Breath holding spell

Most spells start between the ages of 6 and 18 months and resolve by 6 years of age. Occurs in 4% to 5% of healthy children. 30 second episode,  rarely lasts more than a minute.

1. preceded by agitation, pain, crying, fear
2. begins crying, stops in full exhalation then
3. color change (blue or pallid face)
4. limpness, no breathing, + jerks (esp in blue face spells)
5. self-resolution,  no postictal.
6. a complex spell persists until the child loses consciousness. Occasionally, the child will experience a hypoxic seizure with postictal changes.

• Cyanotic spells are due to abnormal respiratory regulation, with color change due to oxygen desaturation during apnea.
• Pallid spells are mediated by an overactive vagal response that leads to bradycardia or asystole.
• An association between anemia and breath-holding spells has been noted in some patients, with treatment of the anemia causing cessation of spells, but a causal connection has not been confirmed.

Ddx:

• seizure usually presents with (1) limpness/shaking 1^st , the (2) face color change, and may finish w/ a post-ictal state.
• cardiac arrhythmia
• gastroesophageal reflux.
• These diagnoses usually are excluded easily with a complete history and physical examination. 

Management

A behavioral issue. The apnea is not dangerous, as the brain stimulates a breath to cut the spell short. When it occurs, place baby in safe place, ie flat on floor (not on a table, could fall off). Although breath-holding spells are benign, behavioral problems may ensue due to the family's fear of provoking a spell. Family education can aid in avoiding secondary behavioral difficulty. Parents should be given clear instructions for managing spells, such as placing the child on his or her side to avoid aspiration in the case of a complex breath-holding spell. Discussion of the expected duration of individual spells and the expected age of resolution provide reassurance to the family.

For recurrent i.e 5-6x/week spells, iron treatment has met w/ some success. 6 mg/kg FeSO4 qd. (research done by dr wendy mitchell, CHLA)

References:
Blum NJ. Repetitive behaviors (breath-holding spells). In: Levine DL,
Carey WB, Crocker AC, eds. Developmental-Behavioral Pediatrics. 3rd
ed. Philadelphia, Pa: WB Saunders Co; 1999:433-434
Daoud AS, Batieha A, al-Sheyyab M, Abuekteish F, Hijazi S.
Effectiveness of iron therapy on breath-holding spells. J Pediatr.
1997;130:547-550
Pakula LC. Consultation with the specialist. Behavior problems.
Pediatr Rev. 1994;15:366-367
Rubin DH, Conway EE Jr, Caplen SM, Singer JI. Neurologic disorders.
In: Rosen P, ed. Emergency Medicine: Concepts and Clinical Practice.
4th ed. St Louis, Mo: Mosby-Year Book, Inc; 1998:1238-1239