Synopsis
Separate common benign paediatric fainting and chest-wall pain from structural or electrical cardiac disease, select proportionate testing, and protect children with exertional, ECG or family sudden-death warning features.
- Most childhood syncope is vasovagal and most chest pain is musculoskeletal, respiratory or idiopathic, but rare cardiac disease is identified by event context, family history, examination and ECG rather than pain intensity.
- Typical vasovagal syncope follows prolonged standing, heat, pain, fear, dehydration or seeing blood, with warmth, nausea, visual dimming and pallor before brief loss of posture and rapid recovery when supine.
- Cardiac syncope is more concerning during exertion or swimming, while supine, after sudden noise or emotion, with palpitations or chest pain, with no prodrome, or in known cardiac disease.
- Ask a witness to reconstruct position, activity, prodrome, colour, pulse or breathing if observed, movements, tongue biting, duration, recovery and injury; brief jerks can occur during cerebral hypoperfusion and do not prove epilepsy.
- Chest-wall pain is focal, reproducible by palpation or movement and often follows cough, exercise or minor trauma. Cardiac pain is rare but exertional association, syncope, palpitations or cardiac risk history mandates referral.
- Initial assessment includes full observations, lying and standing heart rate and blood pressure when safe, four-limb pulses, cardiac and neurological examination, hydration, glucose and a 12-lead ECG for red-flag or unexplained events.
- Read the paediatric ECG systematically for rate and rhythm, PR and QRS, pre-excitation, heart block, QTc, Brugada pattern, hypertrophy and ST-T changes; machine interpretation does not replace clinician review.
- Echocardiography is targeted to abnormal examination or ECG, exertional symptoms, known disease or a concerning family phenotype; it is not a routine reassurance test for every reproducible chest pain.
- Ambulatory rhythm monitoring is useful when symptom frequency matches the device duration; an exercise test can assess exertional arrhythmia or outflow symptoms under specialist supervision.
- Manage uncomplicated vasovagal episodes with education, regular fluid and meals, trigger avoidance, early lying flat with legs raised and physical counter-pressure manoeuvres in an older child.
- A child with sudden-death red flags should avoid competitive or strenuous exercise until paediatric cardiology or inherited-cardiac assessment defines risk and gives an individual activity plan.
Key red flags
Syncope during exercise, while swimming, while supine or without a typical prodrome requires urgent cardiac assessment and temporary restriction from strenuous activity.
Syncope preceded by palpitations, exertional chest pain or breathlessness, or followed by injury or prolonged physiological compromise raises arrhythmia or structural obstruction.
A first-degree relative with sudden unexplained death under 40, inherited arrhythmia, cardiomyopathy, unexplained drowning or recurrent seizure-like collapse changes referral urgency.
Abnormal murmur, gallop, hypertension, weak femoral pulses, heart-failure signs or an abnormal ECG makes a benign vasovagal label unsafe.
Persistent chest pain with fever, tachycardia out of proportion, breathlessness, troponin rise, positional pain or a recent viral illness suggests myocarditis or pericarditis.
Known congenital heart disease, Kawasaki coronary disease, connective-tissue aortopathy, sickle cell disease, malignancy or stimulant exposure lowers the threshold for same-day assessment.
Investigation priorities
Classify syncope, detect current instability and identify neurological, metabolic, cardiac or injury clues.
Management branches
The child is unresponsive, not breathing normally, shocked or has a sustained dangerous rhythm.
- Start paediatric life support, attach an AED or defibrillator and follow the documented rhythm algorithm.
- If a pulse remains, monitor continuously, check glucose, obtain vascular access and treat shock or arrhythmia with senior help.
- Arrange urgent echocardiography and targeted myocardial, coronary, pulmonary or aortic assessment after immediate stabilisation.