Tuesday, August 7, 2012
Though pallid breath-holding spells are less frequent than the cyanotic variety, most pediatric practitioners will be obliged to deal with an occasional patient presenting with such spells. The spells usually begin with a head or upper body bump or injury. The injury appears to trigger breath-holding, followed by loss of color in association with bradycardia followed by loss of consciousness. In the most severe cases the bradycardia can actually be brief periods of asystole. If the event lasts for more than a few seconds the child will manifest increase tone of the trunk and extremities. The episode can have associated incontinence and behavior reminiscent of a post-ictal state. While most patients with pallid breath-holding spells have milder degrees of bradycardia for which management is expectant and providing reassurance, when the episodes of asystole are prolonged and frequent, concern regarding ischemic brain injury has led to the use of a cardiac pacemaker to avoid the prolonged asystole. Dr. Mark Walsh et al. (doi: 10.1542/peds.2011-1257) at Cincinnati Children’s Hospital’s Heart Institute have performed a trial of the use of fluoxetine on patients referred for pacing with severe pallid spells. Though the numbers are small and a larger study is required to confirm the observation, it appears fluoxetine will often (80%) be effective treatment and avoid the need for placing a cardiac pacemaker.
Posted by Dr. Lewis R. First at 12:01 AM