Paediatrics

at a Glance

Lawrence Miall, Mary Rudolf, Dominic Smith

Case Studies

Case 4: Fits, faints and funny spells

Tommy is 18 months old. For some months now he has been throwing temper tantrums. In the last week these have changed in character and on two occasions he has stopped breathing, turned blue and then gone limp. By the time emergency services have been called he has recovered. Tommy has had no medical problems in the past and is developing normally.

  • (a) What is the differential diagnosis?

    The most likely diagnosis is breath-holding spells. Epilepsy and reflex anoxic seizures should also be considered in the differential diagnosis.

  • (b) How can you distinguish breath-holding spells from other fits, faints and funny spells?

    • Breath-holding spells are characteristically precipitated by crying because of pain or temper. The child takes a deep breath, stops breathing, becomes deeply cyanotic and the limbs extend.

    • Loss of consciousness does not usually occur, but if it does the child recovers rapidly with no postictal signs. Other types of fits, faints and funny spells do not usually have a precipitating event.

    • Pallid (reflexic anoxic) spells can be confused with breath-holding spells, but differ in that they are caused by triggering of the vagal reflex following minor injury.

  • (c) If you were not sure that these were breath-holding spells, what might you ask the family to do?

    Always make sure that you get a description by someone who has observed the event. It can be helpful to ask the family to video an episode.

  • (d) How would you advise the family to manage breath-holding spells?

    Reassurance is required. Parents can become quite terrified of these episodes and as a result may have difficulty in imposing discipline on the child for fear of provoking an attack.

  • (e) What is the prognosis for breath-holding spells?

    These attacks are always benign and resolve before the child reaches school age.

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