Skip to Main Content

We have a new app!

Take the Access library with you wherever you go—easy access to books, videos, images, podcasts, personalized features, and more.

Download the Access App here: iOS and Android

Many childhood disorders have paroxysmal features. It is therefore not uncommon that these episodes are interpreted as seizures. In this section, common disorders that may mimic epilepsy are emphasized.

Breath-holding spells (BHS) occur most often between the ages of 6 months and 6 years, with a prevalence rate of 4% to 27%1. There may be a familial predisposition to BHS in 20% to 35% of cases.2 The predisposing setting is frustration, anger, fear, or reaction to pain, which leads to crying or a tantrum. The child then holds his or her breath in expiration, often resulting in pallor, cyanosis, or a mixture of both.3 When the spell resolves without loss of consciousness, it is called simple. The child may appear dazed and ultimately lose consciousness and may even have a few convulsive movements or tonic stiffening. Convulsive activity has been seen in up to 55% of children with BHS. The entire episode lasts less than a few minutes, and the child is not impaired for a prolonged period after the attack. Lambroso and Lerman classified the spells in 1960 as pallid, cyanotic, and mixed, in an attempt to separate them into different pathophysiological mechanisms. The etiology is unclear but data suggest excessive centrally mediated sympathetic reflex activity in cyanotic breath-holders, and excessive centrally mediated parasympathetic reflex activity in pallid breath-holders. EEGs during the event fail to show any electrographic seizures; diffuse background slowing of the EEG in the theta-delta range accompanied with slowing of the heart rate is often seen. Conditions besides seizures that can mimic BHS include central apnea due to an Arnold-Chiari malformation, gastroesophageal reflux (GER), prolonged QT syndrome with syncope, brain stem lesions, rage, panic attacks, and Munchausen-en-proxy. Treatment is directed at reassuring the parents of the benign nature of BHS and its ultimate natural remission. Oral iron therapy at 5 to 6 mg/kg/day of elemental iron has been found to be beneficial in some cases.4 The exact mechanism of iron in improving the spells is unclear, but it may act via its effect on serotonin, its degrading enzyme aldehyde oxidase, sympathomimetic neurotransmitter norepinephrine, or its degrading enzyme monoamine oxidase. Use of atropine or scopolamine in refractory pallid breath-holding spells, tetrabenazine or clonidine in refractory cyanotic breath-holding spells, and cardiac pacing in refractory spells accompanied with prolonged asystole have been tried with some success.5 Medications that have been tried on an experimental basis include theophylline, piracetam, naltrexone, acetazolamide, and madroxyprogesterone, but none have definite clinical utility. Educating the parent about intervention during the event including placing in the lateral position to prevent aspiration and applying a gentle thrust on the back to reinitiate respiration is important. Issues regarding the disruptive effects on the parents and extended family and difficulty in obtaining child care and baby-sitting need to be addressed. Seventeen percent go on to develop syncope by teenage years.

Gastroesophageal reflux (GER) signifies the retrograde movement of gastric contents ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.