Breath-Holding Spells
Age group affected: Rare before 6 mos old; peak about 2
years of age; gone by age 5 years of age.
Mechanism: Cerebral anoxia ultimate factor causing loss of
consciousness; other theories.
Sequelae: There is no increased risk of seizures in
children with breath-holding spells.
Treatment:
Reassure parents after complete history and physical examination reassures
the physician that this is the diagnosis. You must also make sure that the
parents do not make a vulnerable child out of this situation since it is so
terrifying to watch. Usual advice is the same as dealing with a temper
tantrum: leave the room. (Most parents are unable to do this.)
Information that giving iron therapy may be beneficial in treating
breath-holding spells.
One study: 88% of those with spells treated with iron improved vs 6% in
placebo group. (J of Peds 97;130:547-50)
Two major types of breath-holding spells:
- Cyanotic Spells: Provoked by upsetting or scolding an infant.
There is a brief shrill cry followed by forced expiration and apnea. This
kind of spell can be associated with opisthotonus, clonic jerks and
bradycardia. Much more common than pallid spells.
- Pallid Spells: Often started by a painful experience such as
hitting head, child stops breathing and then falls over. In this type
child becomes pale and hypotonic; may even have a seizure.
Treatment: Usually none needed. Some have recommended Atropine
(0.01 mg/kg/24h)
Associated Problems:
- Anemia: particularly with cyanotic spells. (Acta Paediatrica
1992;81:319-21) A second article that found 2 children with increasing
spells due to anemia; treatment of anemia caused recovery. (J of Peds
95;126:395-7)
- Underlying autonomic nervous system dysregulation - again with
cyanotic spells. (Pediatric Neurology 1993;9:268-74)
- Family history: one case report of 7 family members: (J Peds & Child
Health 1992;28:254-6)
The problem in practice is not dealing with these spells, but
differentiating them from other types of episodes that you can confuse with
breath-holding spells. Costly evaluations such as referral to neurologists,
EEGs, are usually unnecessary, however.
Differential Diagnosis:
- Seizures: Often breath-holding spells are confused with seizures-
particularly akinetic seizures. Since children often have tonic-clonic
movements with breath-holding, in these cases, might have to consider
doing an EEG.
- Syncope: Recent case of cough syncope: should be able to tell the
difference by history.
- Benign Paroxysmal Vertigo: No loss of consciousness associated with
this unusual problem. Treat with dimenhydrinate.
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