Mrs. S. brings her 16-month-old daughter, Nessrine, to your office for evaluation. She’s extremely worried because for the past 5 or 6 months, her daughter has episodes of loss of consciousness about once or twice a week. On a couple of occasions this loss of consciousness has ended in a brief clonic-tonic seizure. Mrs. S. describes a typical episode as follows: Nessrine is playing quietly. Then Mom sees that she’s about to fall or hurt herself. She shouts sternly, “No!” and runs to pick her up. Her daughter suddenly appears quite upset, with her mouth open wide in expiration with no sound coming out. Her face becomes cyanotic. After 30-40 seconds, there’s a loud scream and Nessrine starts to cry. She settles down quickly, though, and resumes playing quietly and happily. How would you advise Mrs. S?
The typical episode
Breath-holding isn’t uncommon in young children and mostly occurs between the ages of 6-18 months. It may occur, however, up to 6 years of age. The typical episode is one where the child becomes upset and momentarily stops breathing, the face becoming red or cyanotic and occasionally pallid. He or she may briefly lose consciousness and can even have some brief clonic-tonic movements. Needless to say, parents become quite disturbed when they witness such an event. When they present the child to you, you find the physical exam to be normal and the diagnosis is based on a typical history, just as that of Nessrine. These episodes may arise frequently, but stop completely by the time a child is 6 or 7 years. Breath-holding takes place only when the youngster’s awake, after an inciting event, and never during sleep, unlike epileptic seizures. If the story is typical, further investigations are unnecessary. The EEG is normal in these children.
Iron to the rescue
Iron supplementation, even in kids who aren’t iron deficient, has been shown to reduce the number of breath-holding episodes. The mechanism of action in those who aren’t iron deficient isn’t well-understood but it’s not without biological plausibility. A recent Cochrane review looked at 17 articles examining iron treatment in children with breath-holding spells. Of these, only two studies fulfilled the requirements of a Cochrane analysis. These two trials (n = 87) used iron supplementation (5 mg/kg/day) for 16 weeks. There were reductions in frequency or severity of the spells. Looking at harm vs benefit, the analysis suggested that although further studies are required, iron supplementation can be recommended even in kids who aren’t deficient. If the child is iron deficient, the evidence is even stronger that supplementation is effective.
As for Mrs. S., I’d reassure her that Nessrine is a healthy girl who’ll “outgrow” these spells. She’s not epileptic and breath-holding doesn’t predict epilepsy in the future. In order to reduce the frequency/severity of the episodes, I’d treat her with iron. Anecdotally, I remember a patient of mine many years ago who had classic breath-holding episodes that bedevilled his parents. I recently saw my patient’s picture in a local newspaper, focusing on very successful primary school teachers!
Richard Haber, MD, FAAP, FRCPC is an associate professor of pediatrics at McGill University and the Director of the Pediatric Consultation Centre at the Montreal Children’s Hospital.