Vol. 16 Issue 6
Breath Holding Spells in Children
Parents Require Thorough Education
Involuntary breath holding spells (BHS) in children are poorly understood phenomena. Children who exhibit BHS are distinguished from children who hold their breath on purpose because they lose consciousness and turn cyanotic or pallid. Children who hold their breath on purpose come close to losing consciousness, but a reflex causes them to take a breath at the last moment, and they remain alert. This article focuses on children who have no control over their breath holding.
Prevalence and Onset
Breath holding is classified as simple, complex or complex and severe (Table 1). Simple breath holding affects up to 27% of children, and severe BHS affects as many as 4.6%.1-3
BHS is defined as an involuntary, nonvolitional, reflexic, nonepileptic paroxysmal phenomenon of childhood that is caused by underlying autonomic dysregulation.4,5
The duration of breath holding spells is variable and can range from 2 seconds to 2 minutes. The frequency of BHS is not predictable.
Types of Spells
Breath holding spells that produce cyanosis usually begin between infancy and age 18 months (Table 2). Typically, a child gets frustrated or angry and emits a forceful cry that is rapidly followed by apnea and cyanosis. The child becomes limp or stiff, then quickly returns to breathing without assistance. The cyanosis-inducing spell is the most common form, and it is probably the most frightening to witness.2Spells that produce pallid skin color usually begin between the ages of 12 and 24 months. The sequence of events is similar to that in cyanotic spells, with a couple of exceptions: The triggering event is attributed to fright or pain, the child turns pallid, and seizure-like activity may be associated with the spell. The seizure activity or hypoxic convulsions (tonic-clonic activity) occur at the end of the spell and do not respond to anticonvulsant therapy.3,4The appearance of seizure-like activity does not mean the child has a seizure disorder, but that further testing should be performed. A change in postural tone also occurs (opisthotonic posture) with seizure-like activity.2A small percentage of children exhibit both cyanosis- and pallor-inducing spells and have seizure-like activity afterward. Such a child would be diagnosed with complex, severe breath holding spells.
Seizures are distinguished from BHS by the typical onset of spells. Seizures are not precipitated by a breath holding spell; they occur randomly.
A child who is being evaluated for BHS or seizures should undergo electroencephalograph testing for a seizure disorder. If a child with BHS has seizure-like activity, it will always occur at the termination of the spell and resolve spontaneously.
Breath holding spells that cause pallor may result from centrally mediated cardiac inhibition that results in bradycardia or brief asystole.3Spells that cause cyanosis may be secondary to central inhibition of respiratory movements.3 oth effects are mediated by the vagus nerve.3The final event leading to loss of consciousness in BHS is cerebral anoxia.2In a small number of cases, breath holding spells may be an inherited condition.4Such patients exhibit a more generalized dysregulation of the autonomic nervous system.4
Researchers have examined the role of reduced central nervous system sensitivity in hypoxia and hypercapnia, as well as abnormalities in pulmonary reflexes and lung mechanics, but they have not reached definitive conclusions about their link to BHS.1
The diagnosis of BHS is usually made by a thorough history of the events surrounding the spells. Although a patient's history may be strongly suggestive of BHS, always perform a complete differential diagnosis analysis. Rule out epilepsy by conducting a thorough history and ordering an EEG. Although seizure-like activity may occur in children with BHS, an EEG will produce normal results. A prolonged QT interval may be present in children with BHS, so order an electrocardiogram (ECG) and have it reviewed by a pediatric cardiologist.1 ule out hematologic abnormalities by ordering a complete blood cell count.1
No treatment can stop breath holding spells. The condition is self-limiting, and the child will outgrow them.2
Iron deficiency may play a role in BHS. Researchers studied the effects of ferrous sulfate solution dosed orally at 5 mg/kg per day for 16 weeks.6 Eighty-eight percent of children in the treatment group exhibited a complete or partial response, compared with fewer than 6% who received the placebo.6 ven children who did not have iron deficiency responded to this treatment, and this phenomenon is not well understood.6 complete blood count should be done to measure a baseline iron level, but given the positive results of iron supplementation, this therapy should be tried with most children affected by BHS.
No long-term effects of benign BHS have been documented. These patients are not at increased risk for neurologic problems.1The only significant finding on subsequent follow-up was a mildly increased incidence of syncope later in life, especially in childhood or adolescence. 1Case Example
My daughter Naomi was 7 months old when she experienced BHS for the first time. By the time she was 9 months old, Naomi had experienced five spells (both cyanosis- and pallor-inducing) and began having seizure activity (tonic-clonic) after the spells.
EEG and ECG testing produced normal results. A pediatric neurologist performed a thorough history and workup, and she diagnosed Naomi with complex, severe BHS.
By maintaining a log of the spells, I discovered that most of them occurred before nap time or evening bedtime. I set up a schedule of strict nap times to provide optimum rest. The typical circumstances that triggered BHS were frustration, anger or pain. This prompted her to take a large inhale to cry, and the breath holding would begin. If she could get past the first cry, a spell would not occur.
Despite adjustments to her nap and bedtime routines, Naomi continued to experience BHS one to four times a month until they peaked at the age of 18 months, with seven spells in a single month. At the advice of her pediatrician, I started Naomi on daily iron supplements. Within 2 months, the spells dropped in frequency to only two a month. By the time she was 3 years old, the spells had dropped dramatically in frequency.
The last BHS Naomi experienced was at age 5 years. I have noted no long-term effects of these spells, and Naomi is now a healthy, active and bright 8-year-old.
Putting It Into Practice
Because breath holding spells are frightening to witness, parents need to be reassured that the spells are involuntary and that they should not intervene to stop them. Instruct parents to prevent the child from falling and sustaining an injury. The primary strategies are to hold the child or place him or her in a side lying position to help prevent the tongue from occluding the airway.
Parents should not overreact, use mouth-to-mouth resuscitation, place anything in the child's mouth, give any medications during an episode, or try to overprotect or shelter the child. After the spell ends, the child may be tired and need to lie down before resuming regular activity.
Having a child with BHS is stressful. The spells are unpredictable, and the child is often labeled as having a behavior problem rather than a medical problem.5 t is difficult to find child care due to the unpredictability of the spells and their frightening presentation.
Children who experience severe BHS need structure and consistency to avoid unnecessary tiredness or frustration.7Continue to reassure the parents and educate them that the episodes will likely disappear by the time the child enters elementary school.
Lora Allsman is a family nurse practitioner at Chico Medical Group in Chino, Calif.
1. Jennette R. Breath-holding spells in children: how to distinguish the benign type from the serious conditions. Postgrad Med. 2002;111(5). Available at: http://www.postgradmed.com/issues/2002/05_02/jennette.shtml. Accessed March 17, 2008.
2. DiMario Jr, FJ. Breath-holding spells in childhood. Amer J Dis Children. 1992;146(1):125-131.
3. Goyal M, Avery JA. Paroxysmal disorders and the autonomic nervous system in Pediatrics. American Journal Electroneurodiagnostic Technol. 2005;45(4):240-247.
4. DiMario Jr, FJ. Prospective study of children with cyanotic and pallid breath-holding spells. Pediatrics. 2001;107(2):265-269.
5. Mattie-Luksic M, et al. Assessment of stress in mothers of children with severe breathing-holding spells. Pediatrics. 2000;106(1 Pt 1):1-5.
6. Daoud AS, et al. Effectiveness of iron therapy on breath-holding spells. J Pediatrics. 1997;130(4):547-550.
7. Wilson D et al. Cardiac pacing in the management of severe pallid breathing-holding attacks. Journal Paediatrics Child Health. 2005;41(4):228-230.