Reflex syncope is the most frequent cause of transient loss of consciousness in the pediatric population. A structured diagnostic approach based on clinical evaluation and 12-lead ECG is mandatory to exclude the cardiac causes of syncope. Additional cardiac investigations, such as echocardiography, a stress test, or 24H Holter ECG monitoring, are needed in case of suspected cardiac syncope at initial evaluation. Cardiovascular autonomic function assessment, including ambulatory blood pressure monitoring and a tilt test, is useful for phenotyping syncope (hypotensive or bradycardic mechanism). In case of unexplained syncope after a comprehensive evaluation and high-risk criteria, an implantable loop recorder is indicated. The management is primarily based on reassurance, education, hydration, increased salt intake, and counter-pressure maneuvers. Pharmacological therapies and intervention strategies may be considered for patients with recurrent or disabling forms that are not responsive to lifestyle modifications. Conclusion: Reflex syncope in the pediatric population should be managed through a structured diagnostic pathway focused on excluding cardiac causes and guiding mechanism-based treatment. Education and lifestyle measures remain the cornerstone of management, while pharmacological or invasive strategies should be reserved for selected patients with recurrent or disabling symptoms.<Table Float="No" ID="Taba"> <tgroup cols="2"> <colspec align="left" colname="c1" colnum="1" /> <colspec align="left" colname="c2" colnum="2" /> <tbody> <row> <entry nameend="c2" namest="c1"> What is Known: • Reflex syncope is the most common cause of transient loss of consciousness in children and adolescents, and initial evaluation should rely on careful history taking, physical examination, and a 12-lead ECG to exclude cardiac causes. • Most pediatric reflex syncope can be managed conservatively through education and reassurance, together with adequate hydration, increased salt intake, and physical counter-pressure maneuvers. </entry> </row> <row> <entry nameend="c2" namest="c1"> What is New: • This review proposes a structured stepwise diagnostic pathway that starts with clinical evaluation and ECG and escalates only when cardiac syncope is suspected or the presentation is high-risk. • It emphasizes the role of brief cardiovascular autonomic assessment (ambulatory blood pressure monitoring and tilt testing) to distinguish hypotensive from bradycardic mechanisms and guide individualized management. </entry> </row> </tbody> </tgroup> </Table>

Pediatric reflex syncope: updated insights and future directions

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2026年3月5日

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Vincenzo Russo,
Angelo Comune,
Giangiacomo Di Nardo,
Giovanni Maria Di Marco,
Gabriella Gaudieri,
Erika Parente,
Alfredo Caturano,
Andrea Antonio Papa,
Anna Rago,
Maria Giovanna Russo,
Gerardo Nigro

摘要

Reflex syncope is the most frequent cause of transient loss of consciousness in the pediatric population. A structured diagnostic approach based on clinical evaluation and 12-lead ECG is mandatory to exclude the cardiac causes of syncope. Additional cardiac investigations, such as echocardiography, a stress test, or 24H Holter ECG monitoring, are needed in case of suspected cardiac syncope at initial evaluation. Cardiovascular autonomic function assessment, including ambulatory blood pressure monitoring and a tilt test, is useful for phenotyping syncope (hypotensive or bradycardic mechanism). In case of unexplained syncope after a comprehensive evaluation and high-risk criteria, an implantable loop recorder is indicated. The management is primarily based on reassurance, education, hydration, increased salt intake, and counter-pressure maneuvers. Pharmacological therapies and intervention strategies may be considered for patients with recurrent or disabling forms that are not responsive to lifestyle modifications.

Conclusion: Reflex syncope in the pediatric population should be managed through a structured diagnostic pathway focused on excluding cardiac causes and guiding mechanism-based treatment. Education and lifestyle measures remain the cornerstone of management, while pharmacological or invasive strategies should be reserved for selected patients with recurrent or disabling symptoms.

What is Known:

• Reflex syncope is the most common cause of transient loss of consciousness in children and adolescents, and initial evaluation should rely on careful history taking, physical examination, and a 12-lead ECG to exclude cardiac causes.

• Most pediatric reflex syncope can be managed conservatively through education and reassurance, together with adequate hydration, increased salt intake, and physical counter-pressure maneuvers.

What is New:

• This review proposes a structured stepwise diagnostic pathway that starts with clinical evaluation and ECG and escalates only when cardiac syncope is suspected or the presentation is high-risk.

• It emphasizes the role of brief cardiovascular autonomic assessment (ambulatory blood pressure monitoring and tilt testing) to distinguish hypotensive from bradycardic mechanisms and guide individualized management.