Review Question - QID 104202

This 10-month-old boy is suffering from breath-holding spells, episodic apnea potentially leading to loss of consciousness. There is no definitive treatment needed for breath-holding spells, as they are not harmful and children will outgrow them; therefore, education and reassurance of the parents is the most appropriate course of action.

Breath-holding spells are preceded by an upsetting event involving frustration, anger, or pain. The child typically begins crying and then holds their breath until lips turn bluish. Next, the child may syncopize and lose consciousness. The patient then resumes normal breathing and is fully alert within 1 minute. These spells occur in approximately 5% of children and are equally common in males and females. Medical attention should be sought if the child is unconscious for longer than 1 minute, there is muscle jerking or twitching, or if these spells occur more frequently than once per week.

Hall and Zalman review the evaluation and management of apparent life-threatening events (ALTEs) in children. The clinical history and presentation is key in differentiating more serious etiologies of ALTE from breath-holding spells. Potential underlying diagnoses are widespread, including gastrointestinal, cardiac, neurologic, and respiratory issues; however, over 50% of cases of ALTE are deemed idiopathic. Observation of an infant that demonstrates normal breathing patterns and occasional 'startles' is considered normal and differentiates breath holding spells from other more serious potential causes of ALTE. The relationship of ALTE to sudden infant death syndrome (SIDS) is controversial.

Goldman discusses the relationship between breath-holding spells and iron-deficiency anemia. Studies have shown a coexistence of iron-deficiency anemia in 50-70% of children who exhibit breath-holding spells. Supplementation with iron leading to increases in both hemoglobin level and total iron binding capacity have resulted in a significantly decreased frequency of breath-holding spells compared to those patients who did not receive iron treatment.

Illustration A summarizes the characteristics of two variants of breath holding spells: pallid and cyanotic. Video V contains a clip showing an example of breath holding spells.

Incorrect Answers:
Answer 2: Although there have been case studies documenting cardiac arrhythmias (prolonged QT syndrome) mimicking breath-holding spells in infants; an echocardiogram is unnecessary given the characteristic presentation and lack of any other findings. If anything, an electrocardiogram should precede obtain an echocardiogram.
Answer 3: Breath-holding spells are commonly confused with seizures, as the period of loss of consciousness may at times be accompanied by muscle twitches; however, given the classic presentation of a trigger followed by apnea and cyanosis, an EEG is not indicated in this patient.
Answer 4: A basic metabolic panel would likely not show any abnormalities and would not be useful in a patient with breath holding spells. A CBC would be useful to detect possible underlying anemia.
Answer 5: Lung spirometery may be useful in confirming a diagnosis of asthma; however, this patient would not benefit from lung function testing.