Breath-holding spells have been described for centuries (45) but controversy as to what they are remains (46). The term "breath-holding" is not at all satisfactory (19,47). It tends to give offence to parents of affected children. It seems to imply temper tantrums and bad behavior. One imagines that many members of the public and even pediatricians actually do believe that breath-holding spells are a manifestation of a behavior disorder and, in some pediatric textbooks, breath-holding attacks are to be found in the section on psychiatric or psychological disorders. However, studies have shown that however one defines breath-holding spells, behavioral disorders in those afflicted do not differ from those in control children (48).
Breath-holding seems to imply some sort of voluntary "I'll hold my breath until I get what I want" behavior, whereas none of the behaviors so described seems to involve this mechanism. There is no difficulty nowadays in recognizing that what used to be called white or pallid breath-holding (12) has a cardiac rather than a respiratory mechanism, as discussed earlier in the section on reflex anoxic seizures and reflex asystolic syncope. The term prolonged expiratory apnea (49) is certainly helpful in discussing those episodes in which the mechanism is predominantly respiratory, even though the patho-physiological details may be in dispute.
One difficulty is, as with so many paroxysmal disorders, that precise detailed documentation of what happens is in short supply. Cinematographic registration has been described (50). Videorecordings—predominantly of several episodes in a single child—have been obtained (1,51) and polygraphic recordings of a few children (52), but the total information compared to the frequency of occurrence of natural episodes is very small. There appears to be a pure respiratory "breath-holding" spell or prolonged expiratory apnea, without any change in cardiac rate or rhythm (albeit information on cardiac output is not available), such attacks being clearly cyanotic or "blue" breath-holding. There are also episodes that may be described as "mixed" breath-holding, insofar as there is not only expiratory apnea but also a degree of bradycardia or cardiac asystole (1,51).
An argument exists about the prognosis of these "cyanotic breath-holding spells" or prolonged expiratory apneas (51,52), but management of neurodevelop-mentally intact children does depend on the general assumption that prolonged expiratory apnea (cyanotic breath-holding) is benign (46). The best prospective study to date is that of DiMario (53), albeit he includes pallid breath-holding spells, which may represent, in our terminology, reflex anoxic seizures or reflex asys-tolic syncope.
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