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Faints, fits and funny turns

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
  • Clinical assessment is key to diagnosis

 

Referral

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
  • Situation, warning symptoms, the events, duration, post event (please ask witnesses to complete the Event Evaluation sheet – link here)
  • 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
  • Look for:
  • 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

 

Unresponsive with stiffness and jerking

Jerks without collapse/   unresponsiveness

Blank spells

Going stiff

Episodes from sleep

Any age

Tonic Clonic Seizure

Hypnogogic jerks

 

Myoclonic epileptic seizures

 

Daydreaming/zoning out

Epileptic ‘absence’ seizure

Gastro-oesophageal reflux

Tonic seizures

Night terrors    

Nightmares

Nocturnal seizures

Babies

Breath holding     

Reflex anoxic seizures  

Febrile seizures

 

 

Benign neonatal sleep myoclonus          

 

Infantile spasms 

Infant gratification/infantile masturbation          

 

School age and adolescence

Vasovagal syncope   

Non epileptic attacks ( apparent unresponsiveness)

Tics

Juvenile myoclonic epilepsy   

Non epileptic attack disorder

Dystonia        

Drug reaction      (common ones being metoclopramide and cetirizine)

 

 

Hypnogogic jerks- myoclonic jerks as falling asleep, extremely common and benign.

Benign neonatal sleep myoclonus  - within first 3months. Mainly affects the distal parts of the upper extremities. Jerks can be synchronous/asynchronous, unilateral/bilateral, mild/violent and can be in clusters. Stops on arousal. Stops by 6months of age. Do NOT occur when awake.

Breath holding- 6months-2yrs, triggered by fright/frustration/minor injury. Vigorous crying leads to stopping breathing, turns blue and LOC. Lasts < 1minute, terminates with a gasp and prompt re-consciousness. Family history 1:3. Can be associated with anaemia.

Reflex anoxic seizures- common in young children but can be any age. Triggered by unexpected bump/fright/seeing blood leading to severe bradycardia, asystole, syncope and anoxic seizure. Education and reassurance is mainstay of treatment. Cardiac pacing for severe cases (very rare).            

Infantile spasms–3months of age. Clusters of ‘salaam attacks’ = eyes rolling, stiffening and collapsing forward for 1-3seconds. 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, walk, run, talk, incoherently. Wide eyed, breathing fast, sweating, confused. Complete amnesia of the event.

Myoclonic epileptic seizures- very fast jerks, often associated with other seizures types, early morning jerks in a teenager think juvenile myoclonic epilepsy.

Epileptic ‘absence’ seizure - lasts a few seconds, associated with eyelid fluttering/gulping/swallowing/chewing lips etc.

Febrile seizures– 6month-6yrs. Seizure during an acute febrile illness (>38.5). Increased risk of recurrence if first seizure < 15months of age, fhx, 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.

Dystonia-painful and worse with activity. Needs referral.

 

Information to include in the referral

  1. Event Evaluation Sheet
  2. 12 lead ECG if available

 

Resources

Seizures – safety issues

 

References

Dr Rebecca Harling, GP and RMS Lead for Paediatrics, April 2019.

Dr Sian Harris, Consultant Paediatrician, Royal Cornwall Hospital, April 2019.

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

Date reviewed                  17/7/2019

Next review due              17/7/2020

Sifter name                        Rebecca Harling

 

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