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.
Pediatrician and Pediatric Neurologist,
Department of Pediatrics,
Army Hospital (Research and
Delhi Cantonment 110 010,
Colina FC, Herbert T A. Resolution of breath holding spells with treatment of
concomitant anemia. J Pediatr 1995; 126: 395-397.
2. Brett EM, Neville BGR. Epilepsy and convulsions: The surgical
treatment of Epilepsy in childhood. In: Pediatric
,Neurology. Ed Brett EM. New York, Churchill Livingstone, 1997; pp
3. Di Mario FJ Jr, Burleson JA. Autonomic nervous
dysfunction on severe breath holding spells. Pediatr Neurol
1993; 9: 268-274.
4. Bhatia MS, Singhal PK, Dhar NK, Nigam VK, Mali SC, MuIlick DN.
Breath holding spells: An analysis of 50 cases. Indian
Pediatr 1990; 27: 1073-1079.
5. Holowach J, Thurston DL. Breath-holding spells and anemia. New
Engl J Med 1963; 268: 21 -23.
6. Di Mario FJ Jr. Breath holding spells in childhood. Am J Dis
Child 1992; 146: 125-131.
7. Garg RK. Piracetam for the treatment of
breath-holding spells. Indian Pediatr. 1998; 35: