Funny turns in children

Abstract

Funny turns in children are common and usually triggered by a benign cause. There is a wide range of possible pathologies underlying these episodes. Many children will only be looked after by their GP but some complex cases may be managed by a number of different specialities including general paediatrics, paediatric neurology, paediatric cardiology and the ear, nose and throat department. This article aims to outline a primary care approach to a child presenting with a funny turn to enable appropriate reassurance or referral to the appropriate specialty.

The GP curriculum and funny turns in children

Clinical example 3.04: Care of children and young people expects GPs to:

Manage and treat sensory deficit

Clinical example 3.15: Care of people with ENT, oral and facial problems requires GPs to:

Manage primary contact with patients who have a common/important ENT, oral or facial problem, e.g. benign positional vertigo and Ménière's disease

Assessing a funny turn in a child

History

The first priority in your assessment is to establish an accurate history. The term ‘funny turn’ has no consistent definition within the medical literature. A GP may see many symptoms within this umbrella term including dizziness, vertigo, loss of consciousness, seizure activity and emotional distress.

Different words are used by children, their parents and their doctors regarding funny turns. Dizziness is an uncommon complaint in children and, as a descriptor, is not particularly helpful. Clarify whether the child or parent means light-headedness, vertigo or clumsiness.

Ensure that you use an interpreter to aid your consultation if you do not speak the language of the family. Unless very young, it is best to try to get children to describe their symptoms in their own words. If the child is struggling to answer specific questions; direct these to the parent or any witnesses. Some useful questions to ask children and their parents when they present to you are summarised in Box 1.

Box 1.

Questions you may ask during your initial assessment.

• Where did the episode happen and what were the circumstances (ask particularly about last meal, hot environments, prolonged standing, emotion, pain)?

• When was the onset and what was the duration of each episode?

• Were there any precipitating and relieving factors (particularly a history of trauma and episodes which occurred during exercise)?

• Was there a history of any preceding or coexisting febrile illness?

• Was there any loss of consciousness?

• Were there any associated features; particularly vomiting, headache, photophobia?

• Any features suggestive of a cardiac cause: breathlessness, colour change?

• Any features suggestive of a neurological cause: seizure activity (including tongue biting and incontinence), weakness in a limb or face, lack of co-ordination, clumsiness, regression of developmental milestones?

• Any features suggestive of an ENT cause such as ear pain or visual disturbance?

• What was the recovery time following the episode?

• Is there any relevant past medical, pregnancy or birth history?

• Is there any family history of epilepsy, or sudden death?

• Are the immunisations up to date?

• Is there any concerns about developmental delay?

• Are there any psychosocial concerns. Has there been any concerns from the other members of the team around the child such as health visitors or school?

• Are there any safeguarding concerns?

Examination

You are unlikely to witness the child’s funny turn as it happens, but it is increasingly common for parents to bring a mobile phone recording of the funny turn to consultations with a GP. This can be an extremely helpful complement to your assessment and can provide crucial information.

General observation will also provide useful information. First, assess how the child comes into the consulting room. This will highlight any gait abnormality, photophobia, general alertness and comfort.

As with the assessment of all children, use an opportunistic approach using careful explanation and play used to avoid distress. Baseline observations of temperature, pulse rate and rhythm, respiratory rate and capillary refill should be noted. Document the moistness of mucous membranes and whether the child is alert and behaving appropriately. A cardiorespiratory examination is useful to look for possible cardiac causes. Assess for any infective source.

Examination of other systems should be based on the presenting symptoms. A targeted neurological examination, for example, might include examination of the pupils, eye movements and nystagmus, tone, power and reflexes of the limbs. A focussed examination of the ears should include the general appearance of the pinna and the presence of any accessory auricles, skin tags or pits that may suggest underlying embryological abnormalities. Otoscopy is best achieved in young or uncooperative children by asking the parent to sit the child sideways across the parent’s lap and using one of the parent’s hands to secure the upper arms close against the child’s trunk, and the other hand to steady the child’s head against the parent’s body. The tympanic membrane should be visualised. Commonly, glue ear (otitis media with effusion) will be seen on examination as a dull eardrum. Tuning fork testing can help establish a diagnosis of conductive or sensorineural hearing loss by using Weber and Rinne’s tests. However, these tests rely on children being able to communicate effectively and are rarely practical in children under 4 years of age.

Findings suggestive of serious illness.

There is useful guidance prepared by the National Institute for Health and Care Excellence (NICE) on management of the febrile child. In addition to the targeted examination approaches explained above febrile children should be carefully assessed. Box 2 summarises this approach.

Box 2.

Concerning features in funny turns.

General findings

• Pale, mottled, blue

• Unable to rouse

• Weak, high-pitched, or continuous crying which is inconsolable

• Pyrexia (concerning level: 3–6 months 39°C or greater, 0–3 months temperature 38°C or greater)

• Non-blanching rash

• Neck stiffness

Respiratory findings

• Tachypnoea (respiratory rate over 60 breaths/minute)

• Signs of increased work of breathing including chest in-drawing

• Oxygen saturations under 95%

Circulation/cardiology findings

• Tachycardia (greater than: 160 beats/minute under 1 year, 150 beats/minute 1–2 years, 140 beats/minute 2–5 years)

• Reduced skin turgor

• Capillary refill time of over 3 seconds

• Reduced urine output

• Episode is associated with a new murmur or arrhythmia

• Episode is associated with exercise

Neurological findings

• Status epilepticus

• Focal neurological signs

• Focal seizures

Adapted from National Institute for Health and Care Excellence 2013. Feverish illness in children: Assessment and initial management in children younger than 5 years. Issued May 2013. Retrieved from http://guidance.nice.org.uk/CG160

Referral

Management of funny turns in children depends on the individual clinical presentation. If the child displays red flags in the context of an acute feverish illness this should be referred to a paediatrician as an emergency. In addition, evolving hard neurological signs should be reviewed in secondary care as an emergency. Complex cases may be reviewed by both a general paediatrican and another specialist (for example neurologist or ear, nose and throat (ENT) surgeon) depending on the presentation and local services.

Urgent referrals to outpatients can be made if there is no immediate threat to life but clinical findings are found that could point to a serious underlying cause. For cases of diagnostic doubt in an otherwise well child a routine referral is appropriate. It can be difficult distinguishing conditions that should be seen by paediatrics or ENT. If in doubt, discussing the case with either one of these specialist teams can provide useful information to guide the onward referral. This ensures the child goes to the right place in a timely fashion.

In cases where the diagnosis is not clear, or where there are suspected congenital abnormalities, appropriate investigations in secondary care may be performed. Cerebellar lesions and tumours of the central nervous system are best evaluated with magnetic resonance imaging. Imaging in young children may require a general anaesthetic.

Common causes of funny turns in children

Breath-holding attacks

Breath-holding attacks commonly present between 6–12 months of age and are frightening for parents. They frequently self-resolve by 2 years. Classically the attack is triggered by emotion – such as pain, frustration or anger. Initially the infant starts to cry then holds his or her breath for several seconds. The child’s face may discolour, often turning blue. The child then loses consciousness and goes limp briefly, usually for less than 60 seconds. The attack ends when the infant takes a deep breath and suddenly regains consciousness without any residual symptoms or signs.

Breath-holding attacks tend to run in families and, although triggered by emotion, are not intentionally ‘performed’ by the child. There is no relationship to other causes of syncope or to epilepsy but these attacks are more common in children who are anaemic. An important aspect of managing these children is parental education and reassurance.

Migraine

Migraine is common in schoolchildren, affecting about 5% (Morrison, 2008). It is the most common cause of recurrent vertigo in children (Choung, Park, Moon, Kim, & Ryu, 2003). There is often a strong family history which helps make the diagnosis.

Presentation of childhood migraines can be extremely variable. The International Headache Society classification for childhood migraine is summarised in Table 1. Due to varying presentations of childhood migraine and the potential for missing serious underlying pathology, referral to general paediatrics or paediatric neurology is wise.

Table 1.

The International Headache Society Classification of Migraine including variants (some rare) seen in childhood.

Type of headache	Subsets	Further details
Migraine without aura	The most common variety in children and adults
Migraine with aura	Constitutes 14–30% of migraine in children and including:
	Aura without headache	More common in childhood
	Hemiplegic migraine	More common in childhood
	Basilar migraine	More common in childhood, particularly in young girls
	Ophthalmoplegic migraine	Very rare but more common in children than in infants, and even rarer in adults
	Acute confusional migraine	Seen in childhood
Childhood periodic syndromes	Commonly precursors of migraine and almost exclusively confined to childhood, including:
	Cyclical vomiting
	Abdominal migraine
	Benign paroxysmal vertigo of childhood
Retinal migraine	Seen more in children and in young adults

Treatment is targeted at avoidance of triggers, and symptomatic or prophylactic medications dependent on the frequency and severity of episodes. Concerning neurological features such as progressive dizziness, increasingly severe or prolonged headaches, or neurological signs warrant urgent paediatric review.

ENT causes

Mild light-headedness can occur in acute otitis media. Identifying otitis media is straightforward with an adequate history and examination. Grommet insertion following referral to ENT is often beneficial in children with dizziness, speech delay and poor concentration due to glue ear (Hart, Nichols, Butler, & Barin, 1998).

Vertigo can be described by children as feeling as if on a roundabout and usually points to an ENT or neurological cause. In young children, vertigo may manifest as behavioural changes, including cowering in the corner of the cot, vomiting or hiding their eyes. In walking infants there may be a history of frequent falling and unsteadiness which is non-specific but may represent underlying pathology. In pre-walking infants, recurrent torticollis may be a feature of underlying vestibular dysfunction (Casselbrant & Mandel, 2005).

Acute labyrinthitis is thought to be caused by an inflammatory process in the bony labyrinth (consisting of the semicircular canals, vestibule and cochlea). This inflammation results in vertigo and hearing impairment. It is most commonly seen in adults, but can occur in children. If the vertigo is worsened by head movements and there are no auditory symptoms then vestibular neuritis is more likely. This is inflammation confined to the vestibular nerve, and does not affect the cochlea. For both conditions management should focus on early return to safe physical activity, but symptoms of vertigo may persist for several weeks.

Benign paroxysmal vertigo in childhood is a form of migraine resulting in brief (less than 1 minute) attacks of vertigo, which can be manifest as screaming, crying or falling followed by a rapid return to normality. These episodes rarely have a clear precipitant and are not positional. This is in contrast with benign paroxysmal positional vertigo (which is extremely rare in children). Children may have episodes as regularly as every week, but will generally grow out of the condition after a few years. However 20% will develop migraines when they are older (Lindskog, Odkvist, Noaksson, & Wallquist, 1999). There is no specific treatment.

Night terrors

Night terrors are common and are often more distressing for the parents than the child. Children aged 3–12 years are affected. They usually happen when the child enters the rapid eye movement phase of sleep within 90 minutes of falling asleep. Children display sudden partial arousal and may sit up, talk, scream, walk and be agitated. Typically night terrors resolve by adolescence and can usually be managed with reassurance and parental education. An information leaflet about night terrors may be very helpful.

Epilepsy

Epilepsy is a disorder of the brain and is characterised by frequent seizure activity. Epilepsy syndromes are varied and complex and will not be covered in full here. Features that suggest epilepsy are neurological aura followed by seizure activity (either partial or generalised) with a significant post-ictal period following the episode. The frequency and nature of the seizure activity depends on the epilepsy syndrome diagnosed. Children with suspected epilepsy should always be referred to secondary care using the 2-week wait urgent referral pathway if the child has had a first fit. Electroencephalography (EEG) is rarely helpful unless informing diagnosis of a specific epilepsy syndrome to guide tailored management.

Cardiac causes

It is thought that 20% of all children will experience at least one episode of syncope in their childhood (McLeod, 2003). Most cases are due to a benign neurocardiogenic cause, such as vasovagal syncope. More serious causes are mostly cardiac and include long QT syndrome and congenital heart defects. As with breath-holding attacks, most children lose consciousness in response to emotion or pain. Hot environments, dehydration, low blood sugar, prolonged standing or the sight of blood can all trigger syncope.

In children (and adults) urinary incontinence, vocalisation and involuntary movements are possible during syncope. Unlike other causes such as epilepsy, recovery is prompt and the child does not have any neurological sequelae.

A targeted neurological and cardiac examination should be performed. If there are no abnormalities on examination, there has been a specific trigger and the episode is isolated, general advice regarding avoiding triggers, increasing fluid and salt intake, regular meals and reducing caffeine can be helpful. If the presentation is more complex, the episodes are persistent and/or there are abnormal findings on examination the child may need further investigations in secondary care, such as an electrocardiogram, echocardiogram and EEG.

Reflex anoxic seizures can occur at any age, but are more common in younger children. Much like breath-holding attacks they can be triggered by emotion and pain that leads to a vasovagal syncopal episode. Clinically, there is an initial bradycardia, the child then loses consciousness and looks pale and limp. During the syncope the child may have a period of asystole, which then triggers an anoxic seizure characterised by stiffening and jerking of limbs. There is no specific investigation or treatment should the history and examination point to this condition. Severe cases require referral to cardiology.

A funny turn (particularly if full syncope) in a child with known congenital heart disease should be taken as a red flag and urgent referral considered. Cardiac causes may result in an episode that happens during exercise, may be preceded by palpitations or breathlessness and may be associated with a murmur or arrhythmia on examination. Referral for further cardiac investigations should be made. Depending on the nature of the episode this should either be either same day or urgent.

Trauma

Head injury is an important feature to establish early on in your history taking. Significant head injury causing intracranial and bony injury will present to emergency departments and not general practice. That said, children can attend sometime after a head injury with persistent dizziness. Dizziness can be a common component of a post-concussion syndrome, but it should resolve after a few weeks. The possibility of non-accidental injury should be considered and appropriate child safeguarding policies utilised if necessary.

Key points

Funny turns in children pose a unique situation where collaboration between primary and secondary care specialties may be needed

A careful history and targeted assessment will enable you to determine what system is involved to plan further management

Some conditions require reassurance only. Others need specialist investigations and treatment in hospital

References

American Academy of Otolaryngology-Head and Neck Foundation, Inc (1995) Committee on Hearing and Equilibrium guidelines for the diagnosis and evaluation of therapy in Menière's disease. Otolaryngology Head and Neck Surgery 113: 181–185. doi: 10.1016/S0194-5998(95)70102-8.

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British Tinnitus Association. (2008). Tinnitus in childhood. Retrieved from www.tinnitus.org.uk/tinnitus-in-childhood.

Casselbrant

M. L.

Mandel

E. M.

(2005) Balance disorders in children. Neurologic Clinics 23(3): 807–829.

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(2003) Various causes and clinical characteristics in vertigo in children with normal eardrum. International Journal of Pediatric Otorhinolaryngology 67: 889–894. doi: 10.1016/S0165-5876(03)00136-8.

GPonline. (2014). How to investigate faints and funny turns in children. Retrieved from www.gponline.com/assessing-faints-funny-turns-children/cardiovascular-system/congenital-cardiac-disorders/article/1227435.

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McLeod, K. A. (2003). Syncope in children. Archives of Diseases in Childhood, 88, 350–353 Retrieved from http://adc.bmj.com/content/88/4/350.full.

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NICE. (2013). Feverish illness in children: Assessment and initial management in children younger than 5 years. Issued May 2013. Retrieved from http://guidance.nice.org.uk/CG160.

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Patient UK. Migraine in children. Retrieved from www.patient.co.uk/doctor/Migraine-in-Children.htm.

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(2002) Neurological involvement in rheumatic disorders and vasculitis in childhood. Revista de Neurologia 35(3): 290–296.

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RCGP. Clinical example 3.04: Care of children and young people. Retrieved from www.rcgp.org.uk/gp-training-and-exams/∼/media/Files/GP-training-and-exams/Curriculum-2012/RCGP-Curriculum-3-04-Children-and-Young-People.ashx.

16.

RCGP. Clinical example 3.15: Care of people with ENT, oral and facial problems. Retrieved from www.rcgp.org.uk/gp-training-and-exams/∼/media/Files/GP-training-and-exams/Curriculum-2012/RCGP-Curriculum-3-15-ENT-Oral-and-Facial-Problems.ashx.