Vertigo in children

Abstract: 

Vertigo is one of the morbid conditions in the pediatric age group. Vertigo is a type of illusion of environmental motion characteristically, described by spinning sensation or dizziness. The symptoms associated with balance disorders are often described in various ways, with the most common term used by patients and parents being ‘dizziness’. This term encompasses a distorted perception of the environment which results from a range of underlying causes, including true vertigo, presyncope, or somatoform disorder. True vertigo refers to a sense of disequilibrium associated with dysfunction of either central or peripheral vestibular system, and evaluating it in young children can be challenging, as they are often unable to describe their symptoms effectively. The first reference in modern scientific literature on pediatric vertigo was published by Harrison in 1962. A thorough history and physical examination can help diagnose vertigo in children. These assessments are essential for identifying the underlying cause and distinguishing vertigo from other conditions with similar symptoms.

Introduction:

 Vertigo is described as a disturbed sense of the relationship between the body and its surroundings, without actual movement. It is also characterized by hallucinations of movement, where the body appears to move in relation to the environment or objects. Collectively these symptoms are described as balance disorders. In paediatric patients, vertigo can be caused by a variety of factors, including vestibular disorders, ear infections, neurological conditions, and even emotional stress1. First, vestibular disorders in children are often neglected because vertiginous symptoms are frequently attributed to a lack of coordination or behavioural issues. Second, children typically lack the ability to communicate their symptoms effectively, making an accurate diagnosis more difficult. Third, although many diseases that cause vertigo in adults also affect children, their frequency may differ depending on the child’s age. A classic example is benign paroxysmal positional vertigo (BPPV), which is the most common form of peripheral vestibular vertigo in adults but is uncommon in children. On the other hand, some disorders that cause vertigo in the paediatric population, such as vestibular migraine (VM) and benign paroxysmal vertigo (BPV), are unique to this age group2. Balance is maintained by 4 main systems- vestibular, cerebellar, visual and proprioceptive. The brainstem interconnects all of these subsystems. Muscle tone on both sides of the body is delicately balanced through the complex interplay of these subsystems2.

 Epidemiology:

Vertigo in children is not well-documented in the literature. The prevalence of dizziness and balance disorders is 5.3% among school-aged children. In adolescents, approximately 72% of 12th-grade students reported experiencing at least one episode of vertigo in the past three months. A study identified several peripheral causes of vertigo in children, including benign paroxysmal positional vertigo (BPPV), Meniere’s disease (MD), viral infections, and vestibular neuritis3,4. A study conducted in Scotland found that BPPV is a common cause of vertigo in the paediatric age group, with a prevalence of 2.6%. Otitis media, migraine, and BPPV account for 50% of the cases of vertigo in children5,6.

                   

Aetiology:

Most common- migraine                              Viral infection or otitis media                              Psychogenic                              Benign paroxysmal vertigo of children (BPVC)                              Neurological disorders

Common – chronic headache                      Trauma                      Postural orthostatic tachycardia syndrome

Less common- intracranial tumors                            Epilepsy, Meniere’s disease, vestibular neuritis                            Demyelinating diseases

                      Most common causes for vertigo in children and adolescence are1,2

1. Benign Paroxysmal Positional Vertigo (BPPV): A rare condition in children, BPPV occurs when small crystals of calcium carbonate (otoconia) dislodge from the inner ear and interfere with the normal functioning of the vestibular system 
2. Vestibular Neuritis or Labyrinthitis: Infections of the inner ear can    lead to inflammation of the vestibular nerve (vestibular neuritis) or the   labyrinth (labyrinthitis), both of which are associated with vertigo. 
3.  Ear Infections: Middle ear infections (otitis media) can cause fluid 

 buildup, affecting the balance mechanism and resulting in dizziness or 

 vertigo. 

1.  Migraines: Migraine-related vertigo (vestibular migraine) is seen in some children, where dizziness and headache occur together. 
2. Trauma or Head Injuries: Any head trauma, such as a concussion, can result in dizziness or vertigo due to disruptions in the brain’s vestibular pathways. 
3. Neurological Disorders: Conditions affecting the brainstem or cerebellum, such as multiple sclerosis or brain tumors, can also cause vertigo. 
4. Psychological Factors: Stress, anxiety, or panic attacks in children can sometimes manifest as vertigo or dizziness, even in the absence of any organic cause.

Clinical features:

Episodic vertigo and dizziness are uncommon symptoms in children. These symptoms have been studied less extensively in children than in adults7.

• Spinning Sensation: A sensation that either the child or their surroundings are moving. 
• Loss of Balance: Difficulty walking, standing or coordinating movements.
• Nausea and Vomiting: Dizziness often triggers nausea which may lead to vomiting.
• Headache: Especially if the vertigo is associated with a migraine. 
• Tinnitus (Ringing in the Ears): Common in children with ear infections or vestibular disorders. 
• Fatigue and Weakness: Children may become excessively tired or weak during or after episodes of vertigo.

Differential diagnosis:

Benign paroxysmal vertigo:

Benign Paroxysmal Vertigo (BPV) is a common cause of vertigo in children. The exact cause of BPV has not yet been established. BPV is considered a variant or equivalent of childhood migraine. Transient ischemia of the vestibular pathway and/or vestibular nuclei are thought to contribute to the development of BPV8. Clinical presentation is characterized by recurrent vertigo episodes of few minutes and resolves spontaneously or otherwise the child remain healthy. Common in 2-12year age group, females are commonly affected9. On examination children will show normal hearing without any vestibular defects.

Otitis media with children:

     Otitis media is an inflammation of the middle ear cleft. it can cause vertigo  

      in children. This condition often results in labyrinthitis. Hearing loss is 

      usually associated with otitis media. common in 4-9 year children. Otitis 

      media with effusion can cause vestibular symptoms.

Vestibular neuritis:

It is a common cause of vertigo in children. It constitutes 16% of all paediatric cases presenting with giddiness. Labyrinthitis typically affects children above 5 years of age. This condition is more prevalent in older children10. Children affected with vestibular neuritis often experience sudden rotatory vertigo. This vertigo typically lasts from a few hours to several days. Nausea and vomiting frequently associated with vertigo. Vestibular neuritis is not typically associated with hearing loss. A proper Clinical evaluations and caloric tests often demonstrate hypofunction of the affected labyrinth.

Post traumatic vertigo:

     Post-traumatic dizziness can occur in children without any associated    

hearing loss. Labyrinthine concussion is a possible cause of post-traumatic dizziness in children. Whiplash syndrome can also cause post-traumatic dizziness in children. Vertiginous seizures are a potential cause of post-traumatic dizziness in children. Basilar artery migraine is a possible underlying cause of post-traumatic dizziness in children. Non-specific giddiness can contribute to post-traumatic dizziness in children. These conditions can cause dizziness in children following a traumatic event.

Diagnosis:

It includes proper medical history and investigation as well.

• Medical History: A detailed history of the child’s symptoms, family history, and any potential triggering factors, such as infections or head injuries.
• Physical and Neurological Examination: An assessment to check the balance, coordination, and response to certain stimuli (such as eye movement tests). 
• Imaging: In some cases, imaging techniques like MRI or CT scans may be used to rule out neurological causes, to suspect brain disorder 
• Vestibular Testing: Specific tests to assess the functioning of the inner ear and balance systems, such as the electronystagmography (ENG) or videonystagmography (VNG), may be used. 
• Blood Tests: These may be performed to rule out infections, anaemia, or other conditions that could be contributing to the dizziness.

Treatment: 

Children with vertigo typically respond well to treatment and recover quickly. Vertigo in children often resolves more rapidly than in adults. Benign Paroxysmal Vertigo (BPV) is a self-limiting disorder that requires minimal medical intervention. The primary management strategy for BPV involves reassuring the affected child and their parents or caregivers.

Pharmacological management:

Benign Paroxysmal Vertigo (BPV) with a family history of migraine often responds well to anti-migraine medications. Triptans and calcium channel blockers are effective treatments for Vestibular Migraine (VM) in children. These medications also serve as prophylaxis for VM in children, yielding satisfactory outcomes. Tricyclics, cyproheptadine, topiramate, and gabapentin are also beneficial in managing VM in children. 

Children with acute otitis media are typically treated with antibiotics and vestibular suppressants.

Non pharmacological management:

Hydration, sleep hygiene, behavioural measures, balanced diet, avoidance of triggering food items, cognitive behavioural therapy, and biofeedback are helpful.

Homoeopathic management:

• Cocculus indicus: This remedy is often indicated for vertigo associated with motion sickness, where the child experiences dizziness, nausea, and a sensation of floating or swaying. Children who need this remedy may feel dizzy when in a moving vehicle or after prolonged periods of reading or screen time11,12.

• Bryonia alba: Used when vertigo occurs with a sensation of heaviness or the need to remain still. The child may feel worse with movement and prefer lying down. This remedy is useful when vertigo is associated with a headache or cold12,14. 

• Chamomilla: Often indicated for children who are irritable and anxious during vertigo attacks. Vertigo caused by teething or frustration, accompanied by intense restlessness or sensitivity to pain, may be treated with this remedy.

• Natrum muriaticum: This remedy is used for vertigo associated with emotional causes, such as grief or stress. Children who need Natrum muriaticum may have a tendency to suppress their emotions and may become withdrawn or melancholic.

• Calcarea carbonica: Ideal for children who are slow to develop or have a tendency to become easily fatigued. Vertigo from inner ear infections or head colds, accompanied by a feeling of weakness, may benefit from Calcarea carbonica. 

• Petroleum: For children who suffer from vertigo and nausea, particularly when they are overheated or in a stuffy environment. This remedy is also helpful for children who experience vertigo after a head injury or as a result of excessive fatigue. 

     Homeopathic treatment for children involves selecting a remedy based    

     on the child’s unique overall state, not just their specific condition14.

Preventive Measures and Lifestyle Adjustments:

• Children with vertigo should avoid triggers like car rides and spinning games.
• Proper hydration is essential to prevent dizziness in children.
• Managing stress through relaxation techniques can help prevent vertigo.
• Adequate sleep is crucial for children with vertigo.
• Establishing a consistent sleep schedule helps promote better sleep. 

Conclusion:

Vertigo in children affects their overall well-being. Conventional medicine treats the underlying causes of vertigo. Homeopathy offers a holistic approach to managing vertigo. Homeopathic remedies are chosen based on the child’s unique symptoms. These remedies provide relief from dizziness and improve balance. A qualified healthcare professional should be consulted for treatment.

References:

1. ECAB Dizziness and Vertigo across Age Groups – E-Book – Google Books 
2. Swain S, Behera IC, Rajvanshi P. Vertigo in children-A review. Indian Journal of Child Health. 2022 May 27;9(5):68-73.
3. Li CM, Hoffman HJ, Ward BK, Cohen HS, Rine RM. Epidemiology of dizziness and balance problems in children in the United States: a population-based study. The Journal of pediatrics. 2016 Apr 1;171:240-7.
4. Balzanelli C, Spataro D, Redaelli de Zinis LO. Benign positional paroxysmal vertigo in children. Audiology Research. 2021 Feb 1;11(1):47-54.
5. Abu-Arafeh I, Russell G. Paroxysmal vertigo as a migraine equivalent in children: a population-based study. Cephalalgia. 1995 Feb;15(1):22-5.
6. Swain SK, Achary S, Das SR. Vertigo in pediatric age: Often challenging to clinicians. Int J Cur Res Rev. 2020 Sep;12(18):136-41.
7. Božanić Urbančič N, Vozel D, Urbančič J, Battelino S. Unraveling the etiology of pediatric vertigo and dizziness: a tertiary pediatric center experience. Medicina. 2021 May 11;57(5):475.
8. Ralli G, Atturo F, de Filippis C. Idiopathic benign paroxysmal vertigo in children, a migraine precursor. International journal of pediatric otorhinolaryngology. 2009 Dec 1;73:S16-8.
9. Al-Twaijri WA, Shevell MI. Pediatric migraine equivalents: occurrence and clinical features in practice. Pediatric neurology. 2002 May 1;26(5):365-8.
10. Sommerfleck PA, Macchi ME, Weinschelbaum R, De Bagge MD, Bernáldez P, Carmona S. Balance disorders in childhood: main etiologies according to age. Usefulness of the video head impulse test. International journal of pediatric otorhinolaryngology. 2016 Aug 1;87:148-53.
11. Vithoulkas, G. (1996). The Science of Homeopathy. 2nd Edition. New York: B. Jain Publishers.
12.   Gupta, R. K. (2014). Textbook of Homeopathic Materia Medica. Delhi: B. Jain Publishers. 
13. Sankaran, R. (2005). The Spirit of Homeopathy. Mumbai: Homoeopathic Medical Publishers.
14.   Kent, J. T. (2000). Lectures on Homeopathic Philosophy. 2nd Edition. New York: B. Jain Publishers

Dr Sneha Subedar

PG Scholar, Dept of Paediatrics

Under the guidance of Dr Reshel Noronha, PG Guide & associate professor,

Fr Muller Homoeopathic Medical College, Manglore