A healthy 16-month-old boy has repeated episodes in which, while crying in frustration or anger, he holds his breath in expiration, becomes cyanotic, and briefly loses consciousness for a few seconds before waking and resuming activity. Neurological examination between episodes is normal and EEG is unremarkable. What is the most appropriate management?

• A Start carbamazepine prophylaxis
• B Refer for cardiac pacing evaluation
• C Begin formal behavioral therapy for the parents
• D Reassure the family and evaluate for iron deficiency anemia ✓

Explanation

This is a typical cyanotic breath-holding spell, provoked by anger or frustration, occurring between 6 months and 5 years, and ending spontaneously with an excellent prognosis. Management is firm parental reassurance plus screening for iron deficiency anemia, since iron supplementation reduces spell frequency even in non-anemic children. Anticonvulsants are inappropriate because the EEG is normal and the trigger and sequence differ from seizures. Cardiac arrhythmia (pallid spells with prolonged asystole) is considered only when spells are pallid, prolonged, or provoked by minor surprise.

Reference: Nelson Textbook of Pediatrics, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.