Original article
Recovery position significantly associated with
a reduced admission rate of children with loss
of consciousness
Sebastien Julliand,1 Marie Desmarest,2 Leticia Gonzalez,3 Yolanda Ballestero,4
Abel Martinez,5 Raffaella Moretti,6 Aristides Rivas,7 Laurence Lacroix,8 Armand Biver,9
Emilie Lejay,2 Lakshmi Kanagarajah,10 Nancy Portillo,4 Giovanni Crichiutti,6
Chiara Stefani,11 Liviana Da Dalt,11 Daniele Spiri,12 Patrick Van De Voorde,13
Luigi Titomanlio2
For numbered affiliations see
end of article.
Correspondence to
Dr Luigi Titomanlio, Pediatric
Emergency Department, Robert
Debré Hospital—Assistance
Publique Hôpitaux de Paris
(APHP), Paris Diderot
University, Sorbonne Paris Cité,
48, Bld Sérurier— Paris
75019, France;
luigi.titomanlio@rdb.aphp.fr
SJ and MD contributed equally
to this work.
Received 24 April 2015
Revised 13 November 2015
Accepted 29 November 2015
ABSTRACT
Background Loss of consciousness (LOC) is often seen
in children. The response of caregivers to a child with
LOC has been poorly investigated. Potential caregivers
( parents, teachers) seem to have a poor knowledge of
the recovery position (RP)—that is, the position into
which an unconscious child should be placed in order to
protect the airway.
Objectives To report the management and diagnoses
of LOC in childhood, and to evaluate variables
associated with an increased hospital admission rate.
Methods We conducted a prospective cohort study of
consecutive children aged between 0 and 18 years
diagnosed with LOC at 11 paediatric emergency
departments (PEDs) of 6 European countries. The
enrolment period was 3 months. Data were obtained
from parental interviews, PED reports and clinical
examination.
Results 553 children were enrolled. The most frequent
final diagnoses causing LOC were seizures (n=278,
50.3%), and vasovagal syncope (n=124, 22.4%).
Caregivers put the child in the RP in 145 cases (26.2%).
The RP was independently associated with a significant
decrease in the admission rate (aOR=0.28; 95% CI 0.17
to 0.48; p<0.0001).
Conclusions Our study demonstrates for the first time
that the RP may reduce the admission rate of infants
with LOC. Caregivers often perform inadequate
manoeuvres when a child becomes unconscious.
Campaigns aiming at increasing knowledge of the RP
should be promoted.
INTRODUCTION
To cite: Julliand S,
Desmarest M, Gonzalez L,
et al. Arch Dis Child
Published Online First:
[please include Day Month
Year] doi:10.1136/
archdischild-2015-308857
Loss of consciousness (LOC) is a common
symptom in the paediatric population, with as
many as 15% of children presenting with at least
one syncopal event before the end of adolescence.1–4 LOC has a wide variety of causes.
Although often benign, it may be the manifestation
of a potentially severe underlying cardiac, neurological or metabolic disorder.5 6 When parents see
their child losing consciousness they are understandably shocked, many of them believing that
their child may die.7 Most parents have inadequate
knowledge of first aid,8 and, more generally, the
level of first-aid knowledge among caregivers is
low.9 10
What is already known on this topic
▸ Loss of consciousness (LOC) is often seen in
children, but the response of caregivers has
been poorly investigated.
▸ The recovery position (RP), into which an
unconscious child can be placed to protect the
airway, is a well-known first-aid manoeuvre.
What this study adds
▸ In this European study, the RP was performed
in only a quarter of children with LOC.
▸ The RP is significantly associated with reduced
hospital admission of infants with LOC.
▸ Campaigns aiming at increasing knowledge of
the RP should be promoted.
The recovery position (RP) is a lateral recumbent
position of the body, into which an unconscious
child must be placed as part of first-aid treatment.11–13 The European Resuscitation Council
Guidelines for Resuscitation recommend that “an
unconscious child whose airway is clear, and who is
breathing normally, should be turned on his side
into the recovery position”.14 The basic principle
of the RP is to protect the airway; the mouth is
downward so that fluid can drain from the patient’s
airway, while the chin is up to keep the epiglottis
open. Arms and legs are locked to stabilise the position of the patient.
The response and behaviour of parents and caregivers when a child becomes unconscious have not
been reported. Although the RP is part of the
guidelines of emergency care organisations, its
effect on children with LOC is not known. Our
primary objective was to study the potential effect
of the RP on children with LOC by analysing its
association with the hospital admission rate.
METHODS
Enrolment
We performed a prospective, observational multicentre study of consecutive children consulting for
Julliand S, et al. Arch Dis Child 2016;0:1–6. doi:10.1136/archdischild-2015-308857
1
Original article
LOC at one of the 11 recruiting paediatric emergency departments (PEDs) between 1 July and 30 September, 2014. Centres
were European tertiary university hospitals from Spain, France,
Italy, Luxembourg, Belgium and Switzerland. Written informed
consent from parents and assent from the children was obtained
when possible. The institutional review board of each country
approved the study protocol.
to the final model to verify that no association had been missed
(factors that were only significant after accounting for others).
Estimators used for multivariable models were adjusted ORs
(aOR) and the 95% CIs.
Statistical analyses were performed with R (R Development
Core Team) software.
Eligibility
RESULTS
We identified all new patients at each centre, aged 0–18 years,
with either a history of LOC within the preceding 24 h or presenting with ongoing LOC, regardless of the cause. LOC was
defined as an interruption of consciousness without response to
stimulation, regardless of the length of that interruption.
Of the 101 926 patients consulting at the participating PEDs
during the study, 557 (0.55%) fitted the inclusion criteria. Four
families refused consent, and thus 553 patients were enrolled
from the participating centres.
The clinical characteristics of these patients are shown in table 1.
In our series, LOC represented 0.55% of all consultations at
the PED. The median age at PED visit was 3.2 years (centiles
0–25–75–100: 0.01–1.5–9.6–17.7 years). A coexisting chronic
disease was identified in about one in five cases, of which epilepsy was the most common (n=41, 7.4%). Nearly half of all
Data collection procedures
Parents were asked to answer questions from a structured questionnaire translated into the language of each country. The questionnaire was administered face to face by the PED physician
caring for the child. Physicians and parents were informed that
the aim of the study was to explore causes of LOC in children
and to describe the manoeuvres performed by caregivers during
the LOC. Caregivers present at the PED were all interviewed in
order to retrieve the most accurate information about the LOC.
Demographic and medical information was collected by clinical
examination and from PED data sheets.
The following clinical data were obtained by parental interviews and clinical examination: demographic data, coexisting
chronic disease, duration of the LOC, clinical signs associated
with the LOC, response of caregivers during the LOC (manoeuvres performed, including the RP, administration of drugs,
call to the national emergency number), clinical parameters at
PED arrival, final diagnosis of the cause of the LOC at the PED
and outcome (immediate discharge from the PED, admission to
a short-stay observation unit followed by discharge, standard
ward admission, admission to a paediatric intensive care unit
(PICU), death during the hospital stay). We also asked caregivers
how they learnt the manoeuvres that they performed to reanimate the child, and asked the physician for his/her judgement
about the potential usefulness or dangerousness of the performed manoeuvres for that child, as they were reported by the
caregivers.
Statistical analyses
The primary objective was an assessment of the association
between the RP and hospital admission rate as primary outcome.
This primary outcome took into account all admissions, including short-stay observational unit admissions. Secondary objectives were the highlighting of other risk factors associated with
this primary outcome, the analysis of factors related to setting
the RP, and analysis of the association between the RP and prolonged hospitalisation (standard ward or PICU hospitalisation vs
direct discharge from the PED or after an admission to a shortstay observational unit). To assess the possible bias due to different causes of LOC in younger children, we performed a subgroup
analysis for patients aged either 0–2 years or ≥2–18 years.
Variables were compared by mixed logistic regression with a
random effect for the enrolling centre for univariate analyses
and multivariable models. The chosen level of significance was
0.05 (two-sided). All collected variables were analysed in a univariate model with both hospital admission and RP as reference
outcomes. The final multivariable model included variables that
were significant in the univariate analysis at the 20% nominal
level. The excluded variables were all investigated as additions
2
Table 1
Characteristics of the 553 included children
Characteristics
Baseline characteristics
Age <2 years
Female gender
Chronic disease(s)
Chronic epileptic disease
History of LOC
LOC characteristics and accompanying signs
LOC duration ≥2 min
Pallor
Cyanosis
Vomiting
Abnormal movements
GCS <15 at PED admission
Manoeuvres by parents or caregivers
Recovery position
Other manoeuvres
Shaking
Water on face
Slapping
Blowing on face
Fingers in the mouth
Mouth to mouth
Chest compressions
Potentially dangerous
Potentially useful
Neither RP nor other manoeuvres
Drugs administration during LOC
National emergency number call
Final diagnoses
Seizures
Vasovagal syncope
Other diagnoses
Patient outcome
Discharge after PED consultation
Short-stay observational unit
Standard ward admission
Paediatric intensive care unit
Number of patients (%)
191
251
109
41
243
(34.5)
(45.4)
(19.7)
(7.4)
(43.9)
351
272
162
87
278
69
(63.5)
(49.2)
(29.3)
(15.7)
(50.3)
(12.5)
145
293
91
77
61
40
36
26
22
95
79
166
41
304
(26.2)
(53.0)
(16.5)
(13.9)
(11.0)
(7.2)
(6.5)
(4.7)
(4.0)
(17.2)
(14.3)
(30.0)
(7.4)
(55.0)
278 (50.3)
124 (22.4)
151 (27.3)
242
185
97
29
(43.8)
(33.5)
(17.5)
(5.2)
GCS, Glasgow Coma Scale; LOC, loss of consciousness; PED, paediatric emergency
department; RP, recovery position.
Julliand S, et al. Arch Dis Child 2016;0:1–6. doi:10.1136/archdischild-2015-308857
Original article
patients had had a previous episode of LOC. The median duration of the acute episode of LOC was 2 min (centiles 0–25–75–
100: 0–1–5–480 min). In 33 cases (6%) the LOC lasted for
more than 20 min. Among accompanying signs of LOC, cyanosis was only peripheral in 111 cases (20.1%) and generalised in
51 cases (9.2%). At PED arrival, 69 children (12.5%) still had
impaired consciousness, with a Glasgow Coma Scale ≤8 in 19
children (3.4%), and rated from 9 to 14 in 50 patients (9%).
Caregivers put the child in the RP in 145 cases (26.2%).
Drugs given by caregivers during the LOC were mainly antiepileptic drugs (intrarectal or intrabuccal benzodiazepines in 25
cases). In 293 cases (53.0%), manoeuvres other than the RP
were made (details shown in table 1). The PED physician considered that the caregivers had performed potentially dangerous
manoeuvres for the child in 95 cases (17.2%). Notably, children
were shaken in 91 cases (16.5%). Infants younger than 1 year,
for whom shaking can lead to severe cerebral injuries, were
shaken in 25/82 (30.5%) cases, and in 18 cases (22.0%) the
shaking was considered potentially dangerous. We also investigated how caregivers learnt the manoeuvres: RP training was
primarily given by doctors (n=74, 51%) or obtained from firstaid training (n=29, 20%), whereas dangerous manoeuvres were
primarily learnt from family (n=28, 29.5%) or media (n=17,
17.9%).
The most frequently reported final diagnoses causing the
LOC episode were febrile seizures (n=147, 26.6%), non-febrile
seizures (n=131, 23.7%) and vasovagal syncope (n=124,
22.4%). In children younger than 2 years, febrile seizures were
the most common diagnosis (48.4%), whereas vasovagal
syncope was the most common diagnosis in children aged
>2 years (31.9%) (figure 1).
After PED consultation, 43.8% of children were immediately
discharged and 56.2% were admitted (33.5% to a short-stay
observation unit, 17.5% to a standard ward and 5.2% to a
PICU).
Six patients (1.1%) died during the hospital stay; these
included one acute myocarditis, one septic shock, one foreign
body aspiration, one traumatic brain injury and two cardiac
arrests of unknown aetiology. Overall, missing data represented
3.8%, which did not concern performed manoeuvres or the
outcome.
The results of univariate analyses of variables associated with
the primary outcome (admission rate) are reported in table 2.
The variables associated with a RP setting by caregivers are
reported in table 3. The RP was more often set in older children
(≥2 years old), when they had a chronic epileptic disease and a
history of LOC, when they presented a prolonged LOC
(≥2 min) or abnormal movements and when the final diagnosis
was a seizure.
The primary analysis (table 4) showed an independent association between the RP and a decreased admission rate with an
adjusted OR of 0.28 (95% CI 0.17 to 0.48, p<0.0001). We
found no statistical interaction between the variables—notably,
between the RP and the age. Variables significantly associated
with the admission rate were also the same when those variables
not significant at the p<0.2 level in the univariate analysis were
added to the final model.
Manoeuvres considered as dangerous by physicians were
independently associated with an increased rate of admission,
with an aOR of 2.12 (95% CI 1.19 to 3.78, p=0.01). Other
variables significantly associated with a higher admission rate
were LOC duration ≥2 min, impaired consciousness at PED
arrival and vomiting. Vasovagal syncope was associated with a
significantly lower admission rate.
The RP was still associated with a decreased admission rate
when a longer hospitalisation was considered as outcome (conventional or PICU hospitalisation vs direct discharge from the
PED or admission in a short-stay observational unit):
aOR=0.43 (95% CI 0.21 to 0.88, p=0.02).
DISCUSSION
The aim of our study was to report caregivers’ behaviour when
faced with a child with LOC, and to evaluate if their actions,
use of the RP in particular, might influence the clinical
outcome. Although LOC occurs frequently in childhood,2 its
management by parents or other caregivers can be confused. We
report results in children aged 0–18 years, whereas the only previous study on the subject focused solely on children aged
>2 years.15 We chose to use the admission rate as the primary
outcome measure because of the very low frequency of deaths
after LOC and owing to the relatively high number of admissions of children with LOC across Europe. We show for the first
time that the RP may reduce the admission rate in children with
LOC.
Causes of LOC in our population differed according to age.
In accordance with the literature, the most frequent diagnoses
Figure 1 Most frequently reported
diagnoses of loss of consciousness
according to age groups.
Julliand S, et al. Arch Dis Child 2016;0:1–6. doi:10.1136/archdischild-2015-308857
3
Original article
Table 2 Univariate analyses: variables associated with the admission rate
Baseline characteristics
Age
Chronic epileptic disease
History of LOC
LOC characteristics
LOC duration
Pallor
Cyanosis
Vomiting
Abnormal movements
GCS at PED admission
Caregivers actions
Recovery position
Potentially dangerous manoeuvres
Final diagnoses
<2 years
≥2 years
Yes
No
Yes
No
<2 min
≥2 min
Yes
No
Yes
No
Yes
No
Yes
No
15
<15
Yes
No
Yes
No
Vasovagal syncope
Seizures
Other diagnoses
Hospital admission N (%)
Odds Ratio (95% CI)
126/191
185/362
27/41
284/512
123/243
188/310
92/202
219/351
152/272
159/281
109/162
202/391
58/87
253/466
156/278
155/275
251/484
60/69
55/145
256/408
68/95
243/458
41/124
162/278
108/151
0.46 (1.03–4.27)
0.0001
2.09 (1.03–4.27)
0.04
0.69 (0.48–0.99)
0.04
2.35 (1.58–3.5)
<0.0001
0.75 (0.51–1.08)
0.12
2.03 (1.34–3.07)
0.0009
1.97 (1.17–3.3)
0.01
1.18 (0.81–1.7)
0.39
(66.0%)
(51.1%)
(65.9%)
(55.5%)
(50.6%)
(60.6%)
(45.5%)
(62.4%)
(55.9%)
(56.6%)
(67.3%)
(51.7%)
(66.7%)
(54.3%)
(56.1%)
(56.4%)
(51.9%)
(87.0%)
(37.9%)
(62.7%)
(71.6%)
(53.1%)
(33.1%)
(58.3%)
(71.5%)
p
6.41 (2.98–13.78)
<0.0001
0.43 (0.28–0.65)
<0.0001
2.75 (1.64–4.61)
0.0001
reference
4.92 (2.85–8.48)
8.35 (4.53–15.38)
reference
<0.0001
<0.0001
GCS, Glasgow Coma Scale; LOC, loss of consciousness; PED, paediatric emergency department.
were febrile seizures (common in children aged <2 years) and
vasovagal syncope (common in older children).16–18 In our
series, 43.8% of children were immediately discharged after the
PED consultation, reflecting the benign cause of LOC in about
half of the cases. Only six patients (1.1%) died during hospital
admission following an episode of LOC owing to the severity of
underlying disease.
We found an association between hospitalisation rate and use
of the RP for children aged <2 years (by 10-fold). Interestingly,
this association was independent of other significant variables
for admission, such as a diagnosis of seizures, Glasgow Coma
Scale <15, and a longer duration of the LOC.
It is therefore possible that by putting a child into the RP
leads to a better recovery by improving the child’s breathing.
This study, by its design, did not retrieve laboratory or radiological investigation results after PED admission, so that some
data, including complications such as the occurrence of aspiration pneumonia, are not known. Future prospective studies
recording clinical complications, laboratory and radiological
investigation results are needed to explore the potential mechanisms of an association between the use of RP and fewer hospital
admissions after LOC.
The RP is a simple manoeuvre which is commonly recommended in first aid for all unconscious people,14 in order to
Table 3 Univariate analyses: variables associated to a setting in the recovery position
Baseline characteristics
Age
Chronic epileptic disease
History of LOC
LOC characteristics
LOC Duration
Pallor
Cyanosis
Vomiting
Abnormal movements
GCS at PED admission
Final diagnoses
<2 years
≥2 years
Yes
No
Yes
No
<2 min
≥2 min
Yes
No
Yes
No
Yes
No
Yes
No
15
<15
Vasovagal syncope
Seizures
Other diagnoses
Recovery position N (%)
Odds ratio (95% CI)
32/191
113/362
20/41
125/512
96/243
49/310
39/202
106/351
56/272
89/281
45/162
100/391
29/87
116/466
95/278
50/275
127/484
18/69
18/124
105/278
22/151
2.37 (1.52–3.72)
0.0002
2.73 (1.41–5.27)
0.003
3.47 (2.31–5.19)
<0.0001
1.84 (1.2–2.82)
0.005
0.59 (0.4–0.87)
0.008
1.15 (0.76–1.75)
0.51
1.58 (0.95–2.62)
0.08
2.25 (1.51–3.36)
<0.0001
1.17 (0.64–2.13)
0.62
reference
3.54 (2.0–6.24)
0.99 (0.5–1.96)
reference
<0.0001
0.98
(16.8%)
(31.2%)
(48.8%)
(24.4%)
(39.5%)
(15.8%)
(19.3%)
(30.2%)
(20.6%)
(31.7%)
(27.8%)
(25.6%)
(33.3%)
(24.9%)
(34.2%)
(18.2%)
(26.2%)
(26.1%)
(14.5%)
(37.8%)
(14.6%)
p
GCS, Glasgow Coma Scale; LOC, loss of consciousness; PED, paediatric emergency department.
4
Julliand S, et al. Arch Dis Child 2016;0:1–6. doi:10.1136/archdischild-2015-308857
Original article
Table 4 Multivariable primary analysis: association with the
admission rate
Recovery position
Potentially dangerous manoeuvres
Vomiting
LOC duration ≥2 min
GCS <15 at PED admission
Final diagnoses
Vasovagal syncope
Seizures
Other diagnoses
Adjusted OR
95% CI
p Value
0.28
2.12
1.92
1.75
5.68
(0.17 to 0.48)
(1.19 to 3.78)
(1.05 to 3.52)
(1.08 to 2.83)
(2.29 to 14.10)
<0.0001
0.01
0.03
0.02
0.0002
Reference
4.39
7.66
–
(2.15 to 9.00)
(3.80 to 15.45)
–
<0.0001
<0.0001
GCS, Glasgow Coma Scale; LOC, loss of consciousness; PED, paediatric emergency
department.
Only variables significant at the p<0.05 level are shown. Other variables included in
the mixed logistic regression model were age, chronic epileptic disease, history of
LOC, pallor, cyanosis and random effect on enrolling centre.
protect the airway against aspiration, which is a recognised
cause of death in patients with epilepsy.19 Ideally, everyone
should be able to position a child on his side after LOC. A study
from Norway found that 4–5-year-old children can learn and
apply basic first aid. Tested 2 months after course completion,
70% of the children assessed consciousness correctly and knew
the correct emergency telephone number; 60% demonstrated
correct assessment of breathing and 40% accomplished other
tasks, including the RP.20 However, in our population we found
that only 26.2% of the caregivers put an unconscious child in
the RP. Many studies have already indicated the lack of knowledge of parents about first aid in children, but only two studies,
which focused on febrile seizures in young children, have evaluated the parents’ ability to put the child into the RP (RP in 15%
and 29% of cases).8 21 In children with a first seizure, 60% of
parents thought that ‘the child was already dead’ and 72% ‘did
not know what to do’,21 or believed that the child was dying.22
This stress can lead to inappropriate behaviour, as reported in a
study which found that 20% of the mothers who witnessed
their child having a febrile seizure put the child in warm water,
held the child tightly, opened the child’s mouth, hugged the
child and blew air into the child’s mouth.23
School teachers are also likely to encounter LOC in a child,
but previous studies have shown that their knowledge of emergency care is often deficient24—notably, only 3.7% of them in
one study had an adequate knowledge of first aid.9 In our own
study, manoeuvres other than the RP were made in 53% of
cases, and more frequently included shaking, putting water on
the face, slapping and blowing on the face. Of these manoeuvres, 17.2% were considered by the PED physician to be
potentially dangerous. Interviews of caregivers showed that
whereas the RP was principally learnt from doctors or first-aid
training courses, dangerous procedures were learnt mainly from
family or the media. Also, to our surprise, considering the
expected stress of the situation, only in about half of all cases
was the national emergency number called, although this did
not significantly affect the admission rate.
Our study has several limitations. First, the duration of the
LOC may be overestimated, as this is primarily reported by
parents or caregivers in a stressful situation in which an accurate
assessment of time is often difficult. However, the aim of our
study was to report frequent real-life situations. To limit a
Julliand S, et al. Arch Dis Child 2016;0:1–6. doi:10.1136/archdischild-2015-308857
potential recall bias, we decided to retrieve the information
during the PED consultation that followed the initial episode.
Second, the outcome might have been biased by caregivers’
behaviour during the LOC. It is possible that parents who put
their child into the RP made doctors more confident, thus lowering the admission rate, and vice versa for parents who carried
out dangerous manoeuvres. To limit these biases, physicians
were only informed that the aim of the study was to explore
causes of LOC. All information about the management of LOC
was retrieved without any particular focus being placed on the
RP, which could potentially have caused bias. Additionally, physicians were unaware that the admission rate was an outcome
measure. Third, we used a classic logistic regression model,
which might have caused some problems of colinearity, instead
of a recursive partitioning analysis to develop a multivariate prediction model.25 Another potential limitation is that we enrolled
only children consulting at a PED, which might not be representative of all children presenting with LOC. However, we
designed the study to serve as a proof of concept. We chose to
perform a multicentre, multinational study so as to include a
sufficient number of patients, thereby increasing the reliability
of our findings.
In conclusion, our study showed that the RP may reduce the
hospital admission rate of children with LOC, but often is not
performed. Campaigns aimed at increasing the knowledge and
skills of adults to deliver safe, effective first aid to children, and
specifically those highlighting the importance of using the RP,
should be promoted. These campaigns could lead to significant
benefits for a child’s health, including reduced morbidity and
mortality, as well as reducing the costs of hospital admissions.
Large, multicentre studies of children who have a LOC are
needed to evaluate the reasons for the significant association
between the RP and reduced hospital admission.
Author affiliations
1
Pediatric Mobile Service for Emergencies and Resuscitation, Robert Debré Hospital,
Paris Diderot University, Paris, France
2
Pediatric Emergency Department, Robert Debré Hospital, Paris Diderot University,
Paris, France
3
Pediatric Emergency Department, Rio Hortega Hospital, Valladolid, Spain
4
Pediatric Emergency Department, Cruces University Hospital, Barakaldo, Spain
5
Pediatric Emergency Department, Barcelona University Hospital, Spain
6
Pediatric Emergency Department, University of Udine, Udine, Italy
7
Pediatric Emergency Department, Gregorio Marañon General Univerisity Hospital,
Madrid, Spain
8
Pediatric Emergency Department, Geneva University Hospital, Switzerland
9
Pediatric Emergency Department, Centre Hospitalier Luxembourg, Luxembourg,
Luxembourg
10
Basildon University Hospital, Essex, UK
11
Pediatric Emergency Department, University of Padova and Treviso Hospital, Italy
12
Pediatric Emergency Department, Milan University Hospital, Italy
13
Pediatric Emergency Department, Ghent University Hospital, Ghent, Belgium
Acknowledgements We thank all the families and physicians who agreed to
participate in our study. We thank the Societe Francaise de Medecine d’Urgence
(SFMU) for their support and the Department Hospitalo-Universitaire (DHU) Protect
of Paris, France, and the Research in European Paediatric Emergency Medicine
(REPEM) Network for their support.
Contributors SJ: statistical analysis, drafting and revision of the article. MD:
acquisition of data, drafting and revision of the article. LG, YB, AM, RM, EL, NP, LL,
AB, CS, DS, PVDV: acquisition of data, interpretation of data, revision of the article.
LK, GC, LDD: interpretation of data, revision of the article. LT: conception and
design, interpretation of data, drafting and revision of the article.
Competing interests None declared.
Ethics approval Institutional review board, Comité d’évaluation de l’éthique des
projets de recherche biomédicale, Paris Nord, France.
Provenance and peer review Not commissioned; externally peer reviewed.
5
Original article
REFERENCES
1
2
3
4
5
6
7
8
9
10
11
12
13
6
Feit LR. Syncope in the pediatric patient: diagnosis, pathophysiology, and treatment.
Adv Pediatr 1996;43:469–94.
Lewis DA, Dhala A. Syncope in the pediatric patient. The cardiologist’s perspective.
Pediatr Clin North Am 1999;46:205–19.
Tanel RE, Walsh EP. Syncope in the pediatric patient. Cardiol Clin 1997;15:
277–94.
Guse SE, Neuman MI, O’Brien M, et al. Implementing a guideline to improve
management of syncope in the emergency department. Pediatrics 2014;134:
e1413–21.
Driscoll DJ, Jacobsen SJ, Porter CJ, et al. Syncope in children and adolescents. J Am
Coll Cardiol 1997;29:1039–45.
Hannon DW, Knilans TK. Syncope in children and adolescents. Curr Probl Pediatr
1993;23:358–84.
Baumer JH, David TJ, Valentine SJ, et al. Many parents think their child is
dying when having a first febrile convulsion. Dev Med Child Neurol
1981;23:462–4.
Huang MC, Liu CC, Huang CC. Effects of an educational program on parents with
febrile convulsive children. Pediatr Neurol 1998;18:150–5.
Li F, Jiang F, Jin X, et al. Pediatric first aid knowledge and attitudes among staff in
the preschools of Shanghai, China. BMC Pediatr 2012;12:121.
Singer AJ, Gulla J, Thode HC, et al. Pediatric first aid knowledge among parents.
Pediatr Emerg Care 2004;20:808–11.
Fulstow R, Smith GB. The new recovery position, a cautionary tale. Resuscitation
1993;26:89–91.
Handley AJ. Resuscitation. Resuscitation Council (UK) wants everyone who uses new
recovery position to report experiences. BMJ 1997;315:1308.
Leaves S, Donnelly P, Lester C, et al. Resuscitation. Trainees’ adverse experiences of
the new recovery position. BMJ 1998;316:1748–9.
14
15
16
17
18
19
20
21
22
23
24
25
Nolan JP, Soar J, Zideman DA, et al. European resuscitation council guidelines
for resuscitation 2010 section 1. Executive summary. Resuscitation
2010;81:1219–76.
Noizet-Yverneau O, Hue V, Vaksmann G, et al. [Syncope and pre-syncope in
children and adolescents: a prospective study in a pediatric emergency
care unit]. Arch Pédiatrie Organe Off Sociéte Fr Pédiatrie 2009;16:1111–7.
Batra AS, Balaji S. Management of syncope in pediatric patients. Curr Treat Options
Cardiovasc Med 2005;7:391–8.
Callegaro S, Titomanlio L, Donegà S, et al. Implementation of a febrile seizure
guideline in two pediatric emergency departments. Pediatr Neurol 2009;40:78–83.
Teyssier G, Patural H, Barthelemy J-C.[Vasovagal syncope in children]. Arch Pédiatrie
Organe Off Sociéte Fr Pédiatrie 2010;17:995–6.
Day SM, Wu YW, Strauss DJ, et al. Causes of death in remote symptomatic
epilepsy. Neurology 2005;65:216–22.
Bollig G, Myklebust AG, Østringen K. Effects of first aid training in
the kindergarten–a pilot study. Scand J Trauma Resusc Emerg Med 2011;19:13.
Flury T, Aebi C, Donati F. Febrile seizures and parental anxiety: does information
help? Swiss Med Wkly 2001;131:556–60.
Başer M, Coban S, Taşci S, et al. Evaluating first-aid knowledge and attitudes of a
sample of Turkish primary school teachers. J Emerg Nurs JEN Off Publ Emerg Dep
Nurses Assoc 2007;33:428–32.
Cu J, Phan P, O’Leary FM. Knowledge and attitude towards paediatric
cardiopulmonary resuscitation among the carers of patients attending the
Emergency Department of the Children’s Hospital at Westmead. Emerg Med
Australas EMA 2009;21:401–6.
Gagliardi M, Neighbors M, Spears C, et al. Emergencies in the school setting: are public
school teachers adequately trained to respond? Prehospital Disaster Med 1994;9:222–5.
Casson IR, Sethi NK, Meehan WP III. Early symptom burden predicts recovery after
sport-related concussion. Neurology 2015;85:110–11.
Julliand S, et al. Arch Dis Child 2016;0:1–6. doi:10.1136/archdischild-2015-308857