Breath-Holding Spells in Pediatrics: A Narrative Review of the Current Evidence

Abstract

Background: Breath-holding spells are common, frightening, but fortunately benign events. Familiarity with this condition is important so that an accurate diagnosis can be made.Objective: To familiarize physicians with the clinical manifestations, diagnosis, evaluation, and management of children with breath-holding spells.Methods: A PubMed search was completed in Clinical Queries using the key term “breath-holding spells”. The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews. Only papers published in the English literature were included in this review. The information retrieved from the above search was used in the compilation of the present article.Results: Breath-holding spells affect 0.1 to 4.6% of otherwise healthy young children. The onset is usually between 6 and 18 months of age. The etiopathogenesis is likely multifactorial and includes autonomic nervous system dysregulation, vagally-mediated cardiac inhibition, delayed myelination of the brain stem, and iron deficiency anemia. Breath-holding spells may be cyanotic or pallid. The former are usually precipitated by anger or frustration while the latter are more often precipitated by pain or fear. In the cyanotic type, the child usually emits a short, loud cry, which leads to a sudden involuntary holding of the breath in forced expiration. The child becomes cyanosed, rigid or limp, followed by a transient loss of consciousness, and a long-awaited inspiration and resolution of the spell. In the pallid type, crying may be minimal or “silent”. The apneic period in the pallid type is briefer than that in the cyanotic type prior to the loss of consciousness and posture. The episode in the pallid type then proceeds in the same manner as a cyanotic spell except that the child in the pallid type develops pallor rather than cyanosis. In both types, the entire episode lasts approximately 10 to 60 seconds. The spells usually disappear spontaneously by 5 years of age.Conclusion: Although breath-holding spells are benign, they can be quite distressing to the parents. Confident reassurance and frank explanation are the cornerstones of treatment. Underlying cause, if present, should be treated. Interventions beyond iron supplementation may be considered for children with severe and frequent breath-holding spells which have a strong impact on the lifestyle of both the child and family.

<p>Neurological Manifestations in Familial Mediterranean Fever: a Genotype-Phenotype Correlation Study</p>

“…The frequency of breath holding as an autonomic dysfunction in this study was 7.4%, which is higher than the general population (4-5%). 27 In this study, 23.2% of patients had paresthesia, which was similar to the result of Salehzadeh et al 15 report 22%, whereas in Kalyoncu et al's 9 work from 18 patients with FMF who had neurological symptoms, 11.1% had paresthesia.…”

Evaluation of Preschool Children with the Diagnosis of Non-epileptic Paroxysmal Disorders in a Pediatric Neurology Outpatient Clinic

“…Only five patients (17%) were given piracetam treatment. It is known that the spells disappear after the age of 5, regardless of whether treatment is given (7). In our study, there was no patient over 5 years old with a history of breath-holding spells.…”

“…In the preschool period, patients with symptoms that may suggest epileptic seizures such as jerking and fainting should be questioned if they cry before the episode. The pallid breathholding spells resemble syncope, develop after pain and fear, crying is minimal and silent, patients become pale and lose consciousness, and bradycardia occurs (7). All patients in our study were evaluated as cyanotic breath-holding spells.…”

Is it really a seizure? The challenge of paroxysmal nonepileptic events in young infants

“…No special treatment is required other than reassuring the caregiver. 62,71) Since there is a possible link to iron-related mechanisms, iron is supplemented in BHS. 24,72) If symptoms are severe, other drugs can be tried.…”