Breath-Holding Spells Associated With Significant Bradycardia: Successful Treatment With Permanent Pacemaker Implantation

Abstract

ABSTRACT. Objective. To determine whether children with pallid breath-holding spells associated with bradycardia can be treated safely and successfully with permanent pacemaker implantation.Methods. The records of pediatric patients who had apparent breath-holding spells and associated bradycardia and were treated with permanent pacemaker implantation were reviewed.Results. Ten pediatric patients with apparent breathholding spells associated with bradycardia were treated with a permanent ventricular demand pacemaker at the Mayo Clinic between 1985 and 1995. Patients had onset of symptoms between ages 6 days and 12 months and presented for evaluation between ages 12 months and 5 years. Duration of spells was 15 seconds to 10 minutes. Medications to prevent spells were unsuccessful. Electrocardiograms documented asystolic pauses of 1.7 to 24 seconds (mean: 11.9 seconds). Permanent ventricular demand pacemakers were implanted at 10 months to 5 years of age (median: 14.5 months): 9 endocardial and 1 epicardial. Three patients required pacemaker revision. At follow-up of 38 to 170 months (median: 65.5), 5 patients had complete resolution of spells, 2 had only mild color change without loss of consciousness or seizure activity, and 3 continued to have minor brief spells.Conclusions. Permanent pacemaker therapy for children with pallid breath-holding spells associated with severe bradycardia is safe, efficacious, and warranted. Pediatrics 2001;108:698 -702; bradycardia, breath-holding spells, pacemaker. ABBREVIATIONS. ECG, electrocardiogram; EEG, electroencephalogram.B reath-holding spells are widely known in the pediatric population. They usually are harmless, albeit distressing for the parents, and resolve with time. We report on 10 patients who presented with symptoms consistent with breathholding episodes. These events were more severe, prolonged, and incapacitating to the families than typical spells, and additional evaluation revealed that they were associated with significant bradycardia. We decided to implant permanent pacemakers in an attempt to alleviate or eliminate symptoms. 1,2 This article reviews these patients and assesses the long-term outcome of pacemaker treatment in this population. METHODSTen patients presented to the Mayo Clinic between 1985 and 1995 for further evaluation of apparent breath-holding spells or seizures (Table 1). Patients were identified by pacemaker records and Mayo Clinic master sheet summaries. Table 1 summarizes the patient characteristics, age at onset, symptoms during spells, age at pacemaker implantation, and course after pacemaker implantation. Their subsequent course was reviewed to evaluate shortand long-term outcomes. Follow-up information was obtained from the Mayo Clinic outpatient and inpatient records and from correspondence with referring physicians and parents. RESULTSThe records of 10 patients who received permanent ventricular demand pacemaker implantation for bradycardia associated with breath-holding spells were reviewed. Patients had onset of symptoms between ...

ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities

“…255,256 In carefully selected cases, cardiac pacing has been effective in the prevention of recurrent seizures and syncope in infants with recurrent pallid breath-holding spells associated with profound bradycardia or asystole. 257 A variant of the bradycardia-tachycardia syndrome, sinus bradycardia that alternates with intra-atrial re-entrant tachycardia, is a significant problem after surgery for congenital heart disease. Substantial morbidity and mortality have been observed in patients with recurrent or chronic intra-atrial re-entrant tachycardia, with the loss of sinus rhythm an independent risk factor for the subsequent development of this arrhythmia.…”

AHA/ACCF Scientific Statement on the Evaluation of Syncope

“…37,49,50 In pediatric patients with aortic stenosis, syncope typically occurs with exercise and is an ominous sign. 46 Syncope frequently is seen in children with primary pulmonary hypertension. Near-syncope or syncope has been reported as the presenting symptom in 13% of children with idiopathic dilated cardiomyopathy.…”

Clinical and Epidemiological Profile of Breath Holding Spells (Bhs)- An Analysis of 115 Cases

“…21 Transdermal scopolamine 22 or even pacemaker implantation has also been utilised. 23,24 Recently, evidence for safe and effective use of piracetam, especially in hyperactive children to control Breath holding spells has emerged, but it still lacks FDA approval. 19,25 …”