Breath holding spells (BHS) occur to some degree in up to 27% of otherwise normal children(1). The etiopathogenesis is as yet unclear. The pallid attack is postulated to be due to cardiac asystole and is similar to a vasovagal attack. The cyanotic BHS is due to a rise in intrathoracic pressure when the breath is held in expiration during crying, resulting in re­duced cerebral circulation(2). Cerebral anoxia is the ultimate factor responsible for the loss of consciousness observed in BHS and an autonomic nervous system dysfunction may be responsible for it(3). Anger and frustration are the most common triggering factors(4); however the subsequent phenomenon of loss of consciousness is involuntary. Many children hold their breaths while crying without complications, or going on to have BHS(5). Thus, Di Mario has noted that BHS is a misnomer because it implies that it is a voluntary action resulting in a prolonged inspiration but the spells are actually involuntary, reflexive and occur in expiration(6).

Most BHS have an excellent prognosis and only counselling is required. However, the attacks cause intense anxiety to the parents, resulting in hospital visits and some children may injure themselves during the attack(1). Besides, anemia is known to be as­sociated with BHS, and correction of anemia' results in resolution of BHS(1,4,5). Holowach and Thurston(5) postulated that children with anemia are more irritable than children with normal hemoglobin levels and are thus prone to greater incidence of BHS. Besides this, they have a low cerebral oxygen tension, and the increased utilization of oxygen during activity, with possible decrease in alveolar and arterial carbon dioxide tension during cry­ing resulting in cerebral vasoconstriction may also be contributory factors.

Thus, all BHS may not be as benign as implied in the comments to "Piracetam in the Treatment of Breath - Holding Spells" in Selected Summaries of a recent issue(7). All cases of BHS need to be worked up for anemia which must be treated if present. Though, counselling of parents would be the mainstay of management of BHS, piracetam appears to be safe and efficacious modality of treatment which may be tried for severe BHS and in those cases which persist despite counselling.

                                                   Rekha Mittal,
Pediatrician and Pediatric Neurologist,
Department of Pediatrics,
Army Hospital (Research and Referral),
Delhi Cantonment 110 010,
india.