Vertigo in Pediatrics

🌀 Types and Frequent Causes

Vertigo in Childhood: It is not always a game

Vertigo in pediatrics is a diagnostic challenge. The causes are divided into peripheral (inner ear) and central (CNS).

Peripheral Causes (the most common)

  • Benign Paroxysmal Postural Vertigo (BPPV) of childhood: Brief, recurrent and self-limited episodes.
  • Vestibular Neuronitis: Acute and prolonged vertigo, often post-infectious.
  • Labyrinthitis: Similar to neuronitis, but with associated hearing loss.
  • Otitis Media: Inflammation can affect the labyrinth.

Central Causes (Alert!)

  • Vestibular Migraine: Most common cause of recurrent vertigo. It can occur without headache.
  • CNS tumors (posterior fossa): Rare but serious. Look for signs of neurological focality.
  • Epilepsy (Vertiginous Aura): Very short and stereotyped episodes.
  • Craniocerebral Trauma.
🩺 Key Diagnostic Tests

The Art of Clinical Suspicion

A good history and physical examination are 80% of the diagnosis. Asking about duration, triggers, associated symptoms (headache, hearing loss, tinnitus) is essential.

  • Essential

    Otoneurological Examination

    Includes otoscopy, cranial nerve evaluation, Romberg, gait and cerebellar (finger-nose) tests.

  • Specific

    Dix–Hallpike maneuver

    It causes the characteristic nystagmus of BPPV. Carry out with caution.

  • HINTS

    HINTS Protocol (Head Impulse, Nystagmus, Test of Skew)

    Helps differentiate central from peripheral causes in acute vertigo. A pathological (central) HINTS requires urgent neuroimaging.

  • Advanced

    Complementary Tests

    Audiometry, Videonystagmography (VNG) or Brain Magnetic Resonance (MRI) are reserved for atypical, recurrent cases or with suspicion of central pathology.

🧘‍♂️ Non-Pharmacological Management

Calm and Repositioning

Before medicating, these measures can be very effective and are the first line of action.

  • Reassure the child and parents: Vertigo is very distressing. Explaining the benign nature in most cases is key.
  • Quiet environment: Reduce visual and auditory stimuli. A dim room can help.
  • Hydration: Ensure good hydration, especially if there is vomiting. Consider serum therapy if necessary.
  • Repositioning Maneuvers (RPPV): If BPPV is diagnosed, the Epley maneuver (for rear channel) or Semont can solve the problem immediately. They must be carried out by trained personnel.
  • Vestibular Rehabilitation: In recurrent or post-neuronitis cases, rehabilitation exercises can accelerate central compensation.
💊 Pharmacological Management in Emergencies

Symptomatic Treatment

The goal is to relieve vegetative symptoms (nausea, vomiting) and the sensation of spinning. Use with caution and for a short time so as not to interfere with vestibular compensation.

Drug Pediatric Dosage Common Presentations Grades
Dimenhydrinate 1-1.5 mg/kg/dose every 6-8 hours (max 300 mg/day) Oral Sol., Suppositories, IV/IM Ampoules Sedative effect. Useful if vertigo predominates.
Ondansetron 0.15 mg/kg/dose every 8 hours (max 8 mg/dose) Oral sol., Comp. orodispersible, IV ampoules Anti-emetic of choice. Does not cause sedation.
Metoclopramide 0.1-0.15 mg/kg/dose every 8 hours Oral Sol., Drops, Ampoules IV/IM Risk of extrapyramidal effects in children. Use with caution.
Diazepam 0.1-0.2 mg/kg/dose slow IV IV Ampoules Reserved for very intense and disabling vertigo. Powerful sedative effect.