What is the management approach for children experiencing breath holding spells or seizures?

Management of Breath Holding Spells and Seizures in Children

For children experiencing breath-holding spells or seizures, the recommended approach includes iron supplementation for those with iron deficiency, midodrine for persistent cases, and cardiac pacing for severe cases with documented asystole, while avoiding beta-blockers which may worsen outcomes. 1

Differentiating Breath-Holding Spells from Seizures

• 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
• There are two main types of breath-holding spells:
  • Cyanotic: Usually precipitated by anger or frustration, characterized by a short loud cry followed by breath holding, cyanosis, rigidity or limpness, and transient loss of consciousness 2
  • Pallid (cardioinhibitory): Often triggered by pain or fear, with minimal crying, briefer apnea, pallor, and loss of consciousness 3, 2
• Children with breath-holding spells may exhibit convulsive movements that mimic epileptic seizures, particularly during pallid spells where 64% exhibit cardiac asystole with pauses >3 seconds 3
• The European Society of Cardiology recommends using terms such as "cardioinhibitory vasovagal syncope" rather than "breath-holding spells" to reduce confusion, as pallid spells don't actually involve respiratory effort 3

Diagnostic Approach

• Obtain a detailed history focusing on:
  • Triggers of episodes (emotional upset, minor injury)
  • Sequence of events and color changes during episodes
  • Family history of similar episodes or syncope 1, 4
• 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 epilepsy; a recent study found only 3.8% of children with breath-holding spells had abnormal EEGs, most of whom had concomitant epilepsy 5
• Consider hemoglobin assessment to rule out iron deficiency anemia, which is associated with breath-holding spells 2

Management Algorithm

Immediate Management During Episodes

• Help the child to the ground, place them on their side in the recovery position, and clear the area around them to prevent injury 3
• Stay with the child during the episode 3
• Do not restrain the child or put anything in their mouth 3
• Do not give food, liquids, or oral medicines during or immediately after an episode 3

When to Activate Emergency Services

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

Treatment Options

1. Reassurance and Education:

   • Primary management for most cases as spells typically resolve spontaneously by 5 years of age 2
   • Explain the benign nature of the condition to parents 6

2. Iron Supplementation:

   • Recommended for children with iron deficiency
   • Has been shown to reduce frequency and severity of spells 1, 4

3. Midodrine:

   • Reasonable to prescribe for children with vasovagal syncope not responding to lifestyle measures 3
   • Studies show significant reduction in recurrence rates from 80% to 22% 3, 1

4. Increased Salt and Fluid Intake:

   • May be reasonable in selected pediatric patients with vasovagal syncope 3
   • In one randomized controlled trial, conventional therapy plus oral rehydration salts resulted in no further recurrence of syncope in 56% of patients versus 39% in the placebo arm 3

5. 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) 3
   • Studies show 86% of infants and toddlers had either complete resolution or significant reduction in syncopal events with pacing 3, 1
   • Single-chamber pacing with hysteresis appears as effective as dual-chamber pacing with rate drop response 3

6. Piracetam:

   • Some evidence suggests effectiveness as prophylactic treatment for severe breath-holding spells
   • In one study, spells disappeared completely in 81% of children and were significantly reduced in 9% 7

Important Considerations and Cautions

• Beta-blockers are not beneficial and may actually increase recurrence rates in pediatric patients with vasovagal syncope 3, 4
• Fludrocortisone has uncertain effectiveness in pediatric patients with orthostatic hypotension associated with syncope 3
• For children with febrile seizures, antipyretics such as acetaminophen, ibuprofen, or paracetamol are not effective for stopping a seizure or preventing subsequent febrile seizures 3
• Consider the long-term implications of cardiac pacing against the fact that pallid breath-holding syncope typically resolves spontaneously with age 3
• Overuse of diagnostic tests like EEG and ECG has been documented in children with typical breath-holding spells 5