See also

Acceptable ranges for physiological variables

Key points

1. This guideline is not applicable to children with severe or critical concerns. In these situations, 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 does not warrant investigations

Assessment

Initial assessment can be done without waking the child, with the objective of excluding concerning features or differential diagnoses

Review:

• History (neurological, cardiac or metabolic conditions)
• Medications
• Vital signs, particularly trend since admission
• Previous investigations eg ECG, electrolytes
• Whether heart rate increases with gentle stimulation. This can often be achieved without waking the child

Features not consistent with sleep bradycardia:

• Bradycardia when accompanied by another abnormal vital sign or poor peripheral perfusion
• Heart rate is not reactive with stimulation
• A confirmed or suspected intracranial pathology
• Sudden drop in heart rate

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

Management

If the child appears critically unwell, activate local escalation response 

• Confirm bradycardia manually
• Check other vital signs
  

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 May 2024