[Donma MM. Clinical efficacy of piracetam in treatment of breath-holding spells. Pediatr Neurol 1998; 18: 41-45].

In this study, 76 consecutive children with breath-holding spells were recruited. Detailed clinical evaluation, electroencephalography and blood biochemical parameter measurements were performed in each case. In all selected children, medical and neurological evaluations were normal. In this blind-placebo controlled study, children were randomized to receive either piracetam suspension (39 patients) or placebo suspension (37 patients). Piracetam (40 mg/kg/day) and placebo suspensions were administered in twice dosage schedule for 2 months. In each group elementary 'iron (5 mg/kg, thrice daily) was given to 9 children who were found to have anemia. Efficacy of piracetam or placebo was evaluated after 2 months, and then at 3 month intervals.

After 2 months, the number of breath- holding episodes per month decreased significantly in piracetam treated group. A significantly higher number of piracetam treated children (92.3%) remained symptom free during the next 6 month period after the completion of treatment for two month, in comparison to that of controls (29.7%). No major side effect was observed, except, abnormal sleep pattern was reported in two patients of piracetam group. One patient of placebo group also reported alteration in sleep habit. Author concluded that piractam is a safe and effective treatment option for the patients of breath- holding spells.

Comments

Breath-holding spells, a type of syncope, are common in infants and young children. Most spells start at 6-28 months of age, but may occur as early as the first month of life and usually disappear by 5 or 6 years of age. Breath-holding attacks may occur several times per day. There are two types of breath-holding syncope (cyanotic and pallid). In cyanotic breath-holding spells, loss of consciousness is triggered by a sudden injury or fright, anger or frustration. The child initially provoked, cries vigorously for a few seconds and then holds his or her breath in expiration and cyanosis develops. Consciousness is lost because of cerebral hypoxia. Stiffening, few clonic movements and urinary incontinence is occasionally observed. These episodes can be distinguished from epileptic fit on the basis of history of provocation and by noting that apnea and cyanosis occur before any alteration of consciousness. In these children neurological examination and EEG is always normal.

In the pallid type of breath-holding attacks, rather than developing cyanosis, some of these children develop pallor before losing consciousness. The episodes generally are provoked by a mild painful injury or startle. The child cries initially, then becomes pale and loses consciousness. As in the cyanotic type stiffening, clonic movements and urinary incontinence may be observed. In these children the loss of consciousness is secondary to excessive vagal tone, resulting in bradycardia and subsequently to cereberal ischemia. This type of breath holding attack is similar to a vasovagal attack(1). No significant relation- ship to either mental retardation or later epilepsy was found. A reported fatality in a breath-holding attack probably followed the aspiration of gastric content(2). There is no convincing evidence at present to indicate that cyanotic breath-holding attacks are other than benign(3).

Children with breath-holding spells are often prescribed with sedative or anti-convulsant drugs either because a mistaken diagnosis of epilepsy is made or because of belief that these drugs will prevent or reduce the frequency of the spells. However, there is absolutely no evidence to support this view(4). McWilliam and Stephenson(5) reported a very successful trial of atropine in a small series of children with unusually severe or frequent breath-holding attacks.

In this series, piracetam was used with success for breath-holding attacks. Piracetam (2-oxo-l-pyrrolidine) has been used for various cognitive disorders of children. In adults this has been used for post-anoxic action myoclonus. The author in his article argues that in children with breath-holding spells there appears to be a close relationship between pathogenesis of spells and diffuse cerebral anoxia leading to un-consciousness. Piracetam is associated with increased brain tissue oxygen consumption and its ability to increase the inhibitory hyperpolarizing processes in a manner similar to that of GABA(6). Probably, because of these reasons piracetam helped in controlling the breath-holding attacks in his series.

Should we prescribe Piracetamto all patients of breath-holding spells? Basically, the attacks are triggered by a disciplinary conflict between parents and child, the child using the attacks or threat of an attack to assert himself and to express his anger. Proper family counselling and assuring the parents that the attack do not represent any danger to the child, are often effective in stopping them(4). A few such children become prone to syncope and behavior disturbances later in life, otherwise no long-term or short-term problem is associated with breath-holding spells. So, expensive therapy in form of piracetam administration will not be worthwhile for routine management of breath-holding spells, especially in our setting. The strong emphasis about innocuous nature of breath-holding spells to parents will mostly bring about the desired result.
 

Ravindra Kumar Garg,
Department of Neurology,
Institute of Medical Sciences,
 BHU, Varanasi 221 005,
India.