Breath-holding spells

Prediction of breath-holding spells based on electrocardiographic parameters using machine-learning model

BACKGROUND

Breath-holding spells (BHS) are common in infancy and early childhood and may appear like seizures. Factors such as autonomic dysfunction and iron deficiency anemia are thought to contribute to the incidence of BHS. In this study, electrocardiographic (ECG) parameters of patients with BHS were compared to those of healthy, normal children. Logistic regression and machine-learning (ML) models were then created to predict these spells based on ECG characteristics.

METHODS

In this case-control study, 52 BHS children have included as the case and 150 healthy children as the control group. ECG was taken from all children along with clinical examinations. Multivariate logistic regression model was used to predict BHS occurrence based on ECG parameters. ML model was trained and validated using the Gradient-Boosting algorithm, in the R programming language.

RESULTS

In BHS and control groups, the average age was 11.90 ± 6.63 and 11.33 ± 6.17 months, respectively (p = .58). Mean heart rate, PR interval, and QRS interval on ECGs did not differ significantly between the two groups. BHS patients had significantly higher QTc, QTd, TpTe, and TpTe/QT (all p-values < .001). Evaluation of the ML model for prediction of BHS, fitting on the testing data showed AUC, specificity, and sensitivity of 0.94, 0.90, and 0.94 respectively.

CONCLUSION

There are repolarization changes in patients with BHS, as the QTc, QTd, TpTe, and TpTe/QT ratio were significantly higher in these patients, which might be noticeable for future arrhythmia occurrence. In this regard, we developed a successful ML model to predict the possibility of BHS in suspected subjects.

A framework to simplify paediatric syncope diagnosis

This paper aims to improve the diagnosis of syncope and transient loss of consciousness (TLOC) in children. Diagnostic problems stem, first, from some causes spanning various disciplines, e.g. cardiology, neurology and psychiatry, while the most common cause, vasovagal syncope, is not embraced by any specialty. Second, clinical variability is huge with overlapping signs and symptoms. Third, the approach to TLOC/syncope of the European Society of Cardiology (ESC) is underused in childcare. We explain the ESC guidelines using an additional paediatric literature review. Classification of TLOC and syncope is hierarchic and based on history taking. Loss of consciousness (LOC) is defined using three features: abnormal motor control including falling, reduced responsiveness and amnesia. Adding a < 5 min duration and spontaneous recovery defines TLOC. TLOC simplifies diagnosis by excluding long LOC (e.g. some trauma, intoxications and hypoglycaemia) and focussing on syncope, tonic-clonic seizures and functional TLOC. Syncope, i.e. TLOC due to cerebral hypoperfusion, is divided into reflex syncope (mostly vasovagal), orthostatic hypotension (mostly initial orthostatic hypotension in adolescents) and cardiac syncope (arrhythmias and structural cardiac disorders). The initial investigation comprises history taking, physical examination and ECG; the value of orthostatic blood pressure measurement is unproven in children but probably low. When this fails to yield a diagnosis, cardiac risk factors are assessed; important clues are supine syncope, syncope during exercise, early death in relatives and ECG abnormalities.  Conclusions: In adults, the application of the ESC guidelines reduced the number of absent diagnoses and costs; we hope this also holds for children. What is Known: • Syncope and its mimics are very common in childhood, as they are at other ages. • Syncope and its mimics provide considerable diagnostic challenges. What is New: • Application of the hierarchic framework of transient loss of consciousness (TLOC) simplifies diagnosis. • The framework stresses history-taking to diagnose common conditions while keeping an eye on cardiac danger signs.

Breath-holding spells after endoscopic third ventriculostomy in a post-ventriculoperitoneal shunted patient

Breath-holding spells (BHS) are commonly observed in children as a result of an autonomic nervous system disorder triggered by crying, emotional distress, or pain. There are several types of BHS and cyanotic type is one of them. We encountered a case of 3-year-old girl who presented with a delayed adaptation period and BHS 2 weeks after an endoscopic third ventriculostomy (ETV). She experienced severe headache due to increased intracranial pressure (ICP) during the delayed adaptation period, which may have contributed to the onset of BHS. Management of BHS warrants treatment of the symptoms and removal of the causative factors; in our case, intensive pain control and resolution of the increased ICP after the adaptation period were effective. While BHS are usually described as a benign condition that improves spontaneously, we highlighted the importance of recognizing and monitoring atypical symptoms such as BHS in pediatric cases.

The importance of acknowledging diagnostic uncertainty in patients with new-onset paroxysmal spells

OBJECTIVE

The aims of this study were to evaluate the frequency of paroxysmal spells of indeterminate nature (PSIN) in a large cohort of children and adults with suspected new-onset seizures, to evaluate the reasons for including patients in this category, and to calculate the rate of erroneous diagnoses if the epileptologists were compelled to label those events as epileptic seizures or nonepileptic paroxysmal spells.

METHODS

Patients identified for this study participated in a prospective study evaluating patients with suspected new-onset unprovoked seizures. The workup included a detailed history and a thorough description of the spells, a 3-hour video EEG recording, and an epilepsy protocol brain MRI. Based exclusively on a detailed description of the ictal events, two epileptologists were asked to independently classify each patient into those with a definite diagnosis of unprovoked seizures or a definite diagnosis of a nonepileptic paroxysmal spells (group 1) and those with PSIN (group 2).

RESULTS

A total of 1880 consecutive patients were enrolled with 255 (13.6%) included in the PSIN group. Patients with PSIN were significantly younger than those with a definite diagnosis, and PSIN were significantly more frequent in children with developmental delay. The most common reason for including patients in the PSIN group was the inability to categorically discriminate between a seizure and a nonepileptic mimicker. When the raters were compelled to classify the spells in the PSIN group, the frequencies of erroneous diagnoses ranged between 32% and 38%. The final diagnoses on those patients were made based on the results of the EEG, MRI, and follow-up visits.

SIGNIFICANCE

Our data indicate that a diagnostic category of PSIN should be recognized and ought to be used in clinical practice. Acknowledging this uncertainty will result in lower frequencies of erroneous diagnoses, possible stigma, and potential exposure to unnecessary antiseizure medications.

The pathophysiology of vasovagal syncope: Novel insights

The pathophysiology of vasovagal syncope (VVS) is reviewed, focusing on hemodynamic aspects. Much more is known about orthostatic than about emotional VVS, probably because the former can be studied using a tilt table test (TTT). Recent advances made it possible to quantify the relative contributions of the three factors that control blood pressure: heart rate (HR), stroke volume (SV) and total peripheral resistance (TPR). Orthostatic VVS starts with venous pooling, reflected in a decrease of SV. This is followed by cardioinhibition (CI), which is a decrease of HR that accelerates the ongoing decrease of BP, making the start of CI a literal as well as fundamental turning point. The role of hormonal and other humoral factors, respiration and of psychological influences is reviewed in short, leading to the conclusion that a multidisciplinary approach to the study of the pathophysiology of VVS may yield new insights.

Indications for epilepsy monitoring in pediatric and adolescent health care

Seizures present in childhood with infinite diversity. History alone may suffice for diagnosis in some cases; more often additional evidence is needed to clarify events of concern. Electroencephalography (EEG) is a primary methodology used for seizure identification and management. Pediatric and adolescent health care providers are increasingly asked to make decisions about when and how to refer patients for eventual monitoring and must then be able to confidently interpret any resulting report(s). Comprehensive literature review was undertaken to provide a succinct and up-to-date overview aimed at general and subspecialty non-neurologist pediatric and adolescent health care providers to not only convey a solid general understanding of EEG and what it entails for patients and their families, but also foster a deeper understanding of the indications for monitoring-and how to interpret documented findings. In plain language this resultant guide reviews EEG basics, provides a crash course in the various types of EEG available, discusses broad indications for epilepsy monitoring, guides counseling and management for patients and their families both before and after EEG, and ultimately aids in the interpretation of both findings and prognosis. This review should allow both primary and subspecialty non-neurologic pediatric and adolescent health care providers to better identify when and how to best utilize EEG as part of a larger comprehensive clinical approach, distinguishing and managing both epileptic and nonepileptic disorders of concern while fostering communication across providers to facilitate and coordinate better holistic long-term care of pediatric and adolescent patients.

Evaluation of the effectiveness of valproic acid for treating cyanotic breath holding spells: A Pilot prospective study

BACKGROUND

Cyanotic breath-holding spells (CBHS) are self-limited conditions among younger children. Frequent spells cause parents' fear and anxiety. Seizures, brain damage and sudden death have been rarely reported with BHS. Some reported spells' frequency reduction with iron or piracetam. We evaluated the effectiveness of valproic acid (VPA) to treat CBHS and predictors of improvement.

METHODS

Participants were 90 children with CBHS (≥4/week) (age: 1.6±0.4yrs). They were treated with VPA (5 mg/kg/d). Follow-ups occurred after 3-≥6 months. Autonomic nervous system functions were evaluated.

RESULTS

The majority (74.4%) had daily spells and 19% had ≥2 spells/d. Crying or anger provoked spells. Postural hypotension was found in 46.7%. They had normal electroencephalography and QT, QTc interval or QTd or QTcd and heart rate. Compared to controls, postural fall in systolic (>20mmHg) and diastolic (>10mmHg) blood pressures and mean arterial pressure (>10mmHg) were observed in 46.7%, 74.4% and 72.2% and miosis observed with 0.125% pilocarpine in 28.9% (P=0.001). Spells' frequency reduction (P=0.001) occurred within 3 months with VPA. The independent prdictors for spell' frequency reduction were reduction of anger and crying [OR=4.52(95%CI=2.35-6.04), P =0.01].

CONCLUSION

VPA therapy reduces CBHS' frequency. Mood improvement is a suggestive effective mechanism.

CLINICAL TRIAL REGISTRATION

www.clinicaltrials.gov identifier is NCT04482764.

Timing of Circulatory and Neurological Events in Syncope

Syncope usually lasts less than a minute, in which short time arterial blood pressure temporarily falls enough to decrease brain perfusion so much that loss of consciousness ensues. Blood pressure decreases quickest when the heart suddenly stops pumping, which happens in arrhythmia and in severe cardioinhibitory reflex syncope. Loss of consciousness starts about 8 s after the last heart beat and circulatory standstill occurs after 10-15 s. A much slower blood pressure decrease can occur in syncope due to orthostatic hypotension Standing blood pressure can then stabilize at low values often causing more subtle signs (i.e., inability to act) but often not low enough to cause loss of consciousness. Cerebral autoregulation attempts to keep cerebral blood flow constant when blood pressure decreases. In reflex syncope both the quick blood pressure decrease and its low absolute value mean that cerebral autoregulation cannot prevent syncope. It has more protective value in orthostatic hypotension. Neurological signs are related to the severity and timing of cerebral hypoperfusion. Several unanswered pathophysiological questions with possible clinical implications are identified.

Ventricular repolarization changes in children with breath holding spells

OBJECTIVE

Breath holding spells is a non-epileptic paroxysmal disease which is frequently seen in childhood. In this study, we aimed to investigate electrocardiographic atrial conduction and ventricular repolarization changes in children with breath holding spells.

MATERIALS AND METHODS

We reviewed the electrocardiograms of 58 patients with breath holding spells who admitted to SBU Okmeydanı SUAM Pediatric Cardiology Clinic between November 2018 and February 2019. QT, QTc (calculated with Bazett formula), T peak-end (Tp-e), QT dispersion (QTd), QTc dispersion (QTcd), Tp-e/QT ratio, Tp-e/QTc ratio, JT interval, JTc (calculated with Bazett formula), Tp-e/JT ratio, Tp-e/JTc ratio and P dispersion (Pd) were measured and compared with the control group of 44 healthy children.

RESULTS

In the control and the case groups, mean QTd was 19.86 ms and 38.57 ms, QTcd was 28.34 ms and 58.03 ms, Tp-e/QT ratio was 0.16 and 0.26, Tp-e/QTc ratio was 0.11 and 0.17, JT interval was 204.09 ms and 224.52 ms, JTc value was 290.00 ms and 333.72 ms, Tp-e/JT ratio was 0.23 and 0.35, Tp-e/JTc ratio was 0.16 and 0.24, Pd was 29.32 ms and 40.53 ms respectively. Differences between two groups were statistically significant (p < 0,001).

CONCLUSION

QTd, QTcd, Tp-e, Tp-e/QT ratio, Tp-e/QTc ratio, JT, JTc, Tp-e/JT, Tp-e/JTc ratio and Pd were increased significantly compared to healthy children. Based on the results, ventricular repolarization and atrial conduction were affected in patients with breath holding spells. These patients may be under the risk of developing rhythm disorders.

Evaluation of Heart Rate Variability in Children With Breath-Holding Episodes

AIM

We evaluated heart rate variability in children with breath-holding episodes (BHEs).

METHODS

Sixty children with BHEs were included in the study; these individuals were further subdivided into children with cyanotic BHEs (n = 42) and children with pallid BHE (n = 18). Sixty healthy children of matched age and sex served as a control group. Twenty-four hour Holter monitoring was applied to all included children. Minimum, mean, maximum heart rate, rhythms, and corrected QT were evaluated. Time domain parameters of heart rate variability such as standard deviation of all R-R intervals, standard deviation of the average of R-R intervals in all five-minute segments of the entire recording, mean of the standard deviations of all N-N (normal-normal RR) intervals for all five-minute segments, root mean squares differences between adjacent R-R intervals, percentage of differences between adjacent R-R intervals that are greater than 50 milliseconds were also assessed.

RESULTS

All time domain parameters of heart rate variability were significantly higher in children with pallid BHEs than those with cyanotic BHEs and control group. Minimum, mean, and maximum heart rate were significantly lower in children with pallid BHEs than those with cyanotic BHEs and control group. Asystole was observed in three children with pallid BHEs. Long corrected QT was observed in another two children with pallid BHEs.

CONCLUSIONS

Heart rate variability increased significantly in children with pallid BHEs. Evaluation of heart rate variability is crucial for children with BHEs especially those with pallid episodes.

Iron deficiency and cyanotic breath-holding spells: The effectiveness of iron therapy

Aim: Frequent cyanotic breath holding spells cause fear and severe anxiety to parents. This study aimed to evaluate clinical, laboratory and treatment characteristics of children with cyanotic breath holding spells. Methods: Included were 180 children (mean age: 1.82 ± 0.53 years) with cyanotic breath holding spells. They were divided into three groups: with iron deficiency, with iron deficiency anemia and without iron deficiency. Blood hemoglobin (HB), ferritin and iron concentrations were measured at baseline and after 3 and 6 months of iron treatment. Results: The mean spell frequency was 24.57 ± 7.31/months, 83% had spells after the age of 1 year, 37% had daily spells, 16% had family history of spells, and 61% had Iron deficiency/Iron deficiency anemia (p = .001). No significant difference in the frequency of spells between children with iron deficiency and those with Iron deficiency anemia. Compared to patients without iron deficiency, there was significant reduction of spells frequency, increased hemoglobin, ferritin and iron levels after 3 and 6 months of iron therapy (p = .0001). Negative correlations were observed between spell frequency with hemoglobin (p = .001), ferritin (p = .0001) and iron (p = .001) levels. Conclusion: Not only Iron deficiency anemia but also iron deficiency alone without anemia is associated with a risk of high-frequency cyanotic breath holding spells. Iron therapy results in reduction in spells' frequency which was correlated with increasing ferritin and iron levels.

Performance of a tracheostomy removal protocol for pediatric patients in rehabilitation after acquired brain injury: Factors associated with timing and possibility of decannulation

OBJECTIVES

We assessed the performance of a tracheostomy decannulation protocol privileging safety over quickness, in pediatric patients undergoing rehabilitation from severe acquired brain injury. We analyzed factors associated with decannulation timing and possibility and examined cases of failure.

HYPOTHESIS

A safe decannulation protocol should minimize failures.

STUDY DESIGN

Retrospective observational study.

PATIENT SELECTION

Patients aged 0-17 admitted to rehabilitation with tracheostomy in the last 15 years (n = 123).

METHODOLOGY

We collected data on clinical and respiratory conditions at admittance, during the first rehabilitation stay and following follow-up controls. We described the sample and tested associations of several factors with the possibility to decannulate patients during either the first stay or follow-up. We described failures, defined as the cases in which tracheostomy tube had to be placed back immediately or after less than 1 month from removal.

RESULTS

At admittance, 93.5% patients were dysphagic and 37.9% had respiratory complications (mainly accumulation of supraglottic secretions). At first discharge, dysphagia was reduced (62.1%) and respiratory complications increased (41.1%). Tracheostomy was removed during the first stay in 55.3% patients, during follow-up in 13%, without failures among the 80 patients who followed the protocol. Four decannulations performed against protocol recommendations resulted in three failures. Decannulation was mainly prevented by the persistence of respiratory complications and dysphagia that constituted a relevant risk of aspiration and suffocation; decannulation was mainly postponed because of respiratory complications and breath-holding spells in very young children.

CONCLUSIONS

By applying a decannulation protocol that privileges safety over quickness, we encountered no failure. Respiratory complications and dysphagia that lead to supraglottic stagnation, and breath-holding spells, are key elements to consider before performing decannulation in pediatric patients.

Diagnostic and Therapeutic Management of a First Unprovoked Seizure in Children and Adolescents With a Focus on the Revised Diagnostic Criteria for Epilepsy

By definition, unprovoked seizures are not precipitated by an identifiable factor, such as fever or trauma. A thorough history and physical examination are essential to caring for pediatric patients with a potential first unprovoked seizure. Differential diagnosis, EEG, neuroimaging, laboratory tests, and initiation of treatment will be reviewed. Treatment is typically initiated after 2 unprovoked seizures, or after 1 seizure in select patients with distinct epilepsy syndromes. Recent expansion of the definition of epilepsy by the ILAE allows for the diagnosis of epilepsy to be made after the first seizure if the clinical presentation and supporting diagnostic studies suggest a greater than 60% chance of a second seizure. This review summarizes the current literature on the diagnostic and therapeutic management of first unprovoked seizure in children and adolescents while taking into consideration the revised diagnostic criteria of epilepsy.

Pathological crying and emotional vasovagal syncope as symptoms of a dorsally exophytic medullary tumor

A 3-year-old boy with a dorsally exophytic tumor arising from the rostral medulla presented with a chief complaint of a change in his emotional behavior, most notably anxiety and paroxysmal crying often followed by syncope. Magnetic resonance imaging revealed that the tumor pushed on the dorsal surface of the medulla and displaced the medulla anteriorly, and also displaced the cerebellar vermis upward and slightly posteriorly. Tissue from a partial resection was diagnosed as a pilocytic astrocytoma. The symptoms did not improved after surgery, but did improve clinically after chemotherapy with vincristine and carboplatin, at which time MR showed a reduction in tumor size. We diagnosed the paroxysmal crying as 'pathological crying' and the syncope with increased anxiety as 'emotional vasovagal syncope'. This case stresses the importance of recognition of this rare presentation as an indication of a medullary tumor.

Novel Findings in Breath-Holding Spells: A Cross-Sectional Study

The mechanism of breath-holding spells (BHS) is not fully understood and most probably multifactorial; so, this study was designed to clarify the pathophysiology of BHS through assessing some laboratory parameters and electrocardiographic (ECG) changes which might be contributing to the occurrence of the attacks. Another aim of the study was to evaluate the differences in the pathophysiology between pallid and cyanotic types of BHS. This was a prospective study performed in Zagazig University Hospitals. Seventy-six children diagnosed with BHS were included as follows: 32 children with cyanotic BHS, 14 children with pallid BHS, and 30 healthy children as a control group. All children were subjected to the following: full history taking, clinical examination, and laboratory work up in the form of CBC, serum iron, ferritin, and zinc levels. Twenty-four hours ambulatory ECG (Holter) recording was also performed. No significant statistical difference was found between cyanotic and pallid groups regarding family history of BHS, severity, and precipitating factors of the attacks. Frequent runs of respiratory sinus arrhythmia (RSA) during 24  hours ECG were significantly higher in children with BHS; the frequency of RSA was significantly correlated with the frequency (severity) of the attacks. Low serum ferritin was significantly associated with BHS groups but not correlated with the severity of the attacks. Autonomic dysregulation evidenced by frequent RSA is considered to be an important cause of BHS in children and is correlated with the frequency of the attacks. Low serum ferritin is additional factor in the pathophysiology. Both pallid and cyanotic BHS are suggested to be types of the same disease sharing the same pathophysiology.

Improved quality of life after treatment of prolonged asystole during breath holding spells with a cardiac pacemaker

Objectives:

To validate the physical and psychological effectiveness of cardiac pacing in pediatric patients with breath-holding spells (BHS) and prolonged asystole.

Materials and Methods:

The records and clinical data of all the patients with BHS who presented to our center in the period of 2001–2013 were reviewed. All patients who received cardiac pacemaker implantation for prolonged asystole during BHS were included. In addition, the parents were asked to fill out a standardized quality of life (QOL) questionnaire.

Results:

Seven patients were identified. The mean onset of symptoms was 7 month (1–12 months) of age, documented asystole was 12–21 seconds, and a permanent cardiac pacemaker device was implanted at a mean age of 23 months (8 months–3.9 years). No pacemaker related adverse events were recorded. Follow up showed immediate resolution from spells in four cases (4/7). Two patients (2/7) showed significant reduction of frequency and severity of spells, with complete elimination of loss of consciousness (LOC). One patient (1/7) with an additional neurologic disorder continued to have minor pallid BHS and eventually switched from pallid to cyanotic spells without further detection of bradycardia or asystole in holter examination. QOL questionnaire revealed significant reduction in subjective stress levels of patients (P = 0.012) and parents (P = 0.007) after pacemaker implantation.

Conclusion:

Cardiac pacing using appropriate pacemaker settings seems effective in the prevention of LOC and reduction of the frequency of BHS. Our results imply a reduction of subjective stress levels of patients and parents as well as an increased quality of everyday life. After all, randomized controlled trials of the influence of cardiac pacemaker implantation on subjective stress levels in patients with BHS are needed.

Assessment of both serum S-100B protein and neuropeptide-Y levels in childhood breath-holding spells

OBJECTIVE

Breath-holding spells are common paroxysmal events in children. Although the spells have a benign prognosis in the long term, they may be complicated by loss of consciousness, tonic-clonic movements, and occasionally seizures. Hence, this study aimed to measure the levels of serum S-100B proteins and neuropeptide-Y in the blood of children who experience breath-holding spells.

METHODS

The study groups consisted of 45 patients (13 females, 32 males) with breath-holding spells and a control group of 32 healthy individuals (12 females, 20 males). The serum S-100B levels were measured using commercially available ELISA kits. The neuropeptide-Y levels in the serum were measured with RayBio® Human/Mouse/Rat Neuropeptide Y ELISA kits.

RESULTS

The mean serum S-100B protein level of the breath-holding spells group was 56.38 ± 13.26 pg/mL, and of the control group, 48.53 ± 16.77 pg/mL. The mean neuropeptide-Y level was 62.29 ± 13.89 pg/mL in the breath-holding spells group and 58.24 ± 12.30 pg/mL in the control group. There were significant differences between the groups with respect to serum S-100B protein levels (p = 0.025), while there was no statistically significant difference in neuropeptide-Y levels between the breath-holding spells group and the control group (p = 0.192).

CONCLUSIONS

The findings of this study suggest that frequent and lengthy breath-holding may lead to the development of neuronal metabolic dysfunction or neuronal damage which is most likely related to hypoxia. In light of these findings, future studies should be conducted using biochemical and radiological imaging techniques to support these results.

Laughter is not always funny: breath-holding spells in familial dysautonomia

Familial dysautonomia (FD) is a genetic disease characterized by primary autonomic dysfunction including parasympathetic hypersensitivity. Breath-holding spells (BHS) are believed to be caused by autonomic dysregulation mediated via the vagus nerve and increased in patients with a family history of BHS. Details and understanding of its pathophysiology are lacking. In this retrospective study of patients with FD, the incidence of BHS was higher at 53.3%, compared with previous studies in normal children. Laughter as a precipitating factor for BHS has not been previously reported in FD and occurred in 10% of patients in this study. Lower lung volumes, chronic lung disease, chronic CO2 retention, and inadequate autonomic compensation occur in those with FD leading to a higher incidence and severity of BHS when crying or laughing. Thus, FD may be a good model for understanding manifestations of the autonomic nervous system dysfunction and contribute to our knowledge of BHS mechanisms.

Pacemaker in complicated and refractory breath-holding spells: when to think about it?

BACKGROUND

Breath-holding spells (BHS) are benign non-epileptic paroxysmal events of infancy, rarely occurring with high frequency and complicated by prolonged syncope, convulsions and even status epilepticus. In these cases response to medical treatment is often unsatisfactory. Pacemaker implantation is a possible therapeutic option, but its indications, efficacy and complications have not been clarified yet.

OBJECTIVE

To report a new case of BHS treated with pacemaker and to review its indications and efficacy in patients with severe BHS.

METHODS

We extensively searched the literature in PubMed on cardiac pacing in patients with BHS and we described a new case.

RESULTS

A previously healthy boy presented at the age of 4 months with frequent BHS inconstantly associated to prolonged syncope and post-anoxic non-epileptic and epileptic seizures. Parental reassurance, iron supplementation and piracetam were ineffective. After cardiac pacing at the age of 16 months, BHS and their complications disappeared. We identified 47 patients with BHS treated with pacemaker in the literature. Based on the available data, in all patients asystole or marked bradycardia were documented during BHS or stimulating maneuvers; syncope complicated BHS in 100% of cases and post-anoxic convulsions in 78.3%. Medical treatment before pacing, when administered, was ineffective or poorly tolerated. After pacing, BHS complications disappeared in 86.4% of cases, and decreased in 13.6%. Technical problems with the device were reported in 25.7% of patients and mild medical complications in 11.4%.

CONCLUSIONS

Pacemaker could be reasonably considered in subjects with frequent and severe BHS, poor response to medications, and demonstration of cardioinhibition during spells.

Transient loss of consciousness and syncope

Syncope describes a sudden and brief transient loss of consciousness (TLOC) with postural failure due to cerebral global hypoperfusion. The term TLOC is used when the cause is either unrelated to cerebral hypoperfusion or is unknown. The most common causes of syncopal TLOC include: (1) cardiogenic syncope (cardiac arrhythmias, structural cardiac diseases, others); (2) orthostatic hypotension (due to drugs, hypovolemia, primary or secondary autonomic failure, others); (3) neurally mediated syncope (cardioinhibitory, vasodepressor, and mixed forms). Rarely neurologic disorders (such as epilepsy, transient ischemic attacks, and the subclavian steal syndrome) can lead to cerebal hypoperfusion and syncope. Nonsyncopal TLOC may be due to neurologic (epilepsy, sleep attacks, and other states with fluctuating vigilance), medical (hypoglycemia, drugs), psychiatric, or post-traumatic disorders. Basic diagnostic workup of TLOC includes a thorough history and physical examination, and a 12-lead electrocardiogram (ECG). Blood testing, electroencephalogram (EEG), magnetic resonance imaging (MRI) of the brain, echocardiography, head-up tilt test, carotid sinus massage, Holter monitoring, and loop recorders should be obtained only in specific contexts. Management strategies involve pharmacologic and nonpharmacologic interventions, and cardiac pacing.

Approach to syncope and altered mental status

Children who present with an episode of altered mental status, whether transient or persistent, present a diagnostic challenge for practitioners. This article describes some of the more common causes of altered mental status and delineates a rational approach to these patients. This will help practitioners recognize the life-threatening causes of these frightening presentations as well as help avoid unnecessary testing for the more benign causes.

Diverse presentation of breath holding spells: two case reports with literature review

Breath holding spells are a common and dramatic form of syncope and anoxic seizure in infancy. They are usually triggered by an emotional stimuli or minor trauma. Based on the color change, they are classified into 3 types, cyanotic, pallid, and mixed. Pallid breath holding spells result from exaggerated, vagally-mediated cardiac inhibition, whereas the more common, cyanotic breathholding spells are of more complex pathogenesis which is not completely understood. A detailed and accurate history is the mainstay of diagnosis. An EKG should be strongly considered to rule out long QT syndrome. Spontaneous resolution of breath-holding spells is usually seen, without any adverse developmental and intellectual sequelae. Rare cases of status epilepticus, prolonged asystole, and sudden death have been reported. Reassurance and education is the mainstay of therapy. Occasionally, pharmacologic intervention with iron, piracetam; atropine may be of benefit. Here we present 2 cases, one of each, pallid and cyanotic breath holding spells.

Prolonged post-hyperventilation apnea in two young adults with hyperventilation syndrome

BACKGROUND

The prognosis of hyperventilation syndrome (HVS) is generally good. However, it is important to proceed with care when treating HVS because cases of death following hyperventilation have been reported. This paper was done to demonstrate the clinical risk of post-hyperventilation apnea (PHA) in patients with HVS.

CASE PRESENTATION

We treated two patients with HVS who suffered from PHA. The first, a 21-year-old woman, had a maximum duration of PHA of about 3.5 minutes and an oxygen saturation (SpO2) level of 60%. The second patient, a 22-year-old woman, had a maximum duration of PHA of about 3 minutes and an SpO2 level of 66%. Both patients had loss of consciousness and cyanosis. Because there is no widely accepted regimen for treating patients with prolonged PHA related to HVS, we administered artificial ventilation to both patients using a bag mask and both recovered without any after effects.

CONCLUSION

These cases show that some patients with HVS develop prolonged PHA or severe hypoxia, which has been shown to lead to death in some cases. Proper treatment must be given to patients with HVS who develop PHA to protect against this possibility. If prolonged PHA or severe hypoxemia arises, respiratory assistance using a bag mask must be done immediately.

Syncopes and other paroxysmal events

Paroxysmal nonepileptic disorders are very frequent in infants and children and pediatric neurologists need to be as familiar with them as with epileptic seizures. Syncopes are the most important of these episodic disorders and amongst the syncopes the various subtypes of so-called neurally mediated syncopes (vagal, vasovagal, and so forth) predominate. In such syncopes there is almost always a trigger or provoking situation and this is the major clinical clue to the diagnosis. Whatever the mechanism of a syncope it is commonly "convulsive" in that there is a motor element, with tonic extensions and arrhythmic nonepileptic spasms ("jerks"). This everyday situation must be distinguished from the much less common combination of a syncope and a true epileptic seizure. In such anoxic-epileptic seizures the epileptic component is usually clonic, with rhythmic or semi-rhythmic jerks quite different from the arrhythmic spasms of the usual nonepileptic convulsive syncope. Syncope from compulsive Valsalva maneuver may be extremely frequent in affected (usually autistic) children. Diagnosis is easy if one obtains a video recording with audio: the premonitory hyperventilation stops leaving 11 seconds of silence before the tonic extension that signifies the syncope. Syncopes of more serious kind include those in long QT syndrome, hyperekplexia, paroxysmal extreme pain disorder, and congenital myasthenia; each has recognizable characteristics. Other nonsyncopal nonepileptic paroxysmal disorders are described further in the text.

Double-blind, placebo-controlled trial on the effect of piracetam on breath-holding spells

Breath-holding spells (BHS) are apparently frightening events occurring in otherwise healthy children.The aim of this study was to evaluate the efficacy of piracetam in the treatment of breath-holding spells. Forty patients with BHS (who were classified into two groups)were involved in a double-blinded placebo-controlled prospective study. Piracetam was given to group A while group B received placebo. Patients were followed monthly for a total period of 4 months. The numbers of attacks/month before and monthly after treatment were documented, and the overall number of attacks/month after treatment was calculated in both groups. The median number of attacks/month before treatment in the two groups was 5.5 and 5,respectively, while after the first month of treatment, it was 2 and 5, respectively. The median overall number of attacks/month after treatment in both groups was 1 and 5, respectively.There was a significant decline of number of attacks after piracetam treatment compared to placebo (p value<0.001). There were no reported side effects of the piracetam throughout the study period. In conclusion, piracetam is a safe and effective drug for the treatment of breath-holding spells in children.

Piracetam in severe breath holding spells

BACKGROUND

Breath holding spells (BHS) are apparently frightening events occurring in otherwise healthy children. Generally, no medical treatment is recommended and parental reassurance is believed to be enough, however, severe BHS can be very stressful for the parents and a pharmacological agent may be desired in some of these children.

OBJECTIVE

In this prospective study aim was to determine the usefulness of piracetam as prophylactic treatment for severe BHS.

METHODS

Children were recruited from Neurology Clinic in Children's Hospital, Islamabad between January 2002 to December 2004. Diagnosis of BHS was based on characteristic history and normal physical examination. Piracetam was prescribed to those children who were diagnosed as severe BHS in a dose ranging from 50-100 mg/kg/day. Iron supplements were added if hemoglobin was less than 10 gm%. Patients were seen at 2-4 weeks interval and follow-up was continued until 3 months after the cessation of drug therapy.

RESULTS

Fifty-two children were enrolled in the study, 34 boys and 18 girls. Ages ranged from 4 weeks to 5 years with mean age of 17 months. In 81% of children, spells disappeared completely and in 9% frequency was reduced to less than one per month and of much lesser intensity. Prophylaxis was given for 3-6 months (mean 5) duration.

CONCLUSIONS

Piracetam is an effective prophylactic treatment for severe BHS.

Cyanotic breath-holding spells in children respond to adenotonsillectomy for sleep-disordered breathing

Children with breath-holding (BH) spells may demonstrate sleep-disordered breathing (SDB) during polysomnography. We studied five young children with cyanotic spells retrospectively and found both SDB and a response to adenotonsillectomy. We therefore proceeded with a prospective investigation of treatment for SDB in children with comorbid cyanotic spells. Nineteen children with cyanotic BH spells were identified and enrolled in the prospective study. Parents chose either treatment or observation. Fourteen children underwent complete SDB evaluation and treatment trials while five selected observation only (control group). Sleep and sleep-surgery specialist evaluation and polysomnography revealed the presence of a narrow upper-airway and an abnormal respiratory disturbance index in all 14 children. Nasal CPAP was not successful, but adenotonsillectomy performed near 14 months of age eliminated SDB. BH spells were eliminated 1 month after surgery, while they persisted to the end of the study (24 months of age) in the control group. In conclusion, the presence of cyanotic BH should prompt investigation and polysomnography for possible SDB. Independent treatment of SDB may hasten resolution of BH spells in these cases.

Clinical diagnosis of syncopes (including so-called breath-holding spells) without electroencephalography or ocular compression

A recent article in this journal suggested that ocular compression during electroencephalography was useful in distinguishing "breath-holding spells and syncope" from epileptic seizures. The method proposed involved measurement of the RR interval on the simultaneously recorded electrocardiographic trace and determining both the absolute RR lengthening and the change in RR interval as compared with the baseline value. It is argued by the present author that this is not an appropriate way to come to a diagnosis in episodic loss of consciousness in children. It is pointed out that so-called "breath-holding spells" are reflex syncopes and that the diagnosis of reflex syncopes should be by clinical history, even if this means delaying the diagnosis until a future consultation. Published evidence on the nature and clinical diagnosis of reflex syncopes in infants and children is reviewed in depth. It is concluded that routine electroencephalography is not an appropriate investigation when the diagnosis of episodic loss of consciousness is in doubt and has the implicit danger of false positive "abnormality". Aside from scientific exploration of the developing autonomic nervous system, the only current indication for diagnostic ocular compression is to induce a syncope so that its nature may be better understood. Such a circumstance might be a history of an apparent reflex syncope but with atypical features, including prolonged post-syncopal unconsciousness such as might indicate epileptic absence status. Several additional investigations of a primarily cardiological nature may be indicated in some cases, but a wait-and-see policy is usually to be preferred.

Sudden death in Lesch-Nyhan disease

To increase awareness of sudden and unexpected death in Lesch-Nyhan disease (LND) and to explore its potential causes, we report the anteceding clinical features and laboratory evaluations of five males with LND who ultimately experienced sudden and unexpected death, along with three additional males who suffered serious respiratory events during life. The ages of patients ranged from 2 to 45 years. The cause of sudden death in LND appears to have a respiratory rather than a cardiogenic basis. All cases cannot be linked readily with a single respiratory process. Instead, different respiratory processes appear to operate in different cases. These may include aspiration, laryngospasm, central apnea, cyanotic breath-holding spells, and high cervical spine damage. Better recognition of these processes will help to guide appropriate workup and management that could include chest imaging, endoscopy of the airways, polysomnography, electroencephalogram, and brain and/or spine imaging.

Usefulness of ocular compression during electroencephalography in distinguishing breath-holding spells and syncope from epileptic seizures

Episodes of syncope or breath-holding spells are often misdiagnosed as epileptic events. The purpose of this study was to assess the usefulness of an electroencephalogram (EEG) with ocular compression to distinguish breath-holding spells and syncope from epileptic seizures. A retrospective analysis was performed on the EEG records of all children on whom ocular compression was performed from 2000 to 2003. Data from 116 patients with a clinical diagnosis consistent with either syncope or breath-holding spells were compared with a group of 46 patients with epilepsy. The RR interval during ocular compression was significantly higher in syncope patients compared with patients with epilepsy (P < .005). Using 2 seconds of asystole as the cutoff, the sensitivity of ocular compression was 26%, with 100% specificity. The change in RR interval from baseline to ocular compression also distinguished patients with breath-holding spells and syncope from patients with epilepsy. Even a small increase of 0.5 seconds in the RR interval demonstrated a sensitivity of 46%, with a specificity of 98%. Ocular compression performed during an EEG is useful in distinguishing patients with breath-holding spells and syncope from those with epileptic seizures. A requirement of a 2-second period of asystole with ocular compression excludes many patients. Our data indicate that an RR interval increase of 0.5 seconds over baseline identifies additional patients with increased vagal tone. Prompt and accurate diagnosis of the etiology of loss of consciousness might preclude the need for further extensive and expensive evaluation and reduce patient and parental distress.

Anoxic-epileptic seizures: observational study of epileptic seizures induced by syncopes

AIMS

To describe a large series of children with anoxic-epileptic seizures (AES)--that is, epileptic seizures induced by syncopes.

METHODS

Retrospective case-note review in a tertiary paediatric neurology unit. For all 27 children seen with a definite diagnosis of AES between 1972 and 2002, a review of clinical histories, videotapes, and EEG/ECG studies was undertaken. Main outcome measures were: age of onset, frequency and type of syncopes; age of onset and frequency of AES; type and duration of induced epileptic seizures; effect of treatment of syncopal and epileptic components.

RESULTS

Median age of onset of syncopes was 8 months (range 0.2-120), frequency 2 in total to 40/day, median total approximately 200. Syncopes were predominantly reflex asystolic (RAS), prolonged expiratory apnoea (cyanotic breath-holding spells), or of mixed or uncertain origin; there was one each of ear piercing and hair grooming vasovagal syncope and one of compulsive Valsalva. Median age of onset of AES was 17 months (range 7-120), frequency from total 1 to 3/day, median total 3. The epileptic component was almost always bilateral clonic; three had additional epilepsy, one each with complex partial seizures, myoclonic absences, and febrile seizures plus. Median duration of epileptic component was 5 minutes (range 0.5-40, mean 11). Cardiac pacing prevented RAS in two patients: most other anti-syncope therapies were ineffective. Diazepam terminated the epileptic component in 6/8. Valproate or carbamazepine abolished AES in 5/7 without influencing syncope frequency.

CONCLUSIONS

Although uncommon compared with simple syncopes, syncope triggered epileptic seizures (AES) are an important treatable basis of status epilepticus.

Ictal pallor is associated with left temporal seizure onset zone in children

PURPOSE

To describe the frequency, localizing and lateralizing value of ictal pallor (IP) in children with focal epilepsy.

METHODS

A retrospective review of medical charts and 514 archived seizures from 100 children < or =12 years old was performed. All patients had a history of therapy-resistant partial epilepsy and a seizure-free postoperative outcome. The presence and attributes of IP were analyzed.

RESULTS

No IP was detected by reviewing the archived seizures. According to medical charts, IP was reported in 11/100 children (six girls) aged 14 months to 12 (mean 5.5+/-4.1) years. Ten of them had temporal lobe epilepsy (p=0.046) - including nine temporo-medial and one temporo-lateral cases - while only one child had an extratemporal (parietal lobe) seizure onset zone. All but one children had left-sided operation (p=0.01). Presence of IP had a positive predictive value of 91% for both lateralizing (left) and localizing (temporal lobe) the seizure onset zone. History of IP was neither age-, epilepsy onset-, nor gender-related.

CONCLUSIONS

Ictal pallor is a frequently reported autonomic symptom during childhood focal seizures but difficult to assess purely by video-monitoring. It has a high predictive value to localize the seizure onset zone to the left temporal region already in very young patients.

Asystole during outbursts of laughing in a child with Angelman syndrome

A girl with Angelman syndrome had recurrent episodes of ventricular asystole and syncope caused by severe vagal hypertonia during outbursts of laughing. After intravenous administration of atropine, laughing no longer induced asystole or syncope. The vast majority of patients with Angelman syndrome have seizures. Since hypoxia associated with asystole can provoke convulsions, we suggest electrocardiographic evaluation of Angelman patients with symptomatic bradycardia, loss of consciousness, or convulsions related to laughing.

Cyanotic breath-holding spell: a life-threatening complication after radical resection of a cervicomedullary ganglioglioma

Cyanotic breath-holding spell is a benign and self-limiting disease of young children but occasionally associated with sudden, unexpected death. The authors report a rare case in a 2-year-old girl with a severe form that started after radical resection of a cervicomedullary ganglioglioma. She was admitted to our hospital because of delayed and unstable gait. Since magnetic resonance imaging showed a cervicomedullary tumor, she underwent a radical resection and histology showed the tumor to be a ganglioglioma. Postoperatively, the function of the lower cranial nerves and cerebellum deteriorated and hemiparesis on the left became apparent, but she returned to the preoperative state in a few months. In addition, mild sleep apnea (Ondine curse) and severe cyanotic breath-holding spells occurred. The former responded to medication but the latter failed and continued several times per day with a rapid onset and progression of hypoxemia, loss of consciousness, sweating and opisthotonos. Five months after the operation, the patient returned home with a portable oxygen saturation monitor equipped with an alarm. This case indicates that cyanotic breath-holding spell, as well as sleep apnea, is critical during the early postoperative period. This is the first report observing that such spells may occur as a complication of radical resection of a cervicomedullary tumor.

Breath-holding spells in somatoform disorder

Breath-holding spells (BHS) are commonly seen in childhood. However, there are no case reports of BHS occurring in adolescents or young adults. We report two young adult cases and discuss the pathogensis, both physically and psychologically. BHS occurred for 1-2 minutes after hyperventilation accompanied by cyanosis in both cases. Oxygen saturation was markedly decreased. Each patient had shown distress and a regressed state psychologically. These cyanotic BHS occurred after hyperventilation, and we considered that a complex interplay of hyperventilation followed by expiratory apnea increased intrathoracic pressure and respiratory spasm. Breath-holding spells can occur beyond childhood.

Syncope in childhood

Syncope in childhood is very common. The vast majority of episodes are benign, and are due to neurocardiogenic syncope. Only a minority are due to something potentially more serious or life threatening. The diagnosis and differentiation of benign from more serious causes of syncope is made primarily by the history. Investigations are often unfruitful. The mainstay of management in neurocardiogenic syncope is reassurance. An increase in dietary fluid and salt can be helpful. Drug treatment is reserved for those with more frequent and severe attacks. Cardiac pacemakers should be reserved for those with very severe symptoms who are refractory to drug therapy.

Adolescent asystolic syncope

When the etiology of syncope is considered, age is a major parameter. Breath-holding spells are thought of as an entity of early childhood, whereas neurogenic syncope is limited to older children and adults. Both entities, however, involve a similar derangement of the autonomic nervous system. We report an adolescent with a history of breath-holding spells presenting to our institution with neurogenic syncope. Her response to vagal stimulation is consistent with that seen by other investigators in both entities. We propose that pallid breath-holding spells and neurogenic syncope are the same entity.

A pacemaker for asystole in breath-holding spells

Two cases of young children with frequent severe breath-holding spells complicated by prolonged asystole and seizures are reported. A ventricular pacemaker was implanted in each child, and both have subsequently remained free of syncope, although they continue to exhibit breath-holding behaviour.

Evaluation and treatment of syncope in infants

Syncope in the infant and newborn occurs as a loss of consciousness due to a variety of etiologies. Because syncope at this age may be a harbinger of sudden infant death, the symptom provokes anxiety and challenges clinicians to identify those babies with an increased risk for life threatening events. Recently introduced diagnostic tests and advances in molecular biology offer promising potential, but the population at risk remains unknown. Controversy surrounds: many potential risk factors; the value of home monitoring; and appropriate preventive and therapeutic strategies. This article reviews the differential diagnosis of syncope in children less than 18 months of age, with particular attention to those diagnoses and problems specific to the evaluation and treatment in this age group. Recommendations are presented for an efficient evaluation, which must include a careful history, complete physical examination and thorough investigation of the family history and home environment. In addition, specific diagnostic tests and a practical approach to treatment are suggested.