Breath-Holding Spells

Breath-Holding Spells

Bashayer AlMohaimeed - R1

Prevelence

Diagnosis

- Ranges from 0.1% - 4% in different studies.

- Age: 6 months -6 years.

- 80-90% their first episode before 18 months of age.

- A family history: present in 20 to 35%

- Autosomal dominant trait has been reported in some families.

- Rate of attacks is highly variable, Most children have 1-6 spells per week.

- Resolve without treatment by age 4, but sometimes persist to age 8 years.

- Usually not serious and don't cause lasting damage.

Treatment

Pathophysiology

What are breath-holding spells?

- The diagnosis of a breath-holding spell is made clinically.

- Hx: age?

Provocation / trigger (eg, head injury, crying)

Prominent color change, pallor or cyanosis.

Duration of Postictal.

- Examination

- Video Record ?

- Referral: Pediatric neurology \ pediatric cardiology clinics ?

- Test: ECG, EEG ?

Zehetner AA, Orr N, Buckmaster A, et al. Iron supplementation for breath-holding attacks in children. Cochrane Database Syst Rev 2010; :CD008132.

- The pathogenesis of these syncopal events is not clear.

- Some studies support a primary role for dysfunction of the autonomic nervous system.

- Maturation delay in myelination of the brainstem

- Iron deficiency ?

Type: cyanotic and pallid

- The most important approach is to reassure the family.

- Time solves the problem.

- Avoid triggers.

- Antiepileptic drugs : secondary seizures, GABA-derivative, ( piracetam ).

- Severe attacks of pallid infantile syncope associated with prolonged, severe bradycardia or asystole, atropine and cardiac pacing

- Benign paroxysmal nonepileptic disorder occurring in healthy children.

- The episodes start with a provocation such as emotional upset or minor injury, and might progress to breath holding, cyanosis, and syncope.

- Involuntary reflex.

- Extremely frightening to parents.

Vurucu S, Karaoglu A, Paksu SM, Oz O, Yaman H, Gulgun M, et al. Breathholding spells may be associated with maturational delay in myelination of brain stem. J Clin Neurophysiol. 2014;31:99-101.

PREETI SINGH, ANJU SETH. Breath Holding Spells – A Tale of 50 Years.VOLUME 52__AUGUST 15, 2015

Pallid breath-holding spells

Yilmaz U, Doksoz O, Celik T, Akinci G, Mese T, Sevim Yilmaz T. The value of neurologic and cardiologic assessment in breath holding spells. Pak J Med Sci. 2014 Jan;30(1):59-64. doi: 10.12669/pjms.301.4204.

Prognosis

- More likely to be mistaken for a seizure.

- Loses consciousness after a minor fall or blow to the head or upper body.

- Loss of consciousness may be delayed up to 30 seconds.

- Stages:

1- Stops breathing

2- Immediate loss of consciousness

3- Infant becomes limp and pale

- Lasts less than one minute.

- The event is caused by cardiac bradycardia.

- Events may be reproduced with 10 seconds of ocular pressure during (ECG).

- EEG : hypersynchronous, high amplitude slowing, followed

by flattening if the episode is prolonged.

Cyanotic breath-holding spells

- Prognosis: excellent.

- The median age of remission is 4 Years.

- All children stop having episodes by 8 years.

- Neurologic development is normal.

- More common

- the child becomes angry or upset in response to a reprimand or a mild injury.

-Stages:

1-Brief period of cry.

2- Prolong Forced expiration and apnea

3- Cyanosis and loss of consciousness

- If the apnea is prolonged, generalized motor seizures and prolonged postictal unconsciousness

- Status epilepticus has been reported.

Refrence

- Nelson Textbook of Pedatrics

- UpToDate

-Medscape