Breath-holding spell

Background

• Episode during which child holds breath, usually during excessive crying upon exhalation
• May occur after painful/scary/irritating event or after being disciplined or becoming angry
• Not intentional e.g. child is not trying to pass out
• Typically occur in children 6-18mo but can be up to 6yo
• Occur in 5% of all children

Clinical Features

• Breath-holding during crying or intense emotion
• May be associated with:
  • Syncope
    • LOC brief, spontaneously resolves
    • May have brief seizure-like activity, but NO postictal period
  • Cyanosis
  • Pallor

Differential Diagnosis

• Seizure
• Toxicological (stimulants or depressant)
• CO poisoning
• Breath-holding spell
• Tet spell
• Cardiac disease
• Pregnancy (especially ectopic)
• Hypoglycemia

Syncope Causes

• Cardiovascular-mediated syncope
  • Dysrhythmias:
    • WPW (pre-excitation)
    • Long QT Syndrome/QT prolongation
    • Brugada Syndrome
    • Catecholaminergic polymorphic ventricular tachycardia
    • 2nd/3rd AV Block
    • Afib/aflutter
    • Vtach/torsades
    • Sick sinus syndrome
    • Arrhythmogenic right ventricular dysplasia
    • Short QT syndrome
  • Cardiovascular disease
    • Valvular Disease (AS, MS, tricuspid stenosis)
    • Aortic Dissection
    • Myocardial Infarction
    • CHF
    • Hypertrophic Cardiomyopathy
    • PE
    • Pericardial Tamponade
    • Myxoma
    • Pulmonary Hypertension
    • Pacemaker malfunction
• Neurally mediated syncope
  • Vasovagal:
    • Fear, pain, emotion, valsalva, breath-holding spell
  • Situational (associated with):
    • Coughing, micturition, defecation, vomiting, swallowing, postexercise
    • Carotid sinus stimulation
• Orthostatic hypotension-mediated syncope:
  • Volume depletion:
    • Dehydration (vomiting, diarrhea)
    • Hemorrhage, (Ectopic Pregnancy, Upper GI Bleed/Lower GI Bleeding, Abdominal Aortic Aneurysm)
    • Sepsis
  • Autonomic Dysreflexia
  • Autonomic failure due to meds
• Other serious causes
  • Stroke
  • SAH
  • TIA
  • Vertebrobasilar Insufficiency
  • Subclavian steal
  • Heat syncope
  • Hypoglycemia
  • Hyperventilation
  • Asphyxiation
  • Seizure
  • Narcolepsy
  • Psychogenic (anxiety, conversion disorder, somatic symptom disorder)
  • Toxic (drugs, carbon monoxide, etc.)

Evaluation

• Consider if BRUE or seizure workup warranted
• EKG
  • Look for prolonged QT syndrome, dysrhythmia, evidence of congenital heart disease
  • Some evidence of increased QT dispersion in children with breath holding spells
• Consider CBC to screen for anemia if poor access to primary care

Management

• No specific treatment
• Reassurance- benign phenomena that does not typically result in injury and will resolve with time
• Do not need cardiology or neurology outpatient referrals

Disposition

• Discharge

See Also

• Syncope (peds)