Breath-holding spells in children

Original post on 10 April 2007

What is a Breath holding spell?
Breath holding spell is a scary event for a parent to witness. The child suddenly goes motionless, as if lifeless, with no breathing at all. Frightened parents may fear the worst and initiate mouth-to-mouth breaths and even chest compressions.

Traditionally breath holding spells have been divided into 2 kinds. One which is associated with bluish discoloration (cyanosis) of the lips, tongue, face or even the whole body. These are called cyanotic breath holding spells. The other type is called the Pallid breath holding spell. In this type the child becomes pale and floppy during the episode.
In both types there is an inciting factor that triggers the event. This may be a sudden painful experience (fall, injury….), or a sudden startling or an upsetting event (like scolding).

How does the breath holding spell occur?
There is usually a trigger event that initiates the attack/ episode. In very small infants this trigger may not always be noticeable. In most cases this provoking or triggering event causes the child to cry. Very strong, sustained crying leads to progressive expulsion of air in the lungs (breathing out) ending in apnea (cessation of breathing). In Dhivehi language this can best be described with the phrase “romun romun gos hidhun”. Sometimes forceful crying may not be noticed. For instance it is common for the crying to be very brief. There may be instances where there isn’t much or any crying.
In some of the cases of breath holding spells the period of cessation of respiration lasts long enough to cause seizure-like activity with stiffening of the body, jerky movements of limbs and opisthotonus (arching of the back – idhifushah dhemun).

What is the common age when these attacks occur?
Breath holding spells are rare before the age of 6 months. The attacks peak at around 2 years of age and usually disappear by about 5 years of age. It is common for the attacks to occur repeatedly and can sometimes occur several times within a few hours.

Is it something that the child does consciously?
Many experts on these events believe that in older kids the breath holding spell is brought on by the child in an attempt to change their environment and the response from the care-givers in much the same way as temper-tantrums (whether consciously or sub-consciously). With this view many experts believe that in these cases the best approach is behaviour modification by changes in parenting. Interventions such as placing the child safely in bed and refusing to cuddle or carry until recovery is complete has been used successfully.
This approach is not always accepted by parents who are concerned about the events and considers them to be life threatening events. Many parents initiate mouth to mouth breathing and other measures. This is not required in cases where the events are stereotypical and are clearly brought on by the will of the child.
There is some debate regarding the occurrence of the same events in infants less than 6 months. Although it has been documented to occur in this age group, it is much rare and the mechanisms are believed to be different. It is believed to be unlikely that the events are brought on by a conscious effort by the child. The most common observation in this age group is that the child cries very strongly followed by breath holding (which is associated with cyanosis and stiffening or jerky movements of the body). The child would spontaneously recover without any assistance.

Does the event cause damage to the brain?
Brain waves have been monitored in kids who have experienced these events. EEG is invariably normal. Statistically these has been no evidence that there is any increased incidence of epilepsy. There is however an association with behavioral changes in older kids, in whom it is believed that the breath holding spells are the result of behaviour changes and not vice versa.

When should a parent be concerned about apnea?
During a breath holding spell the main concern of the parent is that the cessation of respiration could caused the brain to be damaged because of lack of oxygen. The breath holding episode are usually of a short duration, a few seconds to less than about 1 minute. This may seem a lot longer to a parent or an on-looker witnessing the event. It may be difficult for that person to remain calm and do nothing. However, it has been shown that there is no need to do any thing during this short spell. The best thing that one can do is to place the child safely away from harms way and observe.
Many parents want to know, how long they should wait before doing something to help. If the episode lasts longer than described above, assistance in breathing is usually initiated. There is no convincing evidence whether this is needed or not.

What can be done to help?
Although easier said than done, staying calm is perhaps the best thing one can do. This will enable the person to be more objective. I must emphasize here that there is usually no need to do anything! There will be complete recovery with no long term effects. It helps greatly if one is trained in first aid and basic life support skills.

If there is concern about choking, placing the child over the lap face down and giving a couple of gentle but firm blows to the back between the shoulder blades can help to expel the object causing choking. This maneuver is only helpful if there is choking.

If an object is clearly seen within the mouth it may be removed. However, it is no longer recommended to do a blind finger sweep of the mouth. It could cause more damage.
Gentle physical stimulation may initiate breathing in the child. This can be achieved by flicking the sole of the feet or rubbing the back.

Rescue breaths may be required if the apnea lasts longer. This can be done by placing the helpers mouth over the child’s mouth and nose (if mouth only- then the nose would need to be pinched to close it). It is best if the helper takes a fresh breath just before placing his mouth over the child’s. The helper then blows gently to inflate the Childs’ lungs. this has to be done gently to prevent damage. A couple of breaths may be all that is needed.

When resuscitation is required, the diagnosis of breath holding spells should be questioned. Other causes should be looked for.

More detailed resuscitation should only be attempted if one is trained in life support skills.

What should not be done?
The child should not be shaken! Shaking can cause damage to the brain and the spinal cord. Some people have given chest compressions believing that it helps in re-establishing breathing. Chest compressions (as seen on TV) is used only when the heart beat is slowed or absent. It does not help in breathing. Chest compressions should only be attempted by someone skilled in life support.Water (whether cold or not) should not be splashed on the child.

Consulting the health care provider.
Especially in those cases where the breath holding spell is the first episode, the child is younger than 6 months or when there are other associated problems or events it is important to have the child seen by a health care provider.

What should we expect to see at the end of the event?
With a breath holding spell the child would return to his or her normal self a few minutes after the event passes. There would be no lasting effects on the child. If there is any concern about any physical signs after the event has passed, the child should be taken to the health care provider.

Constipation in Children

Original Post on 5 Oct 2007 (Edited)

Constipation is the passage of stools with a frequency much less than usual or passage of hard and difficult to pass stools. Different children may have different “normal” frequency of passing stools and may range from soft stools passed every 3-5 days to passage of soft formed stools a couple of times a day.

Is constipation an illness?
Constipation is not an illness per-se. It is rather a symptom of an illness or condition.

What are the common causes of constipation in children?
By far the most common cause of constipation is the lack of dietary fiber. Consumption of highly refined and processed food leads to formation of compact and hard stools because of lack of fiber. Fiber when present leads to formation of softer and less compact stools.
Poor toilet training habits are also increasingly responsible for cases of constipation in children. Inadequate toilet training causes infrequent emptying of the bowels which in turn leads to desiccation of the fecal mass in the rectum to form hard stools. On the other hand, overly vigorous toilet training practices may also lead to constipation. Children may resent having to go to the toilet and may forcibly hold their bowels leading to inadequate and infrequent emptying and formation of hard stools.
Less frequently, constipation may be a symptom of an abnormal intestine or hormonal imbalance. These need to be specifically ruled out in very young children with very severe constipation.

Strategies and concepts in the management of constipation:
Softening stools: There are several ways of ensuring softer stools. In mild cases of constipation simple stool softening measures may be highly effective by themselves.

  • Natural stool softeners: Dietary fiber from vegetables and fruits are very useful. The fiber in vegetables gives shape and less compactness to the formed stools which prevents constipation. Certain fruits and fruit juices contain non-absorbable osmotic sugars like Sorbitol. These sugars cause the stool to retain larger volumes of fluids making them softer and easier to pass. Juice of Pears, Prunes and Apple contain significant amounts of Sorbitol and are very helpful while managing constipation.
  • Medical stool softeners: There are several agents available as stool softener and many practitioners have their favorites. Lactulose is one such agent commonly used in Maldives. It is a safe and effective compound.

Cathartics: These are agents that cause forced bowel movements and evacuation. These are generally not recommended in children and may be counter-productive. These should be use only under medical guidance.

Enemas and rectal stools softeners: stool softening and lubricating agents may be given per rectally in cases of severe constipation or when stools are very hard and painful to pass or when there is pre-existing rectal or anal injury from constipation. These are sometimes very helpful but are not recommended for routine use because of their invasive nature. These too must be used only under medical guidance.

Improving toilet habits: regular bowel emptying to prevent retention and desiccation is a helpful strategy in children who have severe constipation. These will however only be successful along with stool softening strategies. One concept involves aggressive stool softening measures for a few weeks followed by gradual toilet training routine. The success depends on the child accepting use of toilet bowls as a safe and pain free way of emptying bowels.

Strategies I commonly use:
Mild constipation: If the problem is of acute onset and very mild I usually prescribe a short (about a week) course of oral stool softener (mostly Lactulose) followed by changes to diet to include fiber-rich vegetables (like green leafy vegetables) and packed fruit juices (mostly apple, pear and prune juice). This is usually very effective and the feedback I have received from parents has been very positive.

Acute severe constipation (Especially when a child has not made a stool for several days and has hard and difficult to pass stools): I mainly concentrate on minimizing discomfort and preventing the acute constipation changing to a chronic one. My strategy involves aggressive stool softening measures for about a week. They mainly include use of multiple daily doses of an oral stool softener (like Lactulose) along with rectal stool softeners (like glycerine suppositories) for the first few days of treatment. I tell parents to insert the suppositories and to leave the child be, not making him go to the toilet. The reason for this is that I want to give time for the glycering to lubricate and also soften the stools before the child is made to pass stools. I do this because I believe that the child should have minimum discomfort when passing the long delayed stool. Once stools are being passed regularly I would cut down on the number of times oral stool softener is used to about once a day (mainly just before bed time) for another week. During this second week of treatment I would ask the parents to concentrate on introducing fiber-rich food and stool softening fruit juices and to ensure toilet training measures are in place.

Chronic severe constipation: In addition to the management discussed for acute severe constipation, I would usually investigate these children for other less common causes of constipation such as intestinal anomalies and hormonal imbalances. The management strategies would also concentrate on effective toilet training practices. It is absolutely essential that toilet training be initiated after stool softening strategies are in place and working effectively. I believe in a slow, gradual introduction of toilet training. I would sometimes begin by asking the parents to get the child to simply sit on the toilet seat while fully clothed. They don’t have to pass stools. This is done to remove “potty-fear”. Once this is achieved I would ask the parents to get the kids to sit on the potty just wearing their nappies or under garments. They don’t have to pass stools. One this is achieved, over the next few days I would ask the parents to get the child to sit on the potty undressed and ready to pass stool. Allow them to pass stool if they would like to, it is not compulsory. However, whether they pass a stool or not I would ask the parents to wash their bottoms before allowing them to leave the toilet. At this point many of the kids would have realized that they need not fear passing stools. Passing the softened stools does not hurt at all. That alleviates their fear of the potty and passing stools.

One very common misconception among parents and some medical personnel is that constipation can be resolved just by getting the child to drink more water. While it may be true that drinking very little water could lead to some hardening of stools drinking extra amounts of water has not been found by research to be an effective strategy in managing constipation. The extra water is absorbed from the gut and passed out in the urine and has little or no effect on stools.


Original Post: 13 Nov 2008

What is bronchiolitis?

This is a viral illness of the respiratory tract that usually afflicts children of less than 2 years of age. It is characterized by an increased effort of breathing and wheezing following an uppers respiratory tract infection.

What are the symptoms and signs of Bronchiolitis?

Affected children would have a prodromal illness with runny nose and cough for a few days. The illness will be much like a common cold at this stage. Few children may have fever and malaise at this stage. The illness then progresses to involve the lower respiratory tract. This stage is characterized by increasing severity of cough, increased work of breathing and respiratory distress and wheezing.

Is bronchiolitis a severe illness?

In its classical form it may be a very severe illness requiring hospitalization and varying degrees of respiratory support. In the very young, severe illness may result in fatalities. The illness may be particularly severe in those children with congenital heart disease or those with prematurity related lung disease.

What causes Bronchiolitis?

Bronchiolitis is a viral infection. The most commonly identified virus is RSV (Respiratory Syncytial Virus). In western countries where the illness has been studied, there are reports of over 90% of all cases being caused by RSV. Other viruses identified are Influenza, para-influenza and adenoviruses.

Is bronchiolitis seasonal?

In countries with the four seasons, bronchiolitis is predominantly seen in winter. In countries like Maldives an increased number of cases maybe expected during the rainy season.

What is the treatment of Bronchiolitis?

Much work has gone into finding the best treatment for Bronchiolitis at research institutes around the world. In essence what has been agreed upon among the scientific community is that the illness has no specific treatment that acts as a cure. As is the case with most viral infections of the respiratory tract; Bronchiolitis is also best managed with supportive therapy.  Antibiotics have no role in the management and should not be used routinely. No specific antiviral agent has been identified as particularly useful.

Supportive therapy includes use of humidified Oxygen for inhalation, maintaining fluid balance (including use of intravenous fluids where indicated) and monitoring for signs of respiratory insufficiency.

Bronchodilator therapy is used at many centers, initially as a trial and sometimes in the very severely ill children. The most commonly used bronchodilator is salbutamol (ventolin) as nebulisation or inhalers.

Steroids have no routine role and its use in Bronchiolitis is under review at many centers.

Staying Healthy: School Sports Events.

School Sports Events for small children: Staying healthy.[Kids 4-12y age]

Original Post from 4 Aug 2017 (Originally written on request of parents of kids taking part in pre-school inter-school football tournament)

Sport is a great way for kids to enjoy, exercise, make friends, learn life skills and stay healthy. To get the best out of a sports event, especially on a warm, sunny day with plenty of physical activity, staying hydrated and getting appropriate rest periods in between is important.

Here are some points that may help make the event a good experience for everyone, especially the kids.


  • Kids are more likely to get dehydrated at sports events than adults.
  • Kids usually sweat more than adults. This increases risk of dehydration in kids.
  • Kids can get so engrossed in play that they may not, on their own, respond to their body’s cues to drink fluids.
  • Kids tend to get sunburn and heat related health problems more than adults.
  • New and poorly fitting footwear are a common problem at sports events. Sometimes parents get new shoes for their kids for sports events. This isn’t a good idea. Poorly fitting shoes can cause injuries and spoil the whole fun experience. A properly fitting and known-to-be comfortable shoe are preferred and safer.
  • If your child is unwell (with a fever, bad cold, severe cough, etc) on the day of the sports event, OR they have not adequately recovered from a recent illness, do not allow them participation. Their health comes first.

Before sports events

A. Nutrition and hydration: The most important part of preparing for healthy sports event is to eat well and staying hydrated even before starting the event.

  1. Let kids eat a light, high-carb meal a minimum of 4-6h before the start of the sports event. Avoid too much fat and oils in that meal. They may slow down digestion and remain in the stomach for long.
  2. A fruit snack, like a banana, maybe eaten 2h before the start of the event. Make sure not to give more than kid can comfortably eat.
  3. Pre-hydrate with water or electrolyte fluid (like ORS / Hydralyte) to prepare for the event
  • Give 4-8 ounces of plain water 1-2h before start of the event.
  • Offer another 4 ounces of water 15m before start of the event.
  • Do not force the water on child. Encourage and be responsive to kids needs.

B. Plan for a sunny day: if the event involves exposure to sun before, during and after the event, make plans to protect from harmful effects of excessive sun exposure.

  1. Use an appropriate sunscreen (preferably strength SPF30 or more).
  2. Make sure you have tested the sunscreen on kids skin earlier to ensure there is no hypersensitivity to it.
  3. Have shady areas where kids can take shelter.
  4. Between events, plan to get child to wear a hat/cap to protect against sun.

C. Plan for rainy day: if the weather appears to be overcast and there is chance of rain, be prepared. Getting drenched in cold rain after a period of exercise and not being able to get out of the wet clothes can be harmful. Plan to have a covered area as rain shelter. And an extra set of dry clothes maybe important too.

During sports event

D. Nutrition and hydration: plan ahead and keep plain water, electrolyte fluids (like ORS / Hydralyte) and special fruit-snacks* handy to keep the kids hydrated and energized during the event.

  1. Every 20-30 minutes offer about 5 ounces of water or fluid.
  2. Not all kids will drink the whole amount. But offering the fluid is important as kids may not remember themselves.
  3. The water or fluid may be kept cooled so that it helps cool down kids after physical activity.
  4. When longer breaks are anticipated between activities during the event, offer special fruit-snacks* (small chunks of chilled watermelon, cantaloupe, honeydew melon, grapes, banana and orange slices). Do NOT add glucose or salt to these. This is unnecessary and offer no additional health benefits.
  5. Sugary drinks such as Milo, flavored Indomilk, Rani Juice, Jussie, and other such drinks are NOT healthy and must not have a place in healthy sports events.

E. Allow kids to rest in between activities. Sitting or lying down in the shade for a few minutes may be sufficient.

F. Ask them if they need toilet breaks between activities. Kids may become engrossed in play that they may neglect such needs.

G. If kids complain that they are too tired, take their word for it. Let them rest. You may have to consider allowing them to be a spectator for remainder of the sports event. Their health comes first.

H. Be ready for minor first-aid needs. Kids can easily have falls, bumps, abrasions and scratches during sports events. Keep an ice-pack (for bumps and sprains) and disinfectant wash/spray (for minor scratches, abrasions and bruises). Cover the minor abrasions, scratches or bruises only if they are likely to get contaminated during further play.

After the sports event

I. Re-hydration and meal: the aim is to replace all the fluid lost in sweat during the sports event. Plain water and electrolyte solutions (like ORS / Hydralyte) are preferred.

  1. Offer 5-8 ounces of water to be consumed within 2-4h of the end of the sports event.
  2. Plan to have the post exercise meal about 2-4h after the event. A light high-carb meal is best.

J. Allow kids to rest well after the sports event. A quick shower and a nap may be a good idea.

Q. Some kids may complain of aches and pain, especially in the legs on the night of a day with strenuous physical activity. Warm massage and gentle stretching exercises before bed time maybe a good idea to prevent such episodes.

Best wishes and hope teachers, parents and most importantly kids have a fun and enjoyable sports event.