DESCRIPTION/SIGNS & SYMPTOMS
Cyanotic Breath-Holding Spells
These are also called:
- Blue breath-holding spells
- Cyanotic infantile syncope
These are the most common type of breath-holding spells. They are seen in more than half of cases.
They are provoked and preceded by crying. Sometimes, the crying is not intense. For instance, cyanotic spells can be provoked by mild sobbing.
Triggers involve an emotional upset of some kind. An example might be an older sibling taking away a toy.
Emotions can include:
- Fear
- Anger
- Frustration
Sequence of events seen during a cyanotic spell
- Child cries inconsolably and vigorously.
- Child appears to take a deep breath. Child stops breathing during the process of releasing air from the lungs. In other words, breathing stops during expiration.
- Child turns blue and passes out. This is likely due to a temporary cut-off of oxygen to the brain.
- Child becomes stiff. Child then might lose muscle tone. Or the child might show brief, abnormal jerking movements of the limbs. These movements can be quick or repetitive. This stage may resemble or be mistaken for a seizure.
- As the episode ends, the child takes a deep breath. The child regains consciousness.
- The child then has a quick return to baseline activity. There are usually no physical consequences.
A typical spell like this lasts less than a minute.
This is usually only a respiratory event. It usually does not cause any change in heart rate or rhythm.
Note: These spells are not done on purpose by the child. Crying during a tantrum could provoke a spell. However, spells themselves are not self-induced temper tantrums.
Pallid Breath-Holding Spells
These are also called:
- White breath-holding spells
- Reflex anoxic seizures
These are a less common type of breath-holding spell than cyanotic spells. However, they are more commonly mistaken for epileptic seizures.
Syncope is a loss of consciousness, or fainting. Pallid breath-holding spells resemble fainting. They can mimic other kinds of syncope. For instance, they can look like vasovagal syncope. Vasovagal syncope happens because of an emotional trigger, such as the sight of blood.
Pallid spells can be caused by a sudden fright. They can also be caused by pain from a relatively trivial trauma. For instance, a trivial trauma might look like a bump to the head or a fall on the sofa cushion.
Sequence of events during a pallid spell
- Intense crying is absent. A brief, feeble cry be present.
- Child gasps. Child then suddenly turns pale and looks dead. This can be very scary.
- Child can have some extremity jerking. Sometimes abnormal eye movements maybe seen. Caregivers or observers might think this is an epileptic seizure.
- Child quickly returns to baseline activity. Tiredness and sleepiness may be seen in some.
These spells may last longer than a minute.
During an attack, the child’s pulse slows significantly. This may frighten an observer.
Note: The term “seizure” in reflex anoxic seizure does not make this a true epileptic seizure. It is a syncope (fainting). Seizure-like movements are caused by the loss of oxygen.
Features Similar to Both Spells
Some characteristics are the same in both types of breath-holding spells. These include:
- Variance. Spells can vary in frequency, severity, intensity, and duration. This can be true even in one same child with recurrent events.
- Recurrence. Spells can recur. In some, this can happen even on the same day.
- Wakefulness. Spells always occur while a child is awake.
Breath-Holding Spells Versus True Epileptic Seizures
These spells and epileptic seizures can look similar. However, there are some important differences.
- Provocation. Breath-holding spells are always provoked. This means they have a trigger. True epileptic seizures are not always provoked.
- Return to baseline. Returning to baseline means returning to a child’s state before the incident. There is a quick return to baseline after a breath-holding spell. There is usually a delayed return to baseline after a true epileptic seizure.
- Color change. Color change precedes seizure-like movements in a breath-holding spell. A child may turn blue only during or after a true epileptic seizure.
- Eyes. Eyes always remain closed in breath-holding spells. Eyes are always open in a true epileptic seizure.
- Wakefulness. Breath-holding spells always occur while awake. True epileptic seizures can occur while awake or asleep.
CAUSES
Cyanotic Breath-Holding Spells
The exact mechanism of these is not clearly understood. It is somewhat complex.
Consciousness requires a steady flow of blood and oxygen to the brain. This gets interrupted when a child is holding their breath. As blood and oxygen stop flowing to the brain, a child can pass out and turn blue.
Pallid Breath-Holding Spells
These are believed to be a vasovagal response to pain caused by a relatively trivial trauma. The vagus nerve controls the heart rate. Sometimes it is overactivated. This is called a vasovagal response. This overactivation can result in a decrease in the heart rate. A decrease in heart rate can lead to a reduction in blood and oxygen supply to the brain. This reduction, in turn, can cause a child to lose color and pass out.
Causes Common to Both Types
Sometimes, parents or siblings have also experienced breath-holding spells. This supports a genetic basis for the condition.
Iron deficiency and iron-deficiency anemia may also be associated with breath-holding spells.
TREATMENT AND THERAPIES
No treatment is needed for isolated, rare, or infrequent events.
It is important to reassure and counsel parents. They should understand the benign nature of these spells. Parents may avoid disciplining their child for fear of provoking an event. Decreasing parents’ emotional reaction to the spells allows for age-appropriate discipline.
Oral iron supplementation tends to improve spells. This helps especially if the child is iron deficient. Iron is usually given for between 1 and 4 months.
Extremely severe cases sometimes require a heart pacemaker. A pacemaker is an electrical device used to stimulate or steady the heartbeat. It requires surgery to implant. A pacemaker is used when the spells involve:
- Significant bradycardia. Bradycardia is a decrease in the heart rate below what is normal for one’s age.
- Asystole. Asystole is an arrest of cardiac activity (stopping of the heart).
The use of antiseizure medications is almost never recommended for breath-holding spells. This is true even in cases where the child shows brief convulsive movements during a spell. In rare cases, a breath-holding spell may evolve into an actual epileptic seizure. Still, this typically does not warrant the use of an antiseizure medication.
What to Do During a Breath-Holding Spell
- Do not panic. This is true for both parents and onlookers.
- Place the child sideways.
- Ensure the child is in a safe location.
- Avoid picking the child up during a spell. This may prolong the spell.
- Do not perform mouth to mouth breathing or cardiopulmonary resuscitation. Spells are brief, with quick recovery.
OUTLOOK
Breath-holding spells do not harm the child. However, they are very scary for a parent to watch.
They are age-dependent which means they are related to brain maturity. They resolve over time, usually by 5 to 7 years of age.
Children with pallid breath holding spells may develop vasovagal syncope as adolescents and adults. Again, this is due to an “overactive” vagus nerve.
Overall, outlook is excellent for both types of breath-holding spells.
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