What is the treatment for breath holding spells in children?

Treatment of Breath Holding Spells in Children

For children with breath holding spells, the most effective first-line treatment approach is parental reassurance and education, with pharmacological interventions such as iron supplementation, midodrine, or piracetam reserved for severe and frequent episodes that significantly impact quality of life. 1

Understanding Breath Holding Spells

Breath holding spells (BHS) are common events affecting 0.1-4.6% of otherwise healthy young children, typically with onset between 6-18 months of age 2. They are classified into two main types:

1. Cyanotic BHS:

   • Triggered by anger or frustration
   • Child emits a short cry followed by involuntary breath holding
   • Develops cyanosis and may lose consciousness briefly
   • Most common type

2. Pallid BHS (also called cardioinhibitory vasovagal syncope in small children):

   • Triggered by pain or fear
   • Minimal or "silent" crying
   • Child becomes pale rather than cyanotic
   • Associated with vagally-mediated cardiac inhibition 1

Treatment Algorithm

Step 1: Reassurance and Education

• Provide confident reassurance to parents about the benign nature of BHS
• Explain that spells typically resolve spontaneously by 5 years of age 2
• Teach parents proper positioning during spells (recovery position) to maintain airway patency 1

Step 2: Address Underlying Factors

• Evaluate for iron deficiency anemia and supplement if present
• Consider behavioral modifications to reduce triggering events

Step 3: Pharmacological Interventions for Severe Cases

For children with severe, frequent spells (multiple episodes per week) that significantly impact quality of life:

1. First-line medication options:

   • Midodrine (Level of Evidence: B-R): Reasonable for children with vasovagal syncope not responding to lifestyle measures 1
     • Has shown reduction in syncope recurrence from 80% to 22% when combined with conventional therapy
     • Side effects are rare

2. Second-line medication options:

   • Iron supplementation: For children with or without anemia
   • Increased salt and fluid intake (Level of Evidence: B-R): May be reasonable in selected pediatric patients 1
     • Oral rehydration salts resulted in no further recurrence in 56% of patients versus 39% in placebo

3. Third-line medication options:

   • Piracetam: Shown to be effective in severe BHS 3
     • Complete resolution in 81% of children in one study
     • Typically given for 3-6 months
   • Fludrocortisone (Level of Evidence: C-LD): Uncertain effectiveness 1
     • In the only pediatric RCT, children did better on placebo

Step 4: Interventional Approach for Refractory Cases

• Cardiac pacing (Level of Evidence: B-NR): May be considered in severe cases of pallid BHS with documented prolonged asystole (>4 seconds) 1
  • 86% of infants and toddlers had complete resolution or significant reduction in syncopal events
  • Important to balance against known complications of permanent pacing
  • Consider that pallid BHS eventually resolves with age

Important Caveats

1. Avoid beta blockers (Level of Evidence: B-R): Not beneficial in pediatric patients with vasovagal syncope and may actually increase recurrence rates 1

2. During an acute episode:

   • Place child in recovery position if unresponsive
   • Monitor for signs of airway occlusion or inadequate breathing
   • If position impairs ability to determine presence of signs of life, position supine and reassess 1

3. When to refer to specialists:

   • Episodes associated with seizure-like activity may warrant combined cardiology and neurology evaluation 1
   • Prolonged asystole (>4 seconds) warrants cardiology consultation
   • Atypical features or onset after 4 years of age

4. Emerging treatments with limited evidence:

   • Theophylline: Case reports suggest benefit in selected cases 4
   • Valproic acid: May reduce frequency of cyanotic BHS, possibly through mood improvement 5

By following this treatment algorithm and focusing on parental education and reassurance as the cornerstone of management, most children with breath holding spells can be effectively managed with minimal intervention while ensuring optimal quality of life and development.