The efficacy of the use of atropine in children with pallid breath holding spells: can cardiac pacemaker implantation be avoided?

1. Purpose Reflex anoxic seizures are an overreaction of the vagal system, resulting in bradycardia or brief cardiac arrest. Because of self-limiting character of the spells with no complications on short or long term, treatment is only necessary in case of frequent spells or severe clinical presentation. Treatment options are medication such as atropine or the implantation of a cardiac pacemaker, with the latter being invasive and entailing risk for important complications. We investigated atropine treatment and aimed to examine if pacemaker placement can be avoided. 2. Methods We retrospectively reviewed patients treated in our center for severe reflex anoxic seizures with atropine sulphate from January 2017 until May 2023, and compared our results to those in the literature. 3. Results In our population, 100% of the patients reported adequate symptom management after atropine treatment, with complete resolution in 10%. Minor side effects were reported in 70%, with need for change of treatment in one patient (10%). Severe complications were not reported, unlike up to 40% of permanent or severe complications after pacemaker placement. 4. Discussion Atropine is a safe and efficient treatment to manage the symptoms, with similar success rate to pacemaker implantation. However, pacemaker implantation entails a substantial risk for complications. This might be considered redundant for a benign and temporary condition, when other efficient treatment options are possible.