What is the initial workup for a 9-year-old presenting with dizziness?

Initial Workup for a 9-Year-Old with Dizziness

The initial workup for a 9-year-old presenting with dizziness should focus on classifying the type of dizziness based on timing and triggers, followed by targeted physical examination and testing based on the suspected etiology. 1

Classification of Dizziness

First, determine the pattern of dizziness:

• Timing:

  • Episodic vs. continuous
  • Duration (seconds, minutes, hours, days)

• Triggers:

  • Position changes (suggesting BPPV)
  • Specific actions or movements
  • Spontaneous episodes

History Taking

Obtain detailed information about:

• Exact description of symptoms (spinning, lightheadedness, imbalance)
• Associated symptoms:
  • Hearing loss or tinnitus
  • Headache or migraine history
  • Nausea/vomiting
  • Visual disturbances
  • Recent illness or trauma
  • Medication use

Physical Examination

Vital Signs

• Blood pressure and heart rate (including orthostatic measurements) 1, 2
• Temperature

Neurological Examination

• Complete neurological assessment
• Balance testing
• Coordination testing
• Cranial nerve examination

Vestibular Assessment

• Nystagmus evaluation (spontaneous, gaze-evoked)
• Dix-Hallpike maneuver if positional vertigo is suspected 1, 3
• HINTS examination if acute vestibular syndrome is present 1

Cardiovascular Examination

• Heart sounds and rhythm
• Orthostatic vital signs (measure blood pressure and heart rate lying, sitting, and standing) 1, 2

Laboratory Testing

Laboratory tests should be ordered based on clinical suspicion and not routinely performed 4:

• Blood glucose (if symptoms suggest hypoglycemia)
• Complete blood count (if infection or anemia is suspected)
• Electrolytes (if dehydration or metabolic disturbance is suspected)
• Toxicology screening (if drug exposure is suspected) 4

Imaging

Imaging is not routinely required but may be indicated in specific situations 1:

• MRI brain (without contrast) if:
  • Abnormal neurological examination
  • Persistent symptoms not responding to treatment
  • Central causes are suspected

Special Considerations for Children

• Children may have difficulty articulating dizziness symptoms
• Consider common pediatric causes:
  • Vestibular migraine
  • Post-viral vestibular neuritis
  • BPPV (less common in children but possible)
  • Orthostatic intolerance

When to Consider Referral

Consider referral to specialists if:

• Symptoms persist despite initial management
• Abnormal findings on examination
• Recurrent episodes without clear diagnosis

Appropriate specialists include:

• Pediatric neurology
• Pediatric otolaryngology
• Pediatric cardiology (if cardiac causes are suspected)

Common Pitfalls and Caveats

1. Avoid overreliance on symptom quality - Children often cannot accurately describe their dizziness; focus on timing and triggers instead 2, 5

2. Don't miss cardiac causes - Always perform orthostatic vital signs and cardiac examination 1

3. Limited use of vestibular suppressants - Medications like meclizine should be used sparingly as they may delay central compensation 2

4. Don't overuse imaging - Neuroimaging is rarely needed in the initial evaluation unless there are concerning neurological findings 1

5. Consider psychological factors - Anxiety can cause or exacerbate dizziness symptoms in children

By following this systematic approach to evaluating dizziness in a 9-year-old, clinicians can efficiently identify the underlying cause and implement appropriate management strategies.