See also

Acceptable ranges for physiological variables

Key Points

1. This guideline is not applicable to patients with severe or critical concerns. In these scenarios activate local medical emergency response procedures 
2. This CPG is for admitted children (not neonates) outside of emergency and intensive care settings (NICU and PICU) during sleep only
3. Bradycardia during sleep is usually physiological 
4. Clinical escalation and investigation (including ECGs) are only required if red flags are present 

Background

Bradycardia during sleep:

• is common in children
• is a normal physiological response due to increased vagal tone 
• usually doesn’t warrant investigations

Differential Diagnoses for causes of bradycardia

• Normal physiology
• Cardiac (eg heart block +/- junctional rhythm, long QT syndrome, SA node dysfunction)
• Neurological (eg raised intracranial pressure, autonomic dysregulation)
• Metabolic (eg electrolyte abnormalities, anorexia nervosa, hypothyroidism, hypothermia)
• Medications (eg steroids, clonidine, opioids, beta blockers)
• Hypoventilation and sleep apnoea
• Vagal stimulation (eg in neonates or infants: reflux, apnoea, immature respiratory regulation)

Assessment

Red flag features

• Bradycardia when accompanied by another abnormal vital sign or poor peripheral perfusion
• Heart rate is non-reactive with stimulation. This can often be achieved with gentle stimulation without waking the child
• A confirmed or suspected intracranial pathology
• Any previous abnormal test results, salient history or medications that may be contributory to bradycardia
• Sudden drop in heart rate

Management

If patient appears critically unwell, activate local escalation response 

• Ensure bradycardia confirmed manually
• Check other vital signs
• As per management algorithm (below)

Acceptable minimal heart rates (HR) during sleep adapted from Salameh et al.¹

Consider consultation with local paediatric team when

• Local Medical Emergency Response Services are activated
• Red flags are present or ongoing concerns are present 

Consider transfer when

Child requiring care beyond the comfort level of the hospital

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

Additional notes

APLS Bradycardia Algorithm

Last updated November, 2019