Child while playing has sudden loss of consciousness and appears pale. There is no significant medical history and the child was otherwise healthy. Which of the following is the most probable diagnosis?

Ans. is 'b' i.e., Breath holding spell [Ref.: Nelson 20th/e p. 175)* The clues in the question are that the child was otherwise healthy and that the event might have occurred due to frustration during playing. Although such episodes are precipitated by scolding or upsetting the child, no such history is mentioned in this question.Breath holding spells* Breath holding spell is a paroxysmal event occuring in 0.1% - 5% of healthy children from the age of 6 months to 6 years.* The name for this behaviour may be misnomer in that it connotes prolonged inspiration. Infact, breath-holding occurs during expiration and is reflexive (not volitional) in nature.* There are two major types of breath holding spellsA) Cyanotic form (cyanotic spells)# This is more common and is provoked in response to frustration and anger precipitated by upsetting or scolding infant/child.# Cyanotic spells are due to central sympathetic overactivity.# Clinical features include generalized cyanosis, apnea, forced expiration, opisthotonus, shrill cry and bradycardia. Crying stops during forced expiration. Seizures may occur due to cerebral hypoxia, but antiepileptics are not required.# The only treatment is support and reassurance to parents.B) Pallid form (Pallid spells)# These are initiated by painful experience, e.g falling and striking the head.# Pallid spells are due to excessive central parasympethetic activity.# Clinical features include pallor, apnea, loss of consciousness, hypotonia, seizures and bradycarda.# Treatment includes support and reassurance of parents. Atropine may be used in refractory cases.* Iron supplementation may be useful in some children with breath holding spells.