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• Faints are not always benign
  Anjum Gandhi
  Published on: 13 June 2006

• Published on: 13 June 2006

  Faints are not always benign

  • Anjum Gandhi, Consultant Paediatrician
  • Other Contributors:
    • Orhan Uzun, Consultant Paediatric Cardiologist, University Hospital of Wales, Cardiff

  Dear Editor,

  There is increasing concern regarding misdiagnosis and over-diagnosis of epilepsy1. Children presenting with acute paroxysmal events don’t always have epilepsy or as Drs Hindley, Ali and Robson tell us are quite likely to have syncope. Certainly then clinics dealing with such referrals should not be called as Epilepsy clinics but as the authors so aptly suggest as the ‘fits, faints and funny turns’ clini...

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  Dear Editor,

  There is increasing concern regarding misdiagnosis and over-diagnosis of epilepsy1. Children presenting with acute paroxysmal events don’t always have epilepsy or as Drs Hindley, Ali and Robson tell us are quite likely to have syncope. Certainly then clinics dealing with such referrals should not be called as Epilepsy clinics but as the authors so aptly suggest as the ‘fits, faints and funny turns’ clinics.

  It is chastening to know that syncope is the commonest presenting diagnosis, but worrying to assume that such syncope is always benign and neurocardiogenic. Cardiac syncope e.g. that due to long QT syndrome (LQTS), is well known to present as seizures2. No wonder that it is confused with epilepsy. In our personal practice we have recently seen 2 cases that were being managed as epilepsy but turned out to have LQTS.

  While it is correct to say that the majority of episodes of syncope in children are benign, a minority are caused by something more serious or even life threatening. The warning signs which might indicate a potentially sinister problem are well defined and include3:

  1. Syncope in response to loud noise, fright or extreme emotional stress
  2. Syncope during exercise
  3. Syncope while supine
  4. Family history of sudden death in young person < 30 years old.

  Some of the children in the author’s study had exercise and sudden surprise/shock as triggers for syncopal events. All such children require a 12 lead electrocardiogram (ECG) primarily to rule out a long QT interval but also to look for pre-excitation and heart block. It is important to remember that a normal QT interval on the ECG does not rule out LQTS and in the presence of suggestive history, further evaluation including stress testing and epinephrine challenge tests may be indicated. Adolescent athletes with anomalous origin of coronary arteries may present with exercise related syncope and normal ECG. A detailed echocardiogram with Doppler colour flow may help in making the diagnosis in these cases4.

  The concept of a ‘fits, faints and funny turns’ clinic is holistic but perhaps needs greater cardiology input.

  References: 1. Beach R, Reading R. The importance of acknowledging clinical uncertainty in the diagnosis of epilepsy and non-epileptic events. Arch Dis Child. 2005;90:1219-1222.

  2. Davies AM, Wilkinson JL. The Long QT syndrome and seizures in childhood. J Pediatr Child Health. 1998;34:410-411.

  3. McLeod KA. Syncope in childhood. Arch Dis Child. 2003;88:350-353.

  4. Kumpf M, Sieverding L, et al. Anomalous origin of left coronary artery in young athletes with syncope. BMJ. 2006;332:1139-1141.

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  Conflict of Interest:
  None declared.

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