Breath Holding Spells

Article Author:
Cihangir Buyukgoz
Article Editor:
Magda Mendez
Updated:
3/22/2019 5:51:04 PM
PubMed Link:
Breath Holding Spells

Introduction

Breath holding spells might be a frightening experience for children and consequently for their parents. Breath holding spells may occur in children who have a normal neurological exam and in children who meet age-appropriate developmental milestones, but normally breath-holding spells do not affect the subsequent neurological development of a child.[1] Breath holding episodes usually follow an inciting event in which the patient is being disciplined, is angry, or is being irritated, etc. Then an episode of crying and breath holding episode may occur which may proceed to loss of consciousness.[2] These episodes may be prevented by distracting the child and by avoiding the triggers.

Etiology

Breath holding spells were once considered to be attention-seeking behavior, but studies showed that these episodes are not intentional and are a result of an involuntary reflex.[3] Children who voluntarily hold their breath do not lose consciousness and return to normal breathing after they get what they want. 

There are two types of breath holding spells. The most common ones are the cyanotic breath-holding spells, which are 85% of breath holding spells and are most commonly a result of temper tantrums. The trigger for these episodes is anger or frustration of the child, who will typically cry for a brief period, becomes silent, stop breathing, and then becomes cyanotic. The patient usually recovers in less than a minute, regains consciousness and after the episode gasping for air may occur, and the child may seem tired. Even though the incident appears frightening, children do not have any long-term effects after these episodes. Rarely, another event may be triggered if the child continues crying.

The pallid form usually follows a painful experience or frightful experience. After an inciting event, the heart rate slows down, the child stops breathing, loses consciousness and becomes pale. Children may become sweaty and have body jerks or lose bladder control. Episodes are usually brief, and the child regains consciousness without any intervention; however, the child may seem sleepy for a while.[4]

Sometimes there are features of both cyanosis and pallor, which are termed mixed episodes.  Even though the frequency of breath-holding spells may vary, it could happen many times in a day or just once a year.

Epidemiology

Breath holding spells are a common problem in the pediatric population especially between ages from 6 months to 6 years.  Most of the cases of breath holding spells occur before the child turns 18 months old and may occur in 5% of otherwise healthy children.[5]

Pathophysiology

Some studies suggest that a dysfunctional autonomic nervous system may play a role in the cause of the spells. Also, iron deficiency anemia has been identified very commonly in these children. Genetics may play a role since parents of the children with the condition may have a history of breath holding spells during childhood.[6]

Evaluation

There is no specific diagnostic testing for breath-holding spells. The diagnosis is usually made by the description of the episode. A history of any inciting event should be elicited especially to distinguish any seizure disorder, as history is very typical for breath holding spells. The color of the patient during the episode may help to differentiate the type of the episode. If an incident can be recorded on video for the doctor to review, this often can be helpful in making the diagnosis. Since it may be confusing to distinguish seizure disorders from breath holding spells, an electroencephalogram (EEG) is frequently being done but shows no seizure activity. However, if breath-holding spells persist for more than 2 minutes, EEG may be done to rule out seizure disorders. Neuroimaging studies are unnecessary since these patients have normal anatomy. Other causes of syncope and seizure should be ruled out such as epileptic disorders and cardiac arrhythmias. Since iron deficiency is prevalent among this children complete blood count should be drawn.[7]

Treatment / Management

There is no intervention needed for these episodes. Anti-epileptic drugs are not helpful for these children and treating with seizure medication does not prevent a child from having breath-holding spells.[7]

Several studies suggest that there may be an association between iron deficiency anemia and breath holding spells and iron supplementation can decrease the frequency of breath holding spells frequency, with a starting dose of 4 to 6 mg/kg/day.[8][9] Iron treatment can be given even if the child does not have iron deficiency since it may decrease the frequency of spells.

Since breath-holding spells do not have any long-term effect, parents should be advised to minimize the attention they give to the episodes to keep the child from developing behavioral problems.

Overall it can be stressful for parents to see their child having breath holding spells and working with a professional counselor may help to cope with the situation.

Prognosis

Breath holding spells are not harmful, do not result in brain damage and neurologic development outcome if normal will be normal. By four years of age, most children will no longer have the episodes. Even though these children do not have behavioral disorders, behavioral problems may develop if the family starts to alter the discipline techniques.

Deterrence and Patient Education

Parents should be educated on how to handle the events and receive reassurance that breath-holding spells have no long-term effects. The parents may also benefit from a counselor if these episodes are creating stress and affecting family dynamics. Parents may get help to cope with the stress and may get educated about discipline techniques. 

Enhancing Healthcare Team Outcomes

Breath holding spells might be benign, but they can be extremely stressing for caretakers; therefore reassurance and proper explanation is the mainstay of the treatment. If there is an underlying cause such as iron deficiency anemia, it should be addressed, and treatment options considered if these spells interfere with patients' or parents' regular daily activities. Individual therapies, online support groups, and education by the mental health nurse and clinician may be offered to the families.


References

[1] Subbarayan A,Ganesan B,Anbumani,Jayanthini, Temperamental traits of breath holding children: A case control study. Indian journal of psychiatry. 2008 Jul     [PubMed PMID: 19742234]
[2] DiMario FJ Jr, Breath-holding spells in childhood. American journal of diseases of children (1960). 1992 Jan     [PubMed PMID: 1736640]
[3] Vurucu S,Karaoglu A,Paksu SM,Oz O,Yaman H,Gulgun M,Babacan O,Unay B,Akin R, Breath-holding spells may be associated with maturational delay in myelination of brain stem. Journal of clinical neurophysiology : official publication of the American Electroencephalographic Society. 2014 Feb     [PubMed PMID: 24492453]
[4] Breningstall GN, Breath-holding spells. Pediatric neurology. 1996 Feb     [PubMed PMID: 8703234]
[5] DiMario FJ Jr, Prospective study of children with cyanotic and pallid breath-holding spells. Pediatrics. 2001 Feb     [PubMed PMID: 11158456]
[6] Breukels MA,Plötz FB,van Nieuwenhuizen O,van Diemen-Steenvoorde JA, Breath holding spells in a 3-day-old neonate: an unusual early presentation in a family with a history of breath holding spells. Neuropediatrics. 2002 Feb     [PubMed PMID: 11930276]
[7] Boon R, Does iron have a place in the management of breath holding spells? Archives of disease in childhood. 2002 Jul     [PubMed PMID: 12089132]
[8] Mocan H,Yildiran A,Orhan F,Erduran E, Breath holding spells in 91 children and response to treatment with iron. Archives of disease in childhood. 1999 Sep     [PubMed PMID: 10451402]
[9] Zehetner AA,Orr N,Buckmaster A,Williams K,Wheeler DM, Iron supplementation for breath-holding attacks in children. The Cochrane database of systematic reviews. 2010 May 12     [PubMed PMID: 20464763]