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Evaluation and management of bradycardia in neonates and children

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Abstract

Heart rate is commonly used in pediatric early warning scores. Age-related changes in the anatomy and physiology of infants and children produce normal ranges for electrocardiogram features that differ from adults and vary with age. Bradycardia is defined as a heart rate below the lowest normal value for age. Pediatric bradycardia most commonly manifests as sinus bradycardia, junctional bradycardia, or atrioventricular block. As a result of several different etiologies, it may occur in an entirely structurally normal heart or in association with concomitant congenital heart disease. Genetic variants in multiple genes have been described to date in the pathogenesis of inherited sinus node dysfunction or progressive cardiac conduction disorders. Management and eventual prognosis of bradycardia in the young are entirely dependent upon the underlying cause. Reasons to intervene for bradycardia are the association of related symptoms and/or the downstream risk of heart failure or pause-dependent tachyarrhythmia. The simplest aspect of severe bradycardia management is reflected in the Pediatric and Advanced Life Support (PALS) guidelines.

Conclusion: Early diagnosis and appropriate management are critical in many cases in order to prevent sudden death, and this review critically assesses our current practice for evaluation and management of bradycardia in neonates and children.

What is Known:

• Bradycardia is defined as a heart rate below the lowest normal value for age. Age related changes in the anatomy and physiology of infants and children produce normal ranges for electrocardiogram features that differ from adults and vary with age.

• Pediatric bradycardia most commonly manifests as sinus bradycardia, junctional bradycardia, or atrioventricular block.

What is New:

• Management and eventual prognosis of bradycardia in the young are entirely dependent upon the underlying cause. Bradycardia may occur in a structurally normal heart or in association with congenital heart disease. Genetic variants in multiple genes have been described.

• Reasons to intervene for bradycardia are the association of related symptoms and/or the downstream risk of heart failure or pause-dependent tachyarrhythmia. Early diagnosis and appropriate management are critical in order to prevent sudden death.

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Abbreviations

AV:

atrioventricular

CHD:

congenital heart disease

ECG:

electrocardiogram

LQTS:

long QT syndrome

PAC:

premature atrial complex

PALS:

Pediatric and Advanced Life Support

SACT:

sinoatrial conduction time

SND:

sinus node dysfunction

SNRT:

sinus node recovery time

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Acknowledgments

The authors are grateful to Pr. Edward P. Walsh from Boston Children’s Hospital, Harvard Medical School for his critical review of this manuscript and his useful comments.

Dr. Baruteau is supported by the 2015 Academic Research Grant from the European Heart Rhythm Association and a research grant from the Lefoulon Delalande Foundation-Institut de France.

Author’s contributions

Dr. Baruteau conceptualized and designed the review article, drafted several parts of its initial version, and approved the final manuscript as submitted.

Dr. Perry contributed to draft the paragraph on management of bradycardia in neonates and children. He approved the final manuscript as submitted.

Dr. Sanatani contributed to draft the paragraph on approach of the patient with suspected bradycardia.

Dr. Horie contributed to draft the paragraph on genetic basis of pediatric bradycardia.

Dr. Dubin critically reviewed the whole paper and approved the final manuscript as submitted.

All authors approved the final manuscript as submitted and agreed to be accountable for all aspects of the work.

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Authors and Affiliations

  1. Morgan Stanley Children’s Hospital, Division of Pediatric Cardiology, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA

    Alban-Elouen Baruteau

  2. LIRYC Institute (Electrophysiology and Heart Modeling Institute), Division of Pediatric Cardiology, Hôpital Cardiologique du Haut Lévèque, Bordeaux-2 University, Bordeaux, France

    Alban-Elouen Baruteau

  3. L’Institut du Thorax, INSERM UMR1087, CNRS UMR6291, Nantes University, Nantes, France

    Alban-Elouen Baruteau

  4. Rady Children’s Hospital, Department of Pediatrics, Division of Cardiology, University of California, San Diego, San Diego, CA, USA

    James C. Perry

  5. British Columbia Children’s Hospital, Department of Pediatric Cardiology, University of British Columbia, Vancouver, BC, Canada

    Shubhayan Sanatani

  6. Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Sciences, Otsu, Japan

    Minoru Horie

  7. Lucile Packard Children’s Hospital, Division of Pediatric Electrophysiology, Stanford University, Palo Alto, CA, USA

    Anne M. Dubin

  8. Division of Pediatric Cardiology, Morgan Stanley Children’s Hospital, New York Presbyterian / Columbia University Medical Center, 3959 Broadway, New York, NY, 10032, USA

    Alban-Elouen Baruteau

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  1. Alban-Elouen Baruteau
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Correspondence to Alban-Elouen Baruteau.

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Baruteau, AE., Perry, J.C., Sanatani, S. et al. Evaluation and management of bradycardia in neonates and children. Eur J Pediatr 175, 151–161 (2016). https://doi.org/10.1007/s00431-015-2689-z

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