EEG and ECG are overused in children with breath-holding spells

Electrocardiography (ECG) and electroencephalography (EEG) studies are conducted far more often than is necessary in children who experience breath-holding spells (BHSs). This was the main finding of a retrospective study in 519 Swedish patients younger than 10 years who were diagnosed with BHS during a 15-year period.

In most patients, BHS began and was diagnosed before the age of 2 years, and 26 patients (2.6%) were 3 months or younger at onset. Of the 61 children (11.8%) with comorbidities, asthma was the most frequent culprit. Anger was the most common trigger (in approximately half of patients), followed by pain and head trauma. Many patients were unresponsive during a spell; 43.4% experienced unconsciousness and 71.5% had seizures.

As for diagnostic procedures, although EEG was performed in 30.4% of patients, the study findings indicated pathology in only 6 children (3.6%), 4 of whom received a concomitant epilepsy diagnosis. An ECG was performed in 45.1% of patients, with pathology indicated in only 2 patients (0.9%). Blood samples were investigated at diagnosis in 37.2% of patients, and 10 patients (5.6%) had anemia, 2 of whom had iron deficiency. Another 13 patients had signs of iron deficiency.

Based on these results and those of earlier studies, investigators developed an algorithm indicating that only 7.7% of patients with BHS require an ECG at BHS diagnosis, a much lower proportion than the 45.1% of those who had undergone the test in the study sample. In addition, although almost one-third of children in the study group received an EEG, the algorithm would have called for the EEG in none of these children because they all had typical spells. Investigators also noted that they found pathological hemoglobin and iron levels in many patients who underwent blood analysis. As a result, their algorithm suggests an increase in blood sampling to recognize iron deficiency and anemia.

THOUGHTS FROM DR FARBER:

I was taught that a classic BHS, diagnosed by careful history, did not require any workup. Findings from this study support this with a useful algorithm, although it does suggest testing for iron deficiency (simple enough to do) in children with more than 1 episode. The authors do not routinely recommend an EEG, even though more than 70% of children (a huge number in my experience) had seizures with the BHS.
Reference:

Schmidt SH, Smedenmark J, Jeremiasen I, Sigurdsson B, Eklund EA, Pronk CJ. Overuse of EEG and ECG in children with breath-holding spells and its implication for the management of the spells. Acta Paediatr. 2024;113(2):317-326. doi:10.1111/apa.17020