Kids do odd things.  Some of these “odd things” we attribute to exploring and learning about the world (ex, putting objects in nostrils, ears, or mouth). Other times the “odd conditions” are not quite explained, but are well described as affecting only children (ex, Febrile Seizures).  Since “oddities” often are not familiar, they can lead to significant parental, and even provider, concern.  Let us take a minute to digest a Morsel on a potentially scary, although generally benign “oddity:” Breath Holding Spells.

Breath Holding Spells: Basics

• Episode during which a child cries excessively and, as a part of that, holds her/his breath (usually on exhalation).
  • May occur after a painful, frightening, or irritating event.
  • May also occur in association with being disciplined or becoming angry.
  • NOT INTENTIONAL (the child may be a “brat,” but he/she is not making him/herself pass out to prove a point!) [Goldman, 2015]
• The breath holding episode may lead to syncopal event / loss of consciousness.
  • May be associated with Cyanosis 
  • May be associated with Pallor.
• May even demonstrate seizure-like activity immediately upon loss of consciousness.
  • The period of unconsciousness is short-lived and spontaneously resolves.
  • There is no post-ictal period.

• Mostly occurs in children 6 months to 18 months, but can occur up to 6 years of age.
• Occur in ~5% of all children.

Breath Holding Spells: Reasonable Evaluation

• Breath holding spells are defined by their benign course; however, …
• Always consider worst-first in the ED.
  • ALTE (or BRUE as it is referred to now) and Seizure need to be considered.
  • Use your history and exam to help sort these out, as best you are able.
  • Be careful in the very young (neonates do not have breath holding spells!).

•  ECG is reasonable
  • It is relatively inexpensive and a good screening tool (not perfect, but reasonable).
  • Look for evidence of dysrhythmia predisposing condition
    
  • Prolonged QTc Syndrome
    • Has a similar prevalence in patients with Breath Holding Spells as the general population. [Robinson, 2015]
    • May cause an event that mimics a breath holding spell, so reasonable to get ECG. [Robinson, 2015]
    • Some evidence of increased QT Dispersion (associated with increased risk of dysrhythmia and sudden death) in children with Breath Holding Spell. [Movahedian, 2016]

• Consider checking hemoglobin level
  • Iron deficiency anemia is commonly found in these patients.  [Yilmaz, 2014]
  • If the child has good access to primary care, can defer this and iron studies to outpatient evaluation.
  • If poor access to care, may want to check formal CBC.
  • Treating iron deficiency anemia is also reasonable.

• Do NOT need referral for cardiology or neurology outpatient evaluations. [Yilmaz, 2014]

References