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Ice water immersion, other vagal manoeuvres or adenosine for SVT in children

Three Part Question

In [children with SVT] which [intervention] is most likely to [terminate SVT]?

Clinical Scenario

An 8-year-old girl presents to the paediatric ED with palpitations. She is not distressed, and has a normal BP, but her pulse is 200 beats per minute. An ECG reveals supraventricular tachycardia. If she were an adult, you would try the posturally modified Valsalva manoeuvre and then reach for the adenosine, but you wonder what evidence there is for this or other vagal manoeuvres in children and, indeed, what evidence there is for the use of adenosine.

Search Strategy

Ovid MEDLINE(R) 1946–Week 2, November 2016: [(supraventricular OR (exp Tachycardia, Supraventricular) OR ( OR (exp Tachycardia, Atrioventricular Nodal Reentry) OR (narrow complex OR (junctional] AND [(vagal manoeuvre$.mp.0 OR (vagal manoeuvre$.mp.) OR (exp Diving Reflex) OR (exp Immersion/or OR (exp Valsalva Maneuver) OR (] AND [(exp Child) OR (child$.mp.) OR ( OR (exp paediatrics) OR ( or (exp paediatrics)]

Embase 1980–2016, Week 46: supraventricular or exp supraventricular tachycardia/ OR OR narrow complex junctional OR exp atrioventricular nodal re-entry tachycardia/AND vagal manoeuvre$.mp OR vagal manoeuvre$.mp OR diving or exp immersion/ OR OR exp Valsalva maneuver/limit 14 to (human and English language), yr=’2012–Current’ (infant or child or preschool child <1 to 6 years> or school child <7 to 12 years> or adolescent <13 to 17 years>)

The Cochrane Library date of searching 18 November 2016: MeSH descriptor: [Tachycardia, Supraventricular] explode all trees AND MeSH descriptor: [Child] explode all trees OR MeSH descriptor: [Pediatrics] explode all trees

Search Outcome

After duplicates and non-English language citations were removed, 40 papers remained, 5 of which were relevant. A hand search of these 40 remaining citations identified a further 8 relevant papers. Review of the Cochrane database of systematic reviews did not reveal any papers. Using the same strategy, the checker identified one further paper. These 14 papers are presented in the table

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Whitman V and Zakesian GM
8 year old girl with SVT resistant to several other treatments, had head immersed in bucket of water.Case report (4)Cardioversion to Sinus RhythmThis was the first written account of using the diving reflex to cardiovert children with SVT
Whitman V et al.
Two neonates with SVT and cardiac congestion, had heads immersed in ice water for 4-5 secondsCase series (4)Cardioversion to Sinus RhythmIce-water immersion: 2/2 (100%)No comment on how or why these infants were selected for this treatment.
Bisset GS and Kaplan GS
Ten children presenting with paroxysmal SVT, treated with an ice-bag to face with breath held, until cardioversion or up to 15 secs, whichever shorter.Case series (4)Cardioversion to Sinus RhythmIce-bag to face: 10/10 (100%) No comment on how children were selected for ice-water treatment. No treatment failure suggests some selection bias. Children also asked to breath-hold so this may introduce confounder.
Van Der Horst RL and Harstreiter AR
Two neonates, both presenting with SVT, treated with “an ice cube to the nasal bridge”Case series (4)Cardioversion to Sinus RhythmIce-water: 1/2 (50%) No comment on how why these infants were selected for this treatment.
Sreeram N and Wren C
29 infants treated in the North East of England between 1977 and 1988 for SVT.Case series (4)Cardioversion to Sinus RhythmIce-water to face: 53/59 (90%) No specific protocol applied, no comment on presence of pre-existing cardiac disease
Cardioversion to Sinus RhythmAdenosine: 1/1 (100%)
Cardioversion to Sinus RhythmDigoxin: 11/14 (79%)
Cardioversion to Sinus RhythmVerapamil: 3/3 (100%) NB: One fatal overdose
Cardioversion to Sinus RhythmDC Cardioversion: 6/10 (60%)
Garson A et al.
217 children’s first episode of SVT Retrospective cohort study (2b)Cardioversion to Sinus RhythmDigoxin: 90/142 (63%)Data missing in 20 patients.
Cardioversion to Sinus RhythmDC Cardioversion: 12/20 (60%)
Cardioversion to Sinus RhythmVagal manoeuvres: 12/19 (63%)
Cardioversion to Sinus RhythmAtrial overdrive pacing: 4/5 (80%)
Sperandeo V et al.
10 infants with spontaneous SVT refractory to induced emesis, eyeball pressure and carotid sinus massage, had face immersed in basin of cold water (4-5°C) for 6-7 secs.Case series (4)Cardioversion to Sinus RhythmIce-water immersion: 10/10 (100%) Mixed patient group.
De Wolf D et al.
22 infants in ED or ICU with SVT after failure of vagal manoeuvres, given Adensine 0.05mg/kg in incremental doses up to 1mg/kgRetrospective cohort study (4)Cardioversion to Sinus RhythmAdenosine: 17/22 (77%) Hetrogenous group, no control, change in protocol during study period,
Müller G et al.
49 patients aged 1 day to 18 years with artificially induced SVT, then terminated with, ice to face, vagal manoeuvres and AdenosineRetrospective cohort study (4)Cardioversion to Sinus RhythmIce-bag to face: 9/46 (20%)Heterogenous group; no control, protocol applied variably, artificially induced SVT.
Cardioversion to Sinus RhythmValsalva: 10/22 (45%)
Aydin M et al.
Ten patients, some with multiple episodes of SVT. Faces of children immersed in ice-water for 5 seconds.Case series (4) Cardioversion to Sinus RhythmIce-water immersion: 27/28 (96%)No comment on how children were selected for ice-water treatment or other treatment. Little comment on heterogeneity of patient group.
Koh E et al.
Five patients, each given up to three doses of adenosine for SVT. Max dose 0.2mg/kg.Case series (4)Cardioversion to Sinus RhythmAdenosine: 5/5 (100%)Described as a prospective cohort study but no details of excluded children given, so ultimately can only be taken as a case series.
Sherwood MC et al.
32 children aged 1 day to 16 years, with spontaneous SVT in whom ice water immersion or Valsalva had failed, were given up to 0.3mg/kg Adenosine.Case series (4)Cardioversion to Sinus RhythmIce-water immersion: (31/32) 97%. Sustained in only (23/32) 71%.Heterogenous group which contained children with congenital heart disease who may respond differently.
Venugopalan et al
3 girls aged 4, 5 and 9, presenting with SVTCase series (4)Caridoversion to Sinus RhythmAll three children successfully cardioverted with adenosine. (100%)Heterogenous group, dose and treatment details missing, no comment on side-effects
Clausen H et al.
288 children (<18yrs) presenting to an ED with “non-arrest” arrhythmias. Of these, of which 135 were SVTs (total 250 presentations)Retrospective cohort study (2b) Cardioversion to Sinus RhythmAdenosine: 64/82 (78%).Lack of definition and success rate of vagal manoeuvres


The evidence on the management of SVT in children is made up of poor-quality retrospective cohort studies or case series. There are no controlled studies; so, it is difficult to compare one treatment with another. Brief (5 s) immersion of the face in ice water to induce the dive reflex appears to be safe, quick, effective and non-invasive, although a little uncomfortable. Adenosine also appears to be safe and effective, but is more invasive. The effect of vagal manoeuvres such as Valsalva or carotid sinus massage in children has only been quantified once, and has a moderate success rate. No papers reported side effects from vagal manoeuvres. There is insufficient evidence to support the use of other therapies (digoxin, DC cardioversion, atrial pacing) as a first-line treatment.

Clinical Bottom Line

Ice water to the face appears to be a safe, quick, effective and non-invasive treatment for paediatric SVT. Adenosine also appears safe and effective, but more invasive. Valsalva and carotid sinus massage are less effective.


  1. Whitman V and Zakesian GM. The diving reflex in termination of supraventricular tachycardia in children. J Pediatr 1976;89:1032–3.
  2. Whitman V , Friedman Z , Berman W Jr , et al . Supraventricular tachycardia in newborn infants: an approach to therapy. J Pediatr 1977;91:304-305.
  3. Bisset GS III , Gaum W , Kaplan S . The ice bag: a new technique for interruption of supraventricular tachycardia. J Pediatr 1980;97:593–5.
  4. Van Der Horst RL and Harstreiter AR Initiation of the diving reflex in neonates with supraventricular tachycardia. Heart Lung 1980;9;518–20.
  5. Sreeram N and Wren C Supraventricular tachycardia in infants: response to initial treatment. Arch Dis Child 1990;65:127–9..
  6. Garson A Jr , Gillette PC , McNamara DG . S. Supraventricular tachycardia in children: clinical features, response to treatment, and long-term follow up in 217 patients. J Pediatr 1981;98:875-882.
  7. Sperandeo V , Pieri D , Palazzolo P , et al . Supraventricular tachycardia in infants: use of the diving reflex. Am J Cardiol 1983;51:286-287.
  8. De Wolf D , Rondia G , Verhaaren H , et al . Adenosine triphosphate treatment for supraventricular tachycardia in infants. Eur J Pediatr 1994;153:793–6..
  9. Müller G . Deal BJ , Benson DW Jr . et al. Vagal maneuvers and adenosine for termination of atrioventricular reentrant tachycardia. Am J Cardiol 1994;74:500–3.
  10. Aydin M , Baysal K , Küçüködük S , et al . Application of ice water to the face in initial treatment of supraventricular tachycardia. Turkish J Pediatr 1995;37:15–17.
  11. Koh E , Chan I , Wong KY . Five paediatric case reports of the use of adenosine in supraventricular tachycardia. Ann Acad Med Singapore 1998;27: 363–5.
  12. Sherwood MC , Lau KC , Sholler GF , et al . Adenosine in the management of supraventricular tachycardia in children J Paediatr Child Health 1998;34:53–6.
  13. Venugopalan P , Shakeel A , Al Amry A , et al . Supraventricular tachycardia in children: a report of three cases, diagnosis and current management. Med Sci 2000;2:59-64.
  14. Clausen H , Theophilos T , Jackno K , et al Paediatric arrhythmias in the emergency department. Emerg Med J 2012;29:732–7.