Breath-holding spells (BHS) are the occurrence of episodic

apnea Apnea (also spelled apnoea in British English) is the temporary cessation of breathing. During apnea, there is no movement of the muscles of inhalation, and the volume of the lungs initially remains unchanged. Depending on how blocked the ...

in children, possibly associated with syncope (

loss of consciousness Unconsciousness is a state in which a living individual exhibits a complete, or near-complete, inability to maintain an awareness of self and environment or to respond to any human or environmental stimulus. Unconsciousness may occur as the re ...

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 Epilepsy is a group of non-communicable neurological disorders characterized by a tendency for recurrent, unprovoked seizures. A seizure is a sudden burst of abnormal electrical activity in the brain that can cause a variety of symptoms, rang ...

. They are sometimes observed in response to frustration during or following 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 Arrhythmias, also known as cardiac arrhythmias, are irregularities in the cardiac cycle, heartbeat, including when it is too fast or too slow. Essentially, this is anything but normal sinus rhythm. A resting heart rate that is too fast – ab ...

as a cause. There is some evidence that children with

anemia Anemia (also spelt anaemia in British English) is a blood disorder in which the blood has a reduced ability to carry oxygen. This can be due to a lower than normal number of red blood cells, a reduction in the amount of hemoglobin availabl ...

(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 Cyanosis is the change of tissue color to a bluish-purple hue, as a result of decrease in the amount of oxygen bound to the hemoglobin in the red blood cells of the capillary bed. Cyanosis is apparent usually in the body tissues covered with ...

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, as if blowing up a balloon. Variations of the maneuver can be ...

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 A seizure is a sudden, brief disruption of brain activity caused by abnormal, excessive, or synchronous neuronal firing. Depending on the regions of the brain involved, seizures can lead to changes in movement, sensation, behavior, awareness, o ...

), no

incontinence Incontinence or Incontinent may refer to: * Urinary incontinence, the most commonly occurring type of incontinence, the involuntary excretion of urine *Fecal incontinence Fecal incontinence (FI), or in some forms, encopresis, is a lack of con ...

, 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 bio signals detected by EEG have been shown to represent the postsynaptic potentials of pyramidal neurons in the neoc ...

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 A seizure is a sudden, brief disruption of brain activity caused by abnormal, excessive, or synchronous neuronal firing. Depending on the regions of the brain involved, seizures can lead to changes in movement, sensation, behavior, awareness, o ...

-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

, BHS has been found to be aggravated by the presence of anemia. Other studies have supported the use of

piracetam Piracetam is a drug that has efficacy in cognitive disorders, vertigo, cortical myoclonus, dyslexia, and sickle cell anemia; sources differ on its usefulness for dementia. Piracetam is sold as a medication in many European countries. Piracetam ...

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

placebo A placebo ( ) can be roughly defined as a sham medical treatment. Common placebos include inert tablets (like sugar pills), inert injections (like saline), sham surgery, and other procedures. Placebos are used in randomized clinical trials ...

. 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

External links

{{DEFAULTSORT:Breath-Holding Spells Breathing abnormalities

Diagnosis

Classification

Treatment

References

Further reading

External links