John E. Monaco, M.D
Teens are unique organisms. We can all acknowledge that. It is difficult to categorize them as kids anymore and they are not yet ready to be referred to as adults. So they remain in a category of their own.
Evidence for this is the fact that internists and pediatricians continue to argue about who should be responsible for the care of the adolescent. For the time being at least, they still fall in the pediatric category. And for us, they can sometimes be a challenge.
Recently I took care of a 15-year-old named Tyler. He is an otherwise healthy kid who passed out at school after feeling light headed. He was taken to the emergency room where a chest x-ray, electrocardiogram, echocardiogram and other cardiac tests were performed ‚ all were found to be normal. Since he had vague complaints of headache, an MRI of the brain was done and it was also found to be normal. Because of the worrisome nature of his complaints, he was admitted to our pediatric ward, and placed on a monitor for close observation. Aside from some short-lived light headedness, he had no further problems.
I discussed his case with our cardiologist who agreed that Tyler manifested the symptoms of a disorder known as "vasovagal syncope." This syndrome is somewhat mysterious, so it is appropriate that it occurs during that very mysterious time known as adolescence. Basically the symptoms that Tyler demonstrated ‚ light headedness and passing out ‚ are the result of an endocrine system in flux ‚ what we like to blame everything in adolescence on!
We think of hormones during adolescence as primarily in control of reproductive functions and secondary sexual characteristics (beard growth, the appearance of pubic and armpit hair, etc.). The fact is that they have many other functions as well, including the very complex coordination of blood pressure, heart rate and the blood flow of the very active, growing and changing adolescent body.
Basically, there is coordination between blood pressure and heart rate, among other things, designed to maintain perfusion of blood through vital organs during very simple activities like standing up. If that system is immature or undergoing rapid changes, it may not behave the way it is supposed to.
For example, when we stand up, our blood pressure naturally falls a little simply due to gravity. To compensate for this change, our heart rate slightly increases to maintain blood flow to the brain and other organs.
In adolescence, this mechanism occasionally backfires and instead of the heart rate increasing when the youngster stands up, it decreases. This results in an exaggeration of the diminished blood flow, and if it is extreme, the patient will pass out, or at least become a little dizzy and have to sit down. This can be made even worse if the child is at all dehydrated or hasn't eaten three well balanced meals during the day. (Do you know any adolescents who accomplish this simple goal?)
Usually this condition can be managed by careful attention to hydration, particularly during the hot months, and good nutrition. Sometimes medicine is required, and this is focused primarily on salt and fluid balance, all of which are involved in maintaining adequate blood flow. But the good news is that it is certainly a condition that Tyler, and other kids like him, will outgrow.
In the end, this was one of those cases in which a child went from the ambulance to the emergency department, with all the anxiety that entails, to being discharged with instruction to drink plenty of fluids and eat three square meals a day. If only they all could be this straight forward!
John E. Monaco, M.D., is board certified in both Pediatrics and Pediatric Critical Care. He lives and works in Tampa, Florida. He welcomes your comments, suggestions, and thoughts on his observations.
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