Orthostatic Intolerance

(Dizziness, Fainting / Near Fainting)

Orthostatic intoelrance is a very common problem in children and young adults. It may present differently in every person with symptoms from mild dizziness to fainting. People typically experience a roller-coaster of symptoms going from good to bad to good again with bad episodes becoming less frequent and less severe with time.  Fainting is actually fair common with on average 50% of pople experiencing an episode.  

How will we figure out how bad my episodes are?

People usually classify symptoms as mild, moderate or severe.

Mild is considered dizziness where it clears up in a few seconds, while annoying you usually don’t need to do anything other than stopping for a second to make it go away.

Moderate is dizziness where it may take a few minutes to go away, you may need to sit down or support yourself till it passes and you may feel a bit tired briefly after, but in the end it doesn’t significantly disrupt your day.

Severe is when dizziness is so bad it lasts for several minutes but the key point is that the dizziness actually prevents you from doing something you want or need to do.

Fainting is considered separate from all these but knowing how many actual fainting spells you have is important.

What is going on in Orthostatic Intolerance?

All of this is under the control of what is called the Autonomic Nervous System.  The heart itself is not doing anything incorrectly.

When we are sitting or standing our blood vessels stay somewhat tight (constricted) to fight against gravity and move blood back up to our head and heart. However, when you have Orthostatic Intolerance the blood vessels don’t tighten enough, they stay somewhat relaxed. This means your brain doesn’t get as much blood as it feels it should.

The brain starts sending you signals to lay down (when you lay down your legs and brain are at the same level and blood easily travels to your head). These signals are things like dizziness, bright or dark spots, tunnel vision, blurriness, muffled hearing, sweating, weakness.  If you ignore these signals your brain may force you to lay down by making you faint.

What causes a person to develop Orthostatic Intolerance?

Most people tend to present around puberty and it may have something to do with changes in hormone levels during this time. We know girls are more prone to symptoms than boys.

What testing may be needed to evaluate Orthostatic Intolerance?

To ensure that the heart is not the cause of your child's symptoms we may recommend an EKG, Echocardiogram (ultrasound of the heart), or have them wear a Holter or Event Monitor (portable EKG).  If their complaints are only during activity a Stress Test may rarely be recommended.  You should be relieved to know that in the vast majority of cases the heart is NOT the cause of these problems. 

One thing you can do at home to provide more information is count your child's heart rate with some of their complaints or fainting.  This gives us more information.  If you find counting it difficult there are devices you can purchase that will help you.  It is NOT necessary to routinely check you child's heart rate.   Routine checking doesn't really add much information and tends to make children worry more.  

How can we treat Orthostatic Intolerance with lifestyle changes?

Time: This is the best treatment as naturally these symptoms get better on their own as you get older.

Hydration: You should be drinking about 4-8 bottles of water daily depending on your age.  It is important to spread them out over the course of the day.  If you can’t get enough water in you may try mixing a Sports Drink with water (we suggest half water: half sports drink). Sports drinks are also good for when you are exercising.  Remember to drink more with activity and on hot days.

Meals: It is important to have 3 meals of a good size each day, skipping meals will always make things worse.  If you find you can't eat a meal due to time or other reasons then a meal replacement shake may be a good idea, but a full meal will always be preferred. 

Snacks: By adding snacks between meals you can help if your body burns through your food too quickly. Things like peanut butter crackers make an excellent snack.

Add Salt:  You may add a little salt to foods or just purchase regular salt version of foods instead of the low-salt versions.

Reomve Caffeine: Avoiding Caffeine and Energy drinks is very important since they make you lose fluid faster and can effect how your heart.

Sleep: You need 8 hours of sleep for your body to be rested enough to try and make the adjustments it needs.

Exercise: Routine exercise of 150 minutes per week (an hour every other day) helps keep your blood vessel awake and active. Strength building of your legs and arms can provide some support for your blood vessels and get the blood up to your brain better.

Avoid Triggers:  Heat, stress/anxiety, dehydration, illness all are expected to make things worse.  By doing your best to avoid these things you can hope to minimize your symptoms. 

Recongize Symptoms:  When you begin to feel symptoms you should sit down or preferrably lay down and have your feet raised up or in a knees bent position.  Take the chance to eat and have some water. 

We are happy to provide notes for water, snacks and bathroom breaks for the school.

If you are feeling worse on a particular day, ask yourself if you could have done better in any of these areas.

When would you consider medication?

If you have made all the changes to your life mentioned and you still have symptoms that effect your ability to do things you need / want to do then medicines can be used for a short time (usually no longer than 1 year).  

While these medication can be very helpful they are targeted at helping the severe symptoms.  It is expected that even with medication you will still have some dizziness, but it should be mostly the mild type or rarely the moderate type with less severe episodes.  Medication alone will not be effective in helping Orthostatic Intolerance, you must make the lifestyle changes mentioned above in order to expect success.

We usually will recommend a multivitamin with iron and this does help with symptoms for some people.  

For girls the addition of birth control can sometimes improve symptoms by better regulating hormones.  We may ask you to discuss trying this treatment with your Primary Care Provider.  

Remember the goal of medicine isn’t to make all your symptoms go away, it is so you can do the things you need / want to do.

What should I expect with treatment?

Whether you are treated with lifestyle changes alone or if medication is added you should not expect dizziness to go away completely. Even with medications people will still have some occasional dizziness.  Fainting may also still happen but should be rare.

The goal is that your dizziness should be not bad enough to prevent you from doing things you want. As long as the number of good days is more than bad and your life is not significantly disrupted then you are doing well.

What should the school know about this condition?

This is a common problem that may cause only mild dizziness but could cause fainting.  

If your child feel symptoms are present and getting worse they should:
1.  Sit or lie down and either raise their legs or bend their knees for at least 10-15 minutes while giving them a snack and some fluids.
2.  They should be able to sit up after the feel better but realize they may be a little tired and need a few minutes to rest. 
3. Once feeling well they can return to class.

If your child faints they should:
1.  DO NOT try and sit/stand them up but instead lie them on their side.
2.  Remove safety hazards and check breathing and heart rate
3.  If they regain consciouness in 1-3 minutes allow them to rest at least 15 minutes and once they feel well they can return to class
4.  If they do not regain consciousness in 1 minute lie them on their back and move their knees into a bent position
5.  If after 3 minutes they still have not regained some consciouness call EMS (This is EXTREMELY unlikely).

Day-to-day recommendations:
Allow them to drink fluids during calss and be excused for bathroom breaks.
Allow them to have snacks during class
Allow them to sit near vents or winodws to prevent getting overheated

What is the difference between Orthostatic Intolerance, Postural Orthostatic Tachycardia Syndrome (POTS), Orthostatic Hypotension, Vasovagal (Neurocardiogenic / Reflex) and Dysautonomia?

All lot of people will use these words interchangeably. POTS and Orthostatic Hypotension can be thought of as types of Orthostatic Intolerance that have specific features.  As far as symptoms, treatment and expectations they are essentially the same.

Orthostatic Tachycardia is defined in children 12-19 y/o as a 40bpm increase in HR within 10 minutes of moving from sitting / laying to quietly standing if you. 

Orthostatic Hypotension is a 20 point drop in the systolic blood pressure when you go from sitting standing.  This can occur immediately, within 3 mins (classic), or after 3 mins (delayed).

POTS is characterized by having Orthostatic Tachycardia, typically with a standing heart rate over 120bpm, with symptoms of Orthostatic Intolerance without Orthostatic Hypotension

Dysautonomia tends to be used when a person has the symptoms of Orthostatic Intolerance but also has other systems in their body that are not behaving normally. Such as stomach complaints, irregular periods, temperature issues and other problems.

Neurally-medicated is very common often referred  to as "Reflex" because it is a reflex reaction to a triggger.  There are some different types: 
Vasovagal type is typically triggered by emotional stress or pain.  It is usually associated with sweating, nausea and loss of color.  The triggers cause a inappropriate decrease in heart rate or blood pressure and often followed by tiredness. 
Situational also has triggers but they can be coughing, swalloning, and urinating.