blank and seems unresponsive. These do not require treatment.
Epileptic ‘absence’ seizure – Much less common than inattention / daydreaming. Usually last a few seconds and can happen during any activity. Usually associated with automatisms such as: eyelid fluttering / gulping / swallowing / chewing lips etc. Refer for paediatric review.
Febrile seizures– (6month-6yrs). Seizure during an acute febrile illness (>38 degrees). Increased risk of recurrence if first seizure < 15months of age, family history, complex first seizure. Parental education is important.
Infant gratification/infantile masturbation– (3months-3yrs). Occurs during times of boredom / loneliness / excitement / anxiety. Dystonic posturing, rocking, grunting and posturing of the lower extremities to put pressure on the perineum. No alteration of consciousness. Will stop with distraction. Benign and will spontaneously resolve.
Motor stereotypies- rhythmic, fixed predictable movements ie head banging, hand flapping, rocking, hair twirling. In children developing normally or in those with developmental problems ie autism.
Juvenile myoclonic epilepsy- morning myoclonic jerks with occasional tonic-clonic seizures. Triggered by sleep deprivation. Refer for paediatric review.
Dystonia-painful twisting movements of limbs. Worse with activity and reduces when asleep. Refer for paediatric review.
Information to include in the referral
- Event Evaluation Sheet
- 12 lead ECG if available
Resources
References
Dr Sushil Beri, Assessing faints and funny turns in children, 17 November 2015,https://www.gponline.com/assessing-faints-funny-turns-children/paediatrics/article/1227435. Accessed February 2019.
North & East Devon Formulary and Referral Site, Children & Adolescents, Fits, Faints and Funny Turns. https://northeast.devonformularyguidance.nhs.uk/referral-guidance/eastern-locality/paediatrics/fits-faints-and-funny-turns-in-children-and-young-people
Contributors: Dr Chris Butler, Consultant Paediatrician RCHT (2021
Dr Sian Harris, Consultant Paediatrician, RCHT (2019)
RMS Author: Dr S Burns GP
Date: August 2021
Review Date: August 2022
Version 1.1