Breath-Holding Spells

Abstract

BREATH-HOLDING spells are defined as a temporary interruption of respiration at the end of the expiratory phase, leading to mild cyanosis, unconsciousness, or convulsive seizures of either a tonic or clonic nature. In their developmental sequence there is at first crying, then a long, sustained expiratory cry without a succeeding inspiration; cyanosis replaces the previous flushing of the face (although sometimes pallor is more marked than cyanosis) ; then there is a stiffening of the limbs, usually in extension, followed by loss of consciousness, relaxation, inspiration, and, in a short time, recovery. In some cases, loss of consciousness is followed by generalized clonic movements of the extremities. In nearly all cases, the precipitating factor is either injury or frustration and the resulting anger, or a combination of both.The spells are said to be an early infantile form of temper tantrum\p=m-\a primitive expression of anger or frustration. Such being the case, it is not surprising to find them occurring most frequently in the last half of the first year and during the second year of life. They are extremely rare beyond the age of 5 years, although there are probably no completely accurate figures to be had on this point, since many cases never get to a doctor or a clinic, being handled by intrafamilial disciplinary means. HISTORY AND ETIOLOGYThe literature on breath-holding spells is relatively meager, and there is a good bit of confusion in the older references between breath-holding spells and other forms of respiratory arrest. The earliest reference to be found is that of Barthez and Rilliet,1 who felt that it was impossible to differentiate the "suppression of breathing with accompanying suffocative inspiration that presents itself frequently in angry children from spasm of the glottis." They recognized that the attacks frequently ended in an "epileptic seizure," but felt there was no need to differentiate them from "inward convulsions" (their term for spasm of the glottis related to tetany), as the history of preceding anger was suffi¬ cient to distinguish the two entities.Reference is also made to breath-holding spells by Meigs,2 who cites the above authors x and who gives a description of the affection to which we can add but little 100 years later. He felt that the condition is "a sudden spasm of all the respiratory muscles" and differentiated it from laryngeal stridor and tetany. He ascribed it most commonly to contradiction, but stated that "fright, pain, or crying" could also cause it. He felt that it was connected with dentition in children of nervous temperament.Bull,3 in 1853, advised mothers to "plunge the hand, or both, into cold water; this will induce gasping or sighing, and so the breath will be drawn."Smith,4 in 1869, felt that breath-holding spells probably were best classified with laryngismus stridulus, tetany, and spasm of the glottis, but differed from them in that he believed the primary spasm in breath-holding