What is the approach and treatment for a child experiencing breath holding spells with seizures?

Approach and Treatment for Breath-Holding Spells with Seizures

For children experiencing breath-holding spells with seizures, the recommended treatment includes iron supplementation for those with iron deficiency, midodrine for persistent cases, and cardiac pacing for severe cases with documented asystole. 1

Understanding Breath-Holding Spells

• Breath-holding spells are common, benign events affecting 0.1-4.6% of otherwise healthy young children, typically with onset between 6-18 months of age 2
• These spells are classified into two main types:
  • Cyanotic: Usually precipitated by anger or frustration, characterized by a short loud cry followed by breath-holding in forced expiration and cyanosis 2
  • Pallid: Often triggered by pain or fear, with minimal crying and briefer apneic periods before loss of consciousness and pallor 2
• Both types typically last 10-60 seconds and usually resolve spontaneously by 5 years of age 2
• Seizure-like activity may occur during severe episodes due to cerebral hypoperfusion, not representing true epilepsy 3, 4

Diagnostic Approach

• Obtain a detailed medical history focusing on:
  • Triggers of episodes (emotional stimuli, minor trauma) 1
  • Sequence of events and color changes during episodes 1
  • Family history of similar episodes or syncope 1
• Physical examination should be performed to rule out underlying conditions 2
• Perform a standard 12-lead ECG to exclude cardiac conditions, particularly long QT syndrome 1, 5
• EEG is generally not necessary unless there are atypical features suggesting true epilepsy 5
• Consider hemoglobin assessment to evaluate for iron deficiency 2

Treatment Algorithm

1. First-line approach:

   • Parental education and reassurance about the benign nature of these episodes 2
   • Teach parents proper positioning during episodes (recovery position) to prevent injury 3
   • Instruct parents to stay with the child during episodes 3

2. For children with iron deficiency:

   • Iron supplementation should be provided, as it has been shown to reduce frequency and severity of spells 1

3. For persistent, severe cases:

   • Midodrine therapy should be considered, which has shown significant reduction in recurrence rates from 80% to 22% 1
   • Increased salt and fluid intake may be reasonable in selected pediatric patients 1

4. For severe cases with documented asystole:

   • Cardiac pacing may be considered, with studies showing 86% of infants and toddlers experiencing either complete resolution or significant reduction in syncopal events 1

5. Alternative pharmacological options:

   • Piracetam (50-100 mg/kg/day) may be effective for severe breath-holding spells, with studies showing complete resolution in 81% of children 6

Important Considerations and Cautions

• Beta-blockers are not recommended for pediatric patients with vasovagal syncope, as studies show they may actually increase recurrence rates 1
• During episodes:
  • Do not restrain the child 3
  • Do not put anything in the mouth 3
  • Do not give food, liquids, or oral medicines during or immediately after an episode 3
• For seizures lasting >5 minutes, emergency medical services should be activated 3
• In rare cases, psychological factors may contribute to breath-holding spells, and addressing parent-child relationship issues may be beneficial 7
• Cardiac pacing should be approached cautiously due to potential long-term complications and the fact that pallid breath-holding syncope typically resolves spontaneously with age 1

When to Seek Emergency Care

• First-time seizure or seizure in an infant <6 months of age 3
• Seizure lasting >5 minutes 3
• Multiple seizures without return to baseline mental status between episodes 3
• Failure to return to baseline within 5-10 minutes after seizure activity stops 3
• Seizure with traumatic injuries or difficulty breathing 3