Breath-holding spells - AbsoluteAstronomy.com

Breath holding spells are the occurrence of episodic apnea

Apnea

Apnea, apnoea, or apnœa is a term for suspension of external breathing. During apnea there is no movement of the muscles of respiration and the volume of the lungs initially remains unchanged...

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 observed in response to frustration during disciplinary conflict.

Classification

There are four types of breath holding spells.

The most common is termed simple breath holding spell, in which the manifestation is the holding of breath in end expiration. The usual precipitating event is a frustration or injury leading to the temporary cessation of breathing in end expiration. There is no major alteration of circulation or oxygenation and the recovery is spontaneous.
The second type are the Cyanotic
Cyanosis
Cyanosis is the appearance of a blue or purple coloration of the skin or mucous membranes due to the tissues near the skin surface being low on oxygen. The onset of cyanosis is 2.5 g/dL of deoxyhemoglobin. The bluish color is more readily apparent in those with high hemoglobin counts than it is...

breath-holding spells. They 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
Cyanosis
Cyanosis is the appearance of a blue or purple coloration of the skin or mucous membranes due to the tissues near the skin surface being low on oxygen. The onset of cyanosis is 2.5 g/dL of deoxyhemoglobin. The bluish color is more readily apparent in those with high hemoglobin counts than it is...

(blue in color), loss of muscle tone, and loss of consciousness. The majority of children will regain consciousness. The child usually recovers within a minute or two, 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). The events are thought to occur due to a variety of factors, including the fact that the child is not breathing, there is increased intrathoracic pressure secondary to the Valsalva maneuver, and decreased cardiac output. This eventually leads to a significant decrease of circulation to the brain and ultimately, loss of consciousness. There is no "post ictal" phase (as is seen with seizures), no incontinence
Urinary incontinence
Urinary incontinence is any involuntary leakage of urine. It is a common and distressing problem, which may have a profound impact on quality of life. Urinary incontinence almost always results from an underlying treatable medical condition but is under-reported to medical practitioners...

, and the child is fine in between spells. EEG
EEG
EEG commonly refers to electroencephalography, a measurement of the electrical activity of the brain.EEG may also refer to:* Emperor Entertainment Group, a Hong Kong-based entertainment company...

s are normal in these children. There is no relationship to the subsequent development of seizures or cerebral injury as a consequence of breath holding spells.
In the third type, known as 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 again there is no post ictal phase, nor incontinence
Urinary incontinence
Urinary incontinence is any involuntary leakage of urine. It is a common and distressing problem, which may have a profound impact on quality of life. Urinary incontinence almost always results from an underlying treatable medical condition but is under-reported to medical practitioners...

. The child is usually alert within a minute or so. There may be some relationship with adulthood syncope
Syncope (medicine)
Syncope , the medical term for fainting, is precisely defined as a transient loss of consciousness and postural tone characterized by rapid onset, short duration, and spontaneous recovery due to global cerebral hypoperfusion that most often results from hypotension.Many forms of syncope are...

in children with this type of spell.
A fourth type, known as Complicated breath-holding spells, may simply be a more severe form of the two most common types. This type generally begins as either a cyanotic or pallid spell that then is associated with seizure
Seizure
An epileptic seizure, occasionally referred to as a fit, is defined as a transient symptom of "abnormal excessive or synchronous neuronal activity in the brain". The outward effect can be as dramatic as a wild thrashing movement or as mild as a brief loss of awareness...

like activity. An EEG taken while the child is not having a spell is still generally normal.

The diagnosis of a breath holding spell is made clinically. A good history including the sequence of events, lack of incontinence and no post ictal phase, help to make an accurate diagnosis. Some families are advised to make a video recording of the events to aid diagnosis. An electrocardiogram

Electrocardiogram

Electrocardiography is a transthoracic interpretation of the electrical activity of the heart over a period of time, as detected by electrodes attached to the outer surface of the skin and recorded by a device external to the body...

(ECG) may rule out cardiac arrhythmia as a cause. There is some evidence that children with anemia

Anemia

Anemia is a decrease in number of red blood cells or less than the normal quantity of hemoglobin in the blood. However, it can include decreased oxygen-binding ability of each hemoglobin molecule due to deformity or lack in numerical development as in some other types of hemoglobin...

(especially iron deficiency) may be more prone to breath holding spells.

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

, BHS has been found to be exaggerated by the presence of anemia. Other studies have supported the use of the over-the-counter drug Piracetam

Piracetam

Piracetam is a nootropic drug. Piracetam's chemical name is 2-oxo-1-pyrrolidine acetamide; it shares the same 2-oxo-pyrrolidone base structure with 2-oxo-pyrrolidine carboxylic acid . Piracetam is a cyclic derivative of GABA. It is one of the group of racetams...

; a 1998 study indicating that over two months Piracetam reduced BHS incidence by sixty percent, twice as much as a placebo

Placebo

A placebo is a simulated or otherwise medically ineffectual treatment for a disease or other medical condition intended to deceive the recipient...

. 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

Long QT syndrome

The long QT syndrome is a rare inborn heart condition in which delayed repolarization of the heart following a heartbeat increases the risk of episodes of torsade de pointes . These episodes may lead to palpitations, fainting and sudden death due to ventricular fibrillation...

, a serious but treatable form of cardiac arrythmia.

Classification

Treatment

See also