Syncope
Disclaimer
These guidelines have been produced to guide clinical decision making for general practitioners (GPs). They are not strict protocols. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.
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Introduction
Syncope is a brief and sudden loss of consciousness associated with loss of postural tone and consciousness with spontaneous recovery.
Around 15% of children experience an episode before the end of adolescence.
Most paediatric syncope is benign and has an autonomic cause (i.e. vasovagal or orthostatic).
- Vasovagal syncope usually has a clear prodrome (nausea, pallor, tunnel vision) and a precipitating factor (dehydration, heat, emotional stress). It can be associated with muscle jerks, twitching or convulsive movements which may mimic a seizure.
- Orthostatic syncope typically occurs after standing and is related to autonomic compensation
Less commonly, syncope results from life-threatening cardiac causes (structural heart disease or arrhythmia). Neurological conditions such as epilepsy and migraine may mimic syncope and should be considered.
Pre-referral investigations
- Orthostatic (postural) heart rate and blood pressure
- Neurological and cardiac examinations
- 12-lead-ECG (recommended at least once; repeat if new concerns arise)
- Blood glucose level if child is seen shortly after the event
- Full blood count (if anaemia is suspected)
- Consider pregnancy testing where appropriate
Pre-referral management
Initial management includes non-pharmacological strategies:
- Increase fluid and salt intake
- Regular exercise
- Sleep hygiene
Clinicians should delineate potential alternative causes, including:
- Seizure
- Migraine
- Hypoglycaemia
- Toxin exposure (e.g. carbon monoxide, clonidine)
- Functional neurological disorder
- Breath holding spells
- Dehydration or heat stroke
- Anaphylaxis
- Narcolepsy
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If symptoms persist, worsen, or if abnormal cardiac or neurological findings are present, the child should be directed to urgent care or an emergency department.
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Red flags
Cardiac Red Flags:
- Congenital or acquired heart disease
- Abnormal cardiac examination
- Previous cardiac surgery including implantable cardioverter defibrillator
- Previous cardiac arrest
- Family history of Sudden Unexplained Cardiac Death, cardiomyopathy or arrhythmia
- Abnormal ECG
Other red flags:
- Syncope occurring during exercise (exertional syncope)
- Anaemia
- Hypotension or sinus bradycardia
- Connective tissue disorders
- Systemic inflammatory condition
- Hypercoagulable state
- Recent or history of stimulant or amphetamine use
When to refer
- An isolated episode of likely vasovagal syncope with:
- No red flags
- Clear prodrome (nausea, pallor, tunnel vision)
- Identifiable trigger (dehydration, heat, prolonged standing, emotional stimulus)
- Normal examination
- Normal screening investigations
- These children can be managed in primary care with reassurance, education and safety netting
| PCH Cardiology |
- Suspicion of underlying cardiac cause
- Abnormal cardiac symptoms, examination, or investigations (including ECG)
- Significant family history
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| PCH Neurology |
- Persistent abnormal neurological findings
- Known neurological comorbidities
- Abnormal brain imaging
- Only after syncope has been reasonably excluded as the primary cause
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| General Paediatrics (at local hospital) |
- Suspected first afebrile seizure
- Recurrent vasovagal or orthostatic syncope not responding to non-pharmacological management
- Complex syncopal episodes (“drop attacks”), convulsive syncope, or events where cause is unclear after initial workup
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How to refer
- Routine non-urgent referrals from a GP or a Consultant should go to the Central Referral Service.
- Routine non-urgent referrals from a nurse practitioner, non-medical referrers or private hospitals go to the PCH Referral Office.
- Urgent referrals (less than 7 days) are made via the PCH Referral Office. Please call PCH Switch on (08) 6456 2222 to discuss referral with the General Paediatrician or Cardiologist on call.
Essential information to include in referral
History of episode including:
- Precipitating events such as:
- Sudden or prolonged standing
- Emotional stimulus
- Micturition
- Exercise
- Palpitations or chest pain
- Hyperventilation or exposure to flashing lights
- Dizziness, weakness, tinnitus or visual changes
- Daytime sleepiness
- Preceding syncopal activity (e.g. showering, brushing hair, micturition etc.)
- During the event
- Timing and duration
- Level of consciousness (Glasgow Coma Score or AVPU Score)
- Length of time until recovery
- Abnormal movements or seizure-like activity
- Incontinence
- Need for resuscitation
- Confusion on waking
- After the event
- Any persisting symptoms
- Time to symptom resolution
- Details of neurological and/or cardiac findings
Other relevant information:
- Medications
- Past cardiac history
- Past medical history (eating disorder, sensorineural hearing loss, rapid weight loss)
- Family history of early cardiac death, arrythmia or sudden death
References and useful resources
- Royal Children's Hospital Melbourne – Clinical Practice Guidelines: Syncope
- Royal Children's Hospital Melbourne – Clinical Practice Guidelines: Altered conscious state
- Causes of syncope in children and adolescents - UpToDate
- Children's Health Queensland Hospital and Health service- Syncope Emergency Management in children
| Reviewer/Team: |
General Paediatrics Department |
Last reviewed: |
Nov 2025 |
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Review date: |
Nov 2028 |
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