Breath holding attacks

Question 1

What are the two types of breath holding attacks in children?

Answer 1

“blue breath-holding spell” - precipiated by crying or frustration

“pallid breath holding spell” - precipitated by being scared or in pain

Question 2

Define breath-holding spell.

Answer 2

Breath-holding is when a baby or child stops breathing for up to 1 minute and may faint. It can happen when a child is frightened, upset, angry, or has a sudden shock or pain. It’s usually harmless but can be scary for parents, particularly when it happens for the first time (NHS)

Question 3

What is a typical presentation of breath holding spells?

Answer 3

• crying then silent while holding breath
• open their mouth as if going to cry but make no sound
• turn blue or grey
• be floppy or stiff, or their body may jerk
• faint for 1 or 2 minutes
• sleepy or confused afterwards

Question 4

What are blue breath-holding spells also known as? How fast is recovery?

Answer 4

Expiratory apnoea syncope - because they occur with anger/crying when child cannot catch their breath which is stuck in expiration. So becomes blue then still and limp with rapid recovery.

Question 5

What are pallid breath-holding spells also known as? What is sometimes a consequence of these episodes? How fast is recovery?

Answer 5

Reflex asystolic syncope - may occur with sudden surprising pain, causing pallor, breathing arrest and stiffness.

Sometimes hypoxia leads to generalised tonic-clonic seizures with rapid recovery followed by sleep for an hour or more if severe.

Question 6

Which condition predisposes to reflex asystolic syncope?

Answer 6

Febrile seizures

Question 7

What is the pathophysiology of reflex asystolic syncope?

Answer 7

Cardiac asystole from vagal inhibition

Question 8

What is the management of expiratory apnoea syncope?

Answer 8

Attacks resolve spontaneously, but behaviour modification therapy with distraction may help.

Question 9

What is reflex asystolic syncope sometimes misdiagnosed as?

Answer 9

Epilepsy

However, RAS is anoxic and therefore non-epileptic despite the tonic-conic seizure that sometimes occurs. Correct diagnosis lies in detailed history, review of video, examination and EEG.

Question 10

What advice should you give to parents about breath holding spells?

Answer 10

REASSURE

• stay calm – it should pass in less than 1 minute
• lie the child on their side – do not pick them up
• stay with them until the episode ends
• make sure they cannot hit their head, arms or legs on anything
• reassure them and ensure they get plenty of rest afterwards
• do not tell them off - they are not controlling this

SAFETY NET: see GP if…

• if episodes are more common or affecting daily life
• if seizure lasts >1 minute