What is the management approach for a child experiencing breath holding spells?

Management of Breath Holding Spells in Children

The management of breath holding spells in children should focus on parental education and reassurance as first-line approach, with medication options reserved for severe cases, and cardiac pacing considered only in cases with documented prolonged asystole. 1

Types and Clinical Presentation

• Classification:

  • Cyanotic spells: More common, typically triggered by anger or frustration
  • Pallid spells: Associated with vagally-mediated cardiac inhibition, often triggered by pain or fear 2

• Typical presentation:

  • Onset between 6-18 months of age
  • Triggered by emotional stimuli or minor trauma
  • Episodes last approximately 10-60 seconds
  • May include color change, loss of consciousness, and occasionally seizure-like activity

Management Algorithm

Step 1: Parental Education and Reassurance

• Explain the benign nature of the condition
• Teach parents to:
  • Place the child in recovery position during episodes
  • Maintain airway patency
  • Avoid stimulating or shaking the child during episodes
  • Monitor for resolution of symptoms

Step 2: Evaluate for Underlying Conditions

• Check for iron deficiency anemia
  • Complete blood count with ferritin levels
  • Iron supplementation should be provided if anemia is present 3
  • Consider iron supplementation even without anemia as it may reduce frequency of spells

Step 3: Pharmacological Management for Severe Cases

• For frequent, severe episodes that significantly impact quality of life:

  • First-line medication: Midodrine

    • Evidence shows reduction in syncope recurrence from 80% to 22% when combined with conventional therapy 4
    • Side effects are rare in pediatric populations

  • Second-line options:

    • Increased salt and fluid intake (Level of Evidence: B-R) 4
    • Piracetam (50-100 mg/kg/day) has shown effectiveness in severe BHS 5

  • Not recommended:

    • Fludrocortisone has uncertain effectiveness (Level of Evidence: C-LD) 4
    • Beta blockers are not beneficial and may increase recurrence rates (Level of Evidence: B-R) 4

Step 4: Specialized Interventions for Refractory Cases

• Cardiac pacing consideration:
  • Reserved for severe pallid BHS with documented prolonged asystole (>4 seconds)
  • Has shown complete resolution or significant reduction in syncopal events in 86% of infants and toddlers 4
  • Single-chamber pacing with hysteresis appears as effective as dual-chamber pacing 4
  • Consider the balance between benefits and known complications of permanent cardiac pacing

Management of Acute Episodes

1. Ensure child safety by placing in recovery position
2. Maintain airway patency with appropriate positioning
3. Monitor breathing and circulation
4. Do not attempt to interrupt the spell by shaking or stimulating the child
5. Most episodes self-resolve within 60 seconds

When to Refer

• Episodes associated with seizure-like activity warrant combined cardiology and neurology evaluation 4
• Documented prolonged asystole (>4 seconds) requires cardiology consultation
• Increasing frequency or severity of spells despite initial management

Prognosis

• Most breath holding spells resolve spontaneously by 5 years of age 6
• No adverse developmental or intellectual sequelae are typically seen
• Reassure parents about the benign nature of the condition

The evidence strongly supports a stepwise approach starting with education and reassurance, followed by iron supplementation if indicated, with pharmacological interventions reserved for severe cases, and cardiac pacing considered only in specific circumstances with documented prolonged asystole.