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[1]
Typically occur in children 6-18mo but can be up to 6yo
Occur in 5% of all children[2]

Cardiovascular-mediated syncope
- Dysrhythmias:
  - WPW (pre-excitation)
  - Long QT Syndrome
  - 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.)

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[3]
Consider CBC to screen for anemia if poor access to primary care

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[4]

Goldman RD. Breath-holding spells in infants. Can Fam Physician. 2015 Feb;61(2):149-50. PMID: 25676645
https://pedemmorsels.com/breath-holding-spell/
Movahedian AH1, Heidarzadeh Arani M2, Motaharizad D3, Mousavi GA4, Mosayebi Z5. Evaluation of QT Dispersion in Children with Breath Holding Spells. Iran J Child Neurol. 2016 Winter;10(1):25-30. PMID: 27057184
Yilmaz U1, Doksoz O2, Celik T3, Akinci G4, Mese T5, Sevim Yilmaz T6. The value of neurologic and cardiologic assessment in breath holding spells. Pak J Med Sci. 2014 Jan;30(1):59-64. PMID: 24639832

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