What is the treatment for breath-holding spells in children?

Treatment for Breath-Holding Spells in Children

The most effective treatment for breath-holding spells in children includes iron supplementation for those with iron deficiency, midodrine for persistent cases, and in severe cases with documented asystole, cardiac pacing may be considered. 1, 2

Understanding Breath-Holding Spells

Breath-holding spells (BHS) are common, benign events affecting 0.1-4.6% of otherwise healthy young children, typically with onset between 6-18 months of age 3. They are classified into two main types:

• Cyanotic breath-holding spells: Usually triggered by anger or frustration, characterized by a short loud cry followed by involuntary breath-holding in forced expiration, cyanosis, rigidity or limpness, and transient loss of consciousness 3, 4

• Pallid breath-holding spells (also called reflex anoxic seizures): Typically triggered by pain or fear, with minimal crying, briefer apnea, pallor rather than cyanosis, and loss of consciousness 1, 3, 4

Diagnostic Approach

• Obtain a detailed history focusing on triggers, sequence of events, and color changes during episodes 1, 3
• Perform standard ECG to rule out cardiac conditions, particularly long QT syndrome 1, 4
• Consider family history, as some children with reflex syncope may have a positive family history 1
• Evaluate for iron deficiency with hemoglobin, ferritin, and iron levels 2

Treatment Algorithm

First-Line Approaches:

1. Parental education and reassurance 3

   • Explain the benign nature of the condition
   • Emphasize that spells typically resolve spontaneously by 4-5 years of age 3, 5

2. Iron supplementation

   • Indicated for all children with iron deficiency or iron deficiency anemia 2
   • Effective even in children with iron deficiency without anemia 2
   • Significant reduction in spell frequency correlates with increasing ferritin and iron levels 2

For Persistent or Severe Cases:

1. Midodrine therapy

   • Reasonable to prescribe for children with vasovagal syncope (VVS) not responding to lifestyle measures 1
   • In randomized controlled trials, midodrine with conventional therapy reduced recurrence rates from 80% to 22% 1
   • Side effects are rare in pediatric populations 1

2. Increased salt and fluid intake

   • May be reasonable in selected pediatric patients with vasovagal syncope 1
   • In RCTs, conventional therapy plus oral rehydration salts resulted in no further recurrence in 56% of patients versus 39% in placebo group 1

3. Alternative pharmacological options (for treatment-resistant cases):

   • Piracetam: Studies show complete resolution in 81% of children with severe BHS 6
   • Theophylline: Case reports suggest effectiveness in selected patients with activity-limiting spells 5

For Severe Cases with Documented Asystole:

1. Cardiac pacing
   • May be considered in pediatric patients with severe neurally mediated syncope secondary to pallid breath-holding spells with documented prolonged asystole (pauses >4 seconds) 1
   • Studies show 86% of infants and toddlers with pallid breath-holding spells had either complete resolution or significant reduction in syncopal events with pacing 1
   • Single-chamber pacing with hysteresis appears as effective as dual-chamber pacing 1

Important Considerations and Caveats

• Beta-blockers are not recommended for pediatric patients with vasovagal syncope, as studies show they may actually increase recurrence rates 1

• Fludrocortisone has uncertain effectiveness in pediatric patients with orthostatic hypotension associated with syncope; in the only pediatric RCT, children did better on placebo 1

• Cardiac pacing should be approached cautiously despite effectiveness, as:

  • Pallid breath-holding syncope typically resolves spontaneously with age 1
  • Long-term outcomes with pacing in this population have not been reported 1
  • Permanent pacing carries known complications that must be balanced against benefits 1

• Rule out serious conditions that may mimic breath-holding spells, including:

  • Long QT syndrome
  • Other cardiac arrhythmias
  • Seizure disorders 1, 4

By following this treatment algorithm and considering the severity of symptoms, most children with breath-holding spells can be effectively managed with minimal intervention while ensuring their safety and quality of life.