Management of reflex anoxic seizures in children

Reflex anoxic seizures (RAS) are important in the differential diagnosis of non-epileptic paroxysmal events in infants and preschool-aged children. They are classically provoked by a sudden distressing stimulus, which causes loss of consciousness followed by stiffening and brief clonic movements affecting some or all limbs, often misinterpreted as an epileptic seizure. The underlying pathophysiology is a vagal-induced brief cardiac asystole with resultant transient cerebral hypoperfusion. Parents and carers who witness the event are understandably anxious, and the mainstay of management are ensuring the appropriate timely diagnosis of RAS and excluding cardiac arrhythmia. A detailed history from a witness is all that is needed to diagnose this condition and investigations like EEG or neuroimaging should be avoided. Education and reassurance remain the mainstay in the management. Some children benefit from medical treatment with atropine or fluoxetine; however, there is a lack of evidence for pharmacological treatment. Cardiac pacing is the only definitive treatment, and is reserved for frequent, severe cases in joint consultation with the cardiologist.