Head-up tilt testing in children and young people: a retrospective observational study

Head-up tilt testing (HUTT) is the gold standard investigation for adults with transient loss of consciousness (TLOC), but it is controversial in children and young people, because of a lack of systematic investigation and because the test can be uncomfortable. As it was introduced recently for children attending our hospital, we undertook a retrospective registered clinical audit of its usefulness.

The medical records of 100 consecutive patients aged less than 18 years undergoing HUTT from October 2001 to December 2008 were reviewed. Information about their episodes, prodromes, triggers, previous tests, indications for the HUTT, the HUTT and clinical outcomes was extracted.

Children were 6-17 years old; 68/100 were female. In 32/100, no trigger was reported. The most reported triggers included standing up (20%) and prolonged standing (18%). Dizziness (64%) and altered vision (39%) were the most experienced prodromal symptoms. Twenty-eight of 100 had a positive test, with reproduction of symptoms in 24. Seventeen of 100 tests were negative but symptomatic; 55/100 had a negative asymptomatic test. In 17/28 positive HUTTs, the tilt confirmed the suspected diagnosis and elucidated the mechanism. Two of 28 were started on medication. However, in 9/28, neither was the diagnosis clarified nor was therapy instigated.

Potentially useful information about the TLOC was obtained in 45/100 cases. The 17/100 with negative but symptomatic results may have had medically unexplained TLOC or emotional attacks, although without concurrent electroencephalogram, some uncertainty remains. Therefore, a new protocol with video-electroencephalogram-polygraphy and beat-to-beat finger blood pressure recording, and more explicit clinical reporting is being developed.