Ictal video‐electroencephalogram of breath‐holding attack

Abstract

Breath-holding attacks (BHAs) are non-epileptic paroxysmal events that affect 0.1% to 4.6% of infants from 6 months to 5 years of age. 1 Their frequency peaks at about 2 years of age and reduces by 5 years. The detailed description of the event is the key point for the diagnosis: the child typically emits a short loud cry, followed by breath holding, cyanosis, rigidity or limpness and transient loss of consciousness for a few seconds. Then, an inspiration marks the resolution of the spell. 1 The BHA are considered rare before 6 months of age, although they have been reported in the neonatal age. 2 BHA might be a frightening experience for parents, but its course is known to be benign. 1 Some patients have severe and frequent BHA up to five times per day, so their management can be complicated, especially when occurring under 6 months of age. Electroencephalogram (EEG) is used in specific cases to exclude tonic epileptic seizures. 3 Case HistorySince the age of 1 month and half an infant presented, usually during crying, episodes of apnea with cyanosis, and hypertonia, sometimes followed by hypotonia, pallor, loss of consciousness and finally sleep. For this reason, at 2 months of life, he was admitted to the hospital where physical, neurologic and cardiologic examination, brain ultrasound, standard EEG, blood cell count, serum ferritin level and electrocardiogram (ECG) showed no abnormalities. The infant was discharged with a diagnosis of BHA and a cardiorespiratory monitor was suggested.His medical history was remarkable for obstructive apnea due to gastroesophageal reflux disease and mild congenital laryngomalacia. His mother's history was unremarkable, except for exposure to a stressful event during pregnancy since, at 20 weeks of gestational age, fetal ultrasound showed shortness of long bones, suggesting a possible congenital disease. This event increased the anxious state of the mother already greatly upset by COVID-19 pandemic issues. However, the suspicion of congenital disease was ruled out.After discharge from the hospital, these episodes increased in intensity and frequency up to five times per day becoming so alarming that the patient was admitted to the Paediatric Intensive Care Unit (ICU) and Ambu bag ventilation was used during the episodes. The mother was frightened, fearing for the infant's life, so her capacity to console him was reduced. A long-term video EEG (vEEG) (Video S1) was performed, recording a typical event and demonstrating the non-epileptic nature of the paroxysmal event.After vEEG, resuscitation procedures with Ambu bag were stopped during the episodes and reassurance and psychological support was offered to the parents. In the following days, episodes decreased to 2 per day. Iron supplementation and piracetam 40 mg/kg divided in two daily doses was prescribed and in the following weeks the situation further improved. At 8 months of age he presented a normal development, BHA are still present although with minor manifestations, that the family has learned to manage.