Breath-holding spells (BHS) are the occurrence of episodic
apnea in children, possibly associated with loss of consciousness, and changes in postural tone.
Breath-holding spells occur in approximately 5% of the population with equal distribution between males and females. They are most common in children between 6 and 18 months and usually not present after 5 years of age. They are unusual before 6 months of age. A positive family history can be elicited in 25% of cases. They may be confused with a seizure disorder. They are sometimes observed in response to frustration during disciplinary conflict.
Diagnosis
The diagnosis of a breath-holding spell is made clinically. A good history including the sequence of events, lack of incontinence and no postictal phase, help to make an accurate diagnosis. Some families are advised to make a video recording of the events to aid diagnosis. An
electrocardiogram (ECG) may rule out cardiac
arrhythmia as a cause. There is some evidence that children with
anemia
Anemia or anaemia (British English) is a blood disorder in which the blood has a reduced ability to carry oxygen due to a lower than normal number of red blood cells, or a reduction in the amount of hemoglobin. When anemia comes on slowly, t ...
(especially iron deficiency) may be more prone to breath-holding spells.
Classification
There are four types of breath-holding spells.
; Simple breath-holding spell
: This is the most common type and the cause is the holding of breath. The usual precipitating event is frustration or injury. There is no major alteration of circulation or oxygenation and the recovery is spontaneous.
;
Cyanotic breath-holding spells
: These are usually precipitated by anger or frustration, although they may occur after a painful experience. The child cries and has forced expiration, sometimes leading to cyanosis (blueness in color), loss of muscle tone, and loss of consciousness. The child usually recovers within minutes, but some fall asleep for an hour or so. Physiologically, there is often
hypocapnea (low levels of carbon dioxide) and usually
hypoxia (low levels of oxygen). There is increased intrathoracic pressure and decreased cardiac output following the
Valsalva
The Valsalva maneuver is performed by a forceful attempt of exhalation against a closed airway, usually done by closing one's mouth and pinching one's nose shut while expelling air out as if blowing up a balloon. Variations of the maneuver can ...
maneuver. This eventually leads to a significant decrease in circulation to the brain and ultimately, loss of consciousness. There is no
postictal phase (as is seen with
seizures
An epileptic seizure, informally known as a seizure, is a period of symptoms due to abnormally excessive or synchronous neuronal activity in the brain. Outward effects vary from uncontrolled shaking movements involving much of the body with l ...
), no
incontinence, and the child is fine in between spells.
EEG
Electroencephalography (EEG) is a method to record an electrogram of the spontaneous electrical activity of the brain. The biosignals detected by EEG have been shown to represent the postsynaptic potentials of pyramidal neurons in the neocortex ...
s are normal in these children. There is no relationship to the subsequent development of seizures or cerebral injury.
; Pallid breath-holding spells
: The most common stimulus is a painful event. The child turns pale (as opposed to blue) and loses consciousness with little if any crying. The EEG is also normal, and there is no postictal phase, nor incontinence. The child is usually alert within minutes. There may be a relationship with adulthood
syncope.
; Complicated breath-holding spells
: These may simply be a more severe form of the two most common types. They generally begin as either a cyanotic or pallid spell that is then associated with
seizure
An epileptic seizure, informally known as a seizure, is a period of symptoms due to abnormally excessive or synchronous neuronal activity in the brain. Outward effects vary from uncontrolled shaking movements involving much of the body with l ...
-like activity. An EEG taken while the child is not having a spell is still generally normal.
Treatment
The most important approach is to reassure the family, because witnessing a breath-holding spell is a frightening experience for observers. There is no definitive treatment available or needed for breath-holding spells, as the child will eventually outgrow them.
Some trials have demonstrated the efficacy of iron therapy, especially because although BHS can readily occur without
anemia
Anemia or anaemia (British English) is a blood disorder in which the blood has a reduced ability to carry oxygen due to a lower than normal number of red blood cells, or a reduction in the amount of hemoglobin. When anemia comes on slowly, t ...
, BHS has been found to be aggravated by the presence of anemia. Other studies have supported the use of
piracetam;
a 1998 study indicating that over two months piracetam reduced BHS incidence by sixty percent, twice as much as a
placebo
A placebo ( ) is a substance or treatment which is designed to have no therapeutic value. Common placebos include inert tablets (like sugar pills), inert injections (like saline), sham surgery, and other procedures.
In general, placebos can af ...
. All of these studies agree with the established medical view
that a pharmacological agent is not necessary, although it may be desirable for the comfort of the parent and child.
Two articles on breath-holding spells
strongly suggest that parents consider having their child be tested by
electrocardiogram for the rare, but real possibility that the BHS episodes are actually a symptom of
prolonged QT-syndrome, a serious but treatable form of cardiac arrhythmia.
References
Further reading
*
*
*
External links
{{DEFAULTSORT:Breath-Holding Spells
Breathing abnormalities