Breath-holding Spells Research Articles

Effectiveness of iron therapy on breath-holding spells

Objective: The objective of this study is to investigate the effect of iron therapy on breath-holding spells (BHS). Methodology: Sixty-seven children with BHS were enrolled in a clinical trial to evaluate the effect of iron therapy on BHS. At the beginning of therapy, the clinical, laboratory, and demographic characteristics of the patients in the treatment group (n = 33) and placebo group (n = 34) were comparable. Patients were assessed weekly for the first 8 weeks and then every 2 weeks for the next 8 weeks. Response to therapy was assessed by the change in the frequency of BHS. Results: Children treated with iron showed significant reduction in the frequency of BHS (88%) compared with the frequency (6%) in the placebo group. As expected, the treated group showed a significant improvement of a number of blood indexes compared with the placebo group. Baseline mean levels of hemoglobin and total iron binding capacity were predictive of a favorable response to iron treatment. Conclusion: Results of this study indicate that iron therapy is effective in the treatment of BHS and that iron-deficient children seem to be more likely to benefit from such therapy. Response to iron therapy was strongly correlated with improvement in blood indexes. (J Pediatr 1997;130:547-50)

Breath-holding spells in a patient with transient erythroblastopenia of childhood

We describe a child with transient erythroblastopenia of childhood and breath-holding spells. The spells resolved after oral iron supplementation but before the anemia resolved. The physiologic role of iron in autonomic nervous system regulation and its potential role in the treatment of breath-holding spells are discussed. (J Pediatr 1997;130:651-3)

Family pedigree analysis of children with severe breath-holding spells

We examined family pedigrees of children with severe breath-holding spells (SBHS). There were 57 probands (27 males, 30 females; 44 cyanotic, 13 pallid) whose families comprised 1683 individuals. We found that 31 (27%) of 114 proband parents and 9 (21%) of 43 proband siblings had current or prior SBHS. Father-to-son transmission was observed in 7 instances. There were 7 families with 2 or more affected siblings and 5 families with 3 or more affected members. From 85 nuclear families, 130 individuals had current or prior SBHS (59 males, 71 females; male/female ratio, 1:1.2). These data suggest that the most likely underlying genetic inheritance pattern in SBHS is an autosomal dominant trait with reduced penetrance. (J Pediatr 1997;130:647-51)

Nonfebrile seizures.

Nonfebrile seizures.

Update on Epilepsy in Pediatric Patients

Epilepsy is a common condition that affects 0.5 to 1% of all children. Although most children with epilepsy have well-controlled seizures with use of one antiepileptic drug (AED), some children have medically refractory seizures. This situation can be the result of inaccurate classification of the paroxysmal event, use of an inappropriate AED, of a truly medically refractory seizure disorder. Paramount to the initial assessment of a child with presumed epilepsy is the appropriate classification of the paroxysmal event. Several nonepileptic conditions, such as motor tics or breath-holding spells, can cause paroxysmal abnormalities in children, which can be confused with epilepsy. The common pediatric epileptic and nonepileptic conditions are reviewed, and the standard and new AEDs and their side effects are discussed. When a child's seizure disorder is intractable despite adequate trials of AEDs, surgical treatment is increasingly becoming an effective option. Such procedures should ideally be performed at centers with extensive experience in this area and with a multidisciplinary team approach. With improved magnetic resonance imaging technology, increasing numbers of children with medically intractable localization-related epilepsy are being found to have underlying focal cortical dysplasia, tumors, or hippocampal atrophy. These abnormalities can often be surgically resected with excellent results. A generalized epilepsy may also be remediable with surgical treatment. Specifically, preliminary data suggest that infantile spasms, when triggered by an underlying focal cortical dysplasia, may be effectively treated by surgical resection. Patients with certain catastrophic seizure disorders, such as Sturge-Weber syndrome or hemimegalencephaly, require prompt intervention with hemispherectomy. The presurgical evaluation relies heavily on the magnetic resonance imaging, positron emission tomography, and single-photon emission computed tomography scan data as well as the electroencephalogram in identifying the area of epileptogenic abnormality.

Breath-Holding Spells

The clinical characteristics, types, diagnosis, and management of breath-holding spells are reviewed from The Department of Pediatrics (Neurology), Park Nicollet Medical Center, Minneapolis, MN.

Critical stages in mental development: Childhood breath holding spells (BHS)

The authors present the first part of a study on children with BHS (Breath Holding Spells) syndrome. These children were chosen in order to examine a “pathological” situation in infancy that was as close as possible to a “normal” one, and in which obvious somatic symptoms were associated with emotional states. Children with BHSS are not considered to have serious psychological disturbances, even if they are constantly referred to as intolerant of separation, stubborn, oppositional, or easy to temper tantrum. A reduced ability to tolerate frustration is evident in these children both from the patients' history and clinical observation. Parents usually relate BHS to situations in which the child is denied something or gets scolded. The children were observed during three sessions, both with and without the mother, according to a grid used at our Center. Patients are presented to illustrate certain recurrent features in play and interaction with mother. The data suggest that these children stagnate in an area of incomplete mental representation; something makes them oscillate between two states; in one of them, the mental representation of the object and of the bond with it is possible; in the other, the mental representation of the separation, which entails the recognition of the object, is felt as dangerous.

Breath-Holding Spells and Anemia

Two children, ages 32 months and 19 months, with breath-holding spells that resolved after treatment for concomitant anemia, are reported from the University of Washington School of Medicine and the Children’s Hospital, Seattle.

Resolution of breath-holding spells with treatment of concomitant anemia

We describe two children who had breath-holding spells that were accelerating in frequency and severity and in one case had recrudesced. Both patients had signs, symptoms, and laboratory findings of severe anemia. With correction of anemia the breath-holding spells promptly and completely resolved in each case. We conclude that in some patients anemia may be a factor contributing to breath-holding spells and that correction of concomitant anemia may produce amelioration or remission of the spells. (J P EDIATR 1995;126:395-7)

Psychiatric morbidity in preschool children--a clinic based study.

Psychiatric morbidity patterns in preschool children attending a general hospital psychiatric clinic were studied. No psychiatric problem was detected in 48% of the sample, epilepsy being the diagnosis in more than half of these children. Common psychiatric problems were mental retardation (27%), breath-holding spells (11%) and hyperkinetic syndrome (7%). Emotional and behavioral problems, and habit disorders, which are quite common in this age group, were poorly represented in the clinic sample. It appears that mental retardation and epilepsy are the only two main disorders usually perceived by Indian parents as psychiatric problems in preschool age group.

Consultation with the Specialist: Behavior Problems

A variety of children's behaviors are distressing to parents and often very difficult to manage. These can include biting, temper tantrums, breath-holding spells, and hitting.BitingBiting often is the first behavior that provokes major concern and a demand for solutions. The same child who might be excused for hitting may well end up isolated from peers and at risk of being barred from child care for biting. The situation is aggravated by increased parental fears of infection (acquired immunodeficiency syndrome, hepatitis, tetanus, rabies).The initial biting episode often occurs when the child is teething, with parents being the first bitten; they mistakenly may think it is a cute game. A typical scenario is when one child wants the toy of another and bites in frustration. Many parents do not respond until the possibility of penalties that affect them arise. All adults must be encouraged to have a rule that interrupts the behavior with a strong

Consultation with the Specialist

A variety of children's behaviors are distressing to parents and often very difficult to manage. These can include biting, temper tantrums, breath-holding spells, and hitting. Biting Biting often is the first behavior that provokes major concern and a demand for solutions. The same child who might be excused for hitting may well end up isolated from peers and at risk of being barred from child care for biting. The situation is aggravated by increased parental fears of infection (acquired immunodeficiency syndrome, hepatitis, tetanus, rabies). The initial biting episode often occurs when the child is teething, with parents being the first bitten; they mistakenly may think it is a cute game. A typical scenario is when one child wants the toy of another and bites in frustration. Many parents do not respond until the possibility of penalties that affect them arise. All adults must be encouraged to have a rule that interrupts the behavior with a strong "No, we never bite people because it hurts them," which can be extended to include pets and stuffed animals. With children in this age group, longer, more complex explanations only provide additional attention and reward behavior that you are trying to stop. Interruption and prevention before the biting occurs is important.

Ellen R. Grass Guest Lecture: Long-Term Video/EEG Monitoring and Behavior

ABSTRACT.Involvement of the limbic system, the seat of emotions in the brain, can lead to psychiatric accompaniments to epilepsy. Patients with epilepsy may also have depression, psychoses, forced normalization, and personality disorders. Long-term video/EEG has allowed improved differentiation between epileptic syndromes and nonepileptic disorders that may mimic epilepsy clinically. Pseudoseizures are important nonepileptic events that need to be distinguished from epileptic seizures. Other conditions that may accompany epilepsy or be confused with epileptic seizures include migraine and the MELAS syndrome; sleep disorders, such as cataplexy, sleep attacks, and REM sleep behavior disorder; the childhood disorders of breathholding spells, benign paroxismal vertigo of childhood, and Rett syndrome; and movement disorders such as shuddering spells and hyperekplexia.

89 PAROXYSMAL EVENTS RELATED TO INCREASED VAGAL REACTIVITY IN HEALTHY CHILDREN

“Breath-holding spells” and “reflex anoxic seizures” in children are sometimes misdiagnosed as epilepsy. Paroxysmal events may however be vagally-mediated. Initiation of the vagal reflex follows usually a sudden and unexpected fright or pain. The purpose of this study was to evaluate the strength of the vagal reflexes in children with various forms of paroxysmal events.

Diagnosis of childhood seizure disorders.

Convulsive epilepsies are generally unmistakable. Absence epilepsies, which are easily recognized by the provocation of an episode during hyperventilation and by the typical features of the EEG, can be overdiagnosed, especially in the child who daydreams in class and has scattered, asymptomatic, epileptogenic EEG changes. As in adults, complex partial seizures in children can be difficult to distinguish from certain behaviors. Several types of benign childhood epilepsies need to be distinguished from the more intractable and lesional childhood epilepsies. Two common examples, benign rolandic epilepsy and benign occipital epilepsy, can be recognized by their unique EEG changes and clinical features. Juvenile myoclonic epilepsy generally does not remit spontaneously but should be recognized because it appears to respond to valproate. Some recurrent nonepileptic events seen in children can be mistaken for seizures, including shuddering attacks, paroxysmal vertigo, breath-holding spells, cardiogenic syncope, night terrors, and movement disorders, such as paroxysmal kinesigenic choreoathetosis.

A Prospective Evaluation of Pediatric Patients With Syncope

Fifty-eight children with syncope were evaluated prospectively to determine the characteristics of syncope in the pediatric age group and the yield of various diagnostic tests. The age at first syncope ranged from 0.5 to 15 years. Twenty-five children presented after a single episode and 33 after multiple episodes. Ten had a history of breath-holding spells. Nineteen had a family history of syncope. A diagnosis was established in 53 patients (91%): vasodepressor (31), cardioinhibitory (13), tussive (3), hyperventilation (2), and mixed syncope (4). In five patients (9%), the cause remained unknown. The diagnosis was established from the history in 45 cases, by a positive oculocardiac reflex in 11, and by the head-up tilt test in four. We conclude that the cause of most cases of pediatric syncope is vasodepressor or cardioinhibitory and can be diagnosed by good history-taking. Costly evaluations are rarely necessary.

Serum prolactin and cortisol in children with some paroxysmal disorders.

Postictal serum prolactin and cortisol levels were estimated in 73 children having either epilepsy, febrile seizures, breath-holding spells, or fever without other manifestation and in 20 normal controls. Mean serum prolactin levels (28.6 +/- 2.3 ng/ml) were significantly higher (p < 0.001) in the epileptic group than in the group with febrile seizures (12.7 +/- 2.8 ng/ml), non-specific febrile illness (12.2 +/- 2.4 ng/ml), breath-holding spells (8.8 +/- 1.1 ng/ml) and normal controls (9.8 +/- 2.6 ng/ml). Mean serum cortisol levels were non-specifically elevated in children with epilepsy (32.8 +/- 2.2 ug/dl), febrile convulsion (34.2 +/- 4.1 ug/dl) and non-specific febril illness (30.6 +/- 2.4 ug/dl). Our observations suggest that elevated prolactin levels associated with afebrile epileptic seizures may help in differentiating epilepsy from febrile seizures and breath-holding spells. Cortisol levels appear to be non-specifically elevated in all stressful conditions.

Mechanisms of Obstructive Sleep Apneas in Infants

During sleep, infants with obstructive sleep apneas are characterised by snoring, laborious breathing, and profuse sweating. During wakefulness, they may have breath-holding spells, and during feeding, difficult breathing and swallowing coordination. Abnormal weight, difficult growth, and recurring ear infections may also develop. During sleep apneas, cinefluoroscopy shows approximation of tongue and hypopharyngeal tissues, with an obliteration of the air space. The obstructed breaths occur mainly in REM, and light NREM sleep, associated with total short sleep time, and frequent arousals. Preterm infants, and term neonates are more prone to obstructive apneas than older healthy infants. Apneas are more frequently seen in boys and in case of excess in body weight. Obstructive apneas are frequently associated with upper airway anatomic abnormalities: malformations, soft tissue infiltration, and neurologic lesions impairing muscle contractions. Alterations of the autonomic nervous control may induce airways obstructions. Contributing factors include mucopolysaccharide storage disease, hypothyroidism, or Down's syndrome. Superimposed factors may occur, such as nasal obstruction, secretions in the airways, or tissue edema. Pressure- and chemo-sensitive reflexes may also favor obstruction. Environmental factors also contribute to the development of sleep apneas: body position, neck flexion, sleep deprivation, or the effects of sedative drugs.

Autonomic nervous system function in severe breath-holding spells

This study attempted to determine noninvasively whether a dysregulation of autonomic nervous system reflexes exists in children with severe cyanotic breath-holding spells (BHS). This was a cross-sectional study performed in the neurophysiology laboratory at a tertiary care hospital. Patients, 18 months of age and older taken from a referral population of children with severe cyanotic BHS and normal controls, were studied. Fourteen children with cyanotic BHS and 12 controls were evaluated. Several noninvasive measures of parasympathetic and sympathetic reflex functions were assessed and statistically analyzed using analysis of variance and covariance, and Fisher's exact tests. The cyanotic BHS group had a significantly greater increase in pulse rate at 15 s of standing after rising from the supine position ( P<.06), with a trend toward a concomitant higher mean arterial pressure ( P<.09). After adjusting for age, sex, and mean supine systolic and diastolic blood pressures, breath-holders had a greater decrease in diastolic blood pressure ( P<.02) without an increase in systolic blood pressure after standing from the supine position. Breath-holders also had significantly abnormal 30:15 R-R interval ratios compared with controls ( P<.002). These results support the hypothesis that children with cyanotic BHS have underlying autonomic nervous system dysregulation. This dysregulation may contribute to the pathophysiology of severe BHS in these children.

Hair-Grooming Syncope Seizures

Pediatricians are commonly consulted to evaluate children following their first, apparently unprovoked, convulsion. Keenly aware of the old adage that "all that shakes isn't epilepsy," we are ever mindful of the common mimickers of epileptic seizures that include breath-holding spells, benign paroxysmal vertigo, hyperventilation syndromes, narcolepsy-cataplexy, night terrors, and syncopal events. We present the clinical features of 15 children referred for evaluation of witnessed convulsions at home with similar histories of seizures precipitated by hair grooming and accompanied by presyncopal symptoms. METHODS The records of children referred to our neurology clinics from 1982 to 1992 for evaluation of seizures in temporal relationship to hair grooming were retrospectively reviewed.