Pediatric reflex syncope: updated insights and future directions

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.