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Episode of transient loss of consciousness (TLOC), blank staring or other brief episode of unusual behaviour in young people up to their 16th birthday (or 18th birthday if the young person prefers to be seen in a paediatric setting). This guideline covers diagnosis and management in primary care.
There is considerable overlap between this guidance, NICE guidance for adults with TLOC (CG109) and for management of the epilepsies in children and adults (CG137)
Faints, fits and funny turns are very common in children and adolescents. They comprise a wide range of entities and can be challenging for the clinician to diagnose. Misdiagnosis in epilepsy is common (up to 30%). There is no one test that reliably discriminates between the many causes of collapse, loss of awareness or consciousness in children / young people. Clinical assessment is key to diagnosis.
It does not cover management of conditions such as epilepsy in secondary care.
An accurate first-hand witness account of an event is crucial. Ask the child / young person (where appropriate) and any witnesses to describe what happened before, during and after the event. With the consent of the patient / carer, phone witnesses who are not present. Record an event's parts in chronological order.
Encourage witnesses / carers to video events on their mobile phone (which though counter-intuitive whilst administering first aid is hugely useful)
If you believe that the event is due to a condition which requires immediate action, use your clinical judgement to determine the urgency of referral.
Refer a child / young person for an emergency paediatric review with the following features:
Where no red flags, diagnose the type of funny turn focusing on the key features in the history. Here is a guide to the commoner causes of funny turns.
Perform a 12-lead ECG for any blackout or convulsive episode.
Record a 12-lead electrocardiogram (ECG) using automated interpretation. Red flags include any of the following abnormalities reported on the ECG printout:
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 the following abnormalities:
Further tests depend on the clinical diagnosis.
Do not refer for an EEG to 'rule in' or 'rule out' epilepsy.
Benign neonatal myoclonus of sleep – advise on the benign nature of this condition. Babies usually grow out of it and stop worrying their parents by 4 months of age. There are some good YouTube videos of this condition against which parents can check their own baby for reassurance.
'Blue' breath-holding – see supporting information. Anaemia has been associated with breath-holding spells and correction with iron supplementation can be considered. Drug treatment is seldom necessary. The prognosis is excellent. There is no relationship to epilepsy. Addressing parents' stress and educating about continuing to set boundaries around their child is an important aspect of care.
'Pallid' reflex anoxic seizures – see supporting information. Again, the prognosis is good and there is usually no relationship to epilepsy. Treatment is not usually required although Glycopyrrolate has been successfully used in some. Cardiac pacing is used in some persistently frequent cases.
Motor stereotypies – see supporting information. These are very common in young children and should be considered normal behaviour in most cases. They are frequently seen in children with hearing impairment, speech delay or autistic spectrum disorder. However motor stereotypies do not mean that a disorder such as one of these must be present. They are very unlikely to threaten future development or health. No specific treatment is usually needed for young children.
Night terrors – see supporting information. Reassurance about the benign nature of the problem is the mainstay of treatment. Lifting early in sleep (1/2 hour before the predicted night terror) can prevent the onset of deep sleep and therefore the attacks. This is not usually necessary and can, in some, result in night terrors occurring later in the night.
Vasovagal Syncope – see supporting information. Reassurance, education about triggers and ways to avoid syncope – e.g. avoid skipping meals, plenty of fluids in hot weather / with exercise, maintain salt in diet, continue to do exercise, get up slowly out of bed / chairs. If symptoms start sit / crouch down. Education in schools can help to reduce anxiety and reduce sanctioning of activities / trips etc.
Non-epileptic attacks –offer advice and information (see below). Consider CAMHS referral.
First seizure – Refer to paediatrics – urgency depends on other clinical features – see 'referral' section. Pending the paediatric review offer advice on first aid + safety aspects – see below.
e-Referral selection
Blue breath-holding attacks and reflex anoxic seizures - NHS choices
Good advice on both types of episode, distinguishing between the two and promoting self-management as well as 'when to see your GP'
Reflex anoxic seizures - STARS - video + PDF available
Motor stereotypies - Johns Hopkins Medicine (although this is American and talks about research into behavioural management in USA and is geared to children in whom they persist into school age)
Night terrors and nightmares - NHS choices
Vasovagal Syncope - STARS - video & PDF, here called 'reflex syncope'.
Non-epileptic attacks – supportive information including 'what people should do if I have a seizure' advice for schools at Non_Epileptic Attacks
First seizure – first aid advice depends on the type of seizure.
1. NICE Clinical Guideline on Transient Loss of Consciousness (blackouts) in over 16s
2. NICE Clinical Guideline on the Epilepsies in Children and Adults
This guideline has been signed off on behalf of NHS Devon.
Publication date: February 2017