Bath-induced paroxysmal events — response to letter from Stephenson

Thank you for your interest in our case report. What we describe is our process of thinking in this case, in a child with episodes of impaired consciousness, colour change, and hypotonia which were apparently precipitated by water. We believe a systematic approach is important in such situations and disagree that this case report is misleading or factually incorrect. Firstly, reflex anoxic seizures (RAS) in children can be precipitated by distressing events, and if bathing is distressing (for whatever reason), it is possible that a reflex anoxic seizure could be precipitated. Furthermore, splashing of (cold) water on the face is a well recognised cause of vagal overstimulation which can also result in RAS. We did not conclude that it was RAS in this case, nor was this the focus of our case report. We recognise that in your paper, RAS was not thought to be a cause of bath-induced paroxysmal disorders. Secondly, it has been recognised that syncopal events in relation to water can be associated with long QT syndrome [1]. Although the majority of events in this case series were related to submersion and/ or swim racing, these factors were not present in all cases [1]. There is another report of a cardiac sinus arrest (in an adult) from bathing diagnosed on a loop recorder [2]. These cases highlight the importance of at least considering cardiac causes including long QT syndrome when investigating children with paroxysmal events apparently triggered by water, as we did in this case with a simple ECG.