[The use of Pantogam syrup in treating small children's breath holding spells]. / Primenenie preparata pantogam sirop v terapii affektivno-respiratornykh paroksizmov u detei rannego vozrasta.

AIM: To study the efficacy of pantogam syrup 10% (hopantenic acid) in the treatment of breath-holding spells (BHS). MATERIAL AND METHODS: Sixty children, aged from 2 to 4 years, with BHS were studied. The evaluation of clinical manifestations and anxiety level was performed. Results of neurophysiological examination (long-term video-EEG-monitoring) were analyzed. Children were divided into 2 groups: main, in which the patients received pantogam syrup, and control group, in which only psychological methods were used. RESULTS AND CONCLUSION: The results of the clinical and neurophysiological studies performed after the treatment, showed the clinical improvement in 73.3% of patients of the main group compared with similar data from the children in the control group (16.7%). The anxiety level significantly decreased after the neuroprotective therapy. A comparative analysis of electroencephalographic indicators demonstrated a significant (р<0.05) reduction in the power range of slow rhythms and manifestations of functional immaturity of the brain in patients of the main group. These results give evidence for the high efficacy of pantogam syrup in the treatment of children with BHS.

[Voluntary apnea of maximum duration as a model of short-term asphyxia in psycho- and electrophysiological studies].

We evaluated the test with arbitrary external respiratory standstill (AEKS) of maximum duration as a model of short-term asphyxia. The experiments were carried out in volunteer students. The level of oxyhemoglobin saturation and tissue oxygen tension that we registered in a group of sportsmen in the course of AEKS of maximum duration demonstrated that asphyxia developed in some of the probationers within 100-120 seconds. Taking into consideration the fact that registration of many psychophysiological and electrophysiological parameters takes place within the interval from several hundreds of milliseconds to several tens of seconds AEKS of maximum duration may be regarded as an adequate model of short-term asphyxia.

Assessment of stress in mothers of children with severe breath-holding spells.

BACKGROUND: Severe breath-holding spells (BHS) in children consist of a stereotypical sequence of provocation to cry, noiseless expiration, color change, and loss of consciousness. Parenting a child who exhibits BHS is likely more stressful than parenting a healthy child, owing to this additional medical concern. It is also likely more stressful than parenting a child with a convulsive seizure disorder (SD), because it is often not recognized or misdiagnosed as behavioral rather than medical. Mothers of children with BHS were hypothesized to suffer significantly greater stress than mothers of children with SD or mothers of children without any significant medical conditions. OBJECTIVES: To examine maternal stress in parenting a child who exhibits BHS, and to identify the specific areas of stress impact, compared with mothers of children with a convulsive SD and mothers of control children. METHODS: The Parenting Stress Index and questions regarding how mothers coped were individually administered to 34 mothers of children with BHS, 16 mothers of children with SD, and 16 mothers of children with no medical conditions (controls). RESULTS: Mothers of children with BHS or SD experience more overall stress and disruption in their attachment or understanding of their child, compared with control mothers. These groups of mothers (BHS and SD) also perceived their child as more distractible/hyperactive, less adaptive, and more demanding than did control mothers. However, mothers of the BHS group alone showed significant disruption in their sense of competence as a parent, maintaining self-identity, and receiving positive reinforcement from their child. Mothers of children with SD showed a similar trend, but it was not significant. These findings were not related to maternal health or feelings of depression/isolation, insufficient spousal support, child's mood, or other life stresses. CONCLUSION: Parenting a child with BHS or SD impacts a greater degree of life stress on mothers of these children than does parenting control children, although the stress is greater for the BHS group than for the SD group.

Behavioral arousal in newborn infants and its association with termination of apnea.

Arousal is an important protective mechanism that aids in the resolution of obstructive sleep apnea in adults and children, but its role in neonatal apnea has not been investigated. The primary aim of the present study was to determine the role of arousal in the termination of apnea in preterm infants. Videorecording was used to identify spontaneous behavioral arousal in a group of healthy full-term (n = 7) and preterm (n = 10) infants before and during polygraphic monitoring of cardiorespiratory variables and in a group of preterm infants with apnea (n = 10) during similar polygraphic monitoring. Spontaneous arousal rates (mean +/- SE) in full-term infants before and during polygraphic monitoring were 0.18 +/- 0.03 and 0.23 +/- 0.07 episodes/min, respectively. Corresponding values in nonapneic preterm infants were 0.24 +/- 0.03 and 0.24 +/- 0.02 episodes/min. In apneic preterm infants, mean spontaneous arousal rate during polygraphic recording was 0.26 +/- 0.02, but it was considerably higher during apneic sleep periods (0.59 +/- 0.17) than during nonapneic sleep periods (0.25 +/- 0.01). The frequency of occurrence of arousal was significantly higher (P less than 0.005) in long vs. short apnea, mixed vs. central apnea, and severe vs. mild apnea. Although a clear association between arousal and apneic resolution was observed in preterm infants, lack of arousal responses in a large number of apneic episodes suggests that behavioral arousal is not essential for the termination of apnea in these infants.

Anxiety sensitivity, suffocation fear, trait anxiety, and breath-holding duration as predictors of response to carbon dioxide challenge.

We investigated predictors of response to carbon dioxide challenge (i.e. breathing deeply and rapidly into a paper bag for 5 min) in college students. Zero-order correlations indicated that scores on both the Anxiety Sensitivity Index (ASI: Reiss, Peterson, Gursky & McNally, 1986) and the Suffocation Fear Scale (SFS: Rachman & Taylor, 1994), predicted anxious response to challenge, whereas a behavioral measure of carbon dioxide sensitivity (i.e. maximum breath-holding duration) and scores on the State-Trait Anxiety Inventory--Trait form (STAI-T: Spielberger, Gorsuch, Lushene, Vagg & Jacobs, 1983) did not. Multiple regression revealed that all four variables remained in the model, entering in the following order: ASI, breath-holding duration, SFS, and STAI-T. These data suggest that psychological variables reflecting fears of bodily sensations are better predictors of response to challenge than either behavioral sensitivity to carbon dioxide or general trait anxiety.

Voluntary breath holding: not a suitable probe of the suffocation alarm in panic disorder.

Voluntary breath-holding duration was investigated in patients with panic disorder, patients with a mood disorder, and normal controls. There were no differences in mean breath-holding durations, but the pattern of scores was different among groups. Furthermore, the scores were influenced by motivational and cognitive factors. It is argued that voluntary breath-holding is not a suitable test to measure carbon dioxide sensitivity or suffocation alarm threshold in panic disorder.

Prolonged generalized epileptic seizures triggered by breath-holding spells.

We report a 3-year-old female with anoxic-epileptic seizures. Beginning at 11 months of age, she had repeated breath-holding spells with transition into generalized tonic-clonic seizures or status epilepticus. Interictal electroencephalography exhibited no abnormalities. A multidisciplinary diagnostic approach revealed a severely disturbed mother-daughter relationship that was the trigger of the breath-holding spells. Psychotherapy for the mother and daughter led to cessation of the breath-holding spells and, consequently, of the anoxic-epileptic seizures. Her further development was largely normal. We discuss the etiology and treatment of anoxic-epileptic seizures. This case is the first reported case of anoxic epileptic seizures that responded to psychologic rather than antiepileptic treatment. We advocate an initial psychologic assessment to help determine the appropriate treatment in children with recurrent anoxic-epileptic seizures.

The intercostal-to-phrenic-inhibitory reflex (IPIR) in normal and intra-uterine growth-retarded (IUGR) human fetuses from 26 to 40 weeks of gestation.

The existence of an IPIR in the healthy fetus between 37 and 40 weeks of gestation has already been demonstrated: compression of the fetal thoracic wall during an epoch of fetal breathing movements (FBM) consistently caused a fetal apnea (> or = 4 s). The apnea durations were similar in fetal behavioural states 1F and 2F, with a wide inter- and intrafetal variability. We therefore hypothesized that the duration of the IPIR-apnea would increase during gestation and would be increased in IUGR-fetuses as compared to healthy fetuses of the same age. Twenty-six healthy fetuses between 28 and 40 weeks (mean 34.3 weeks) and 14 IUGR-fetuses between 26 and 38 weeks (mean 33.5 weeks) were studied. If FBM were present, the caudolateral part of the fetal thoracic wall was shortly compressed manually and the duration of the resulting apnea was measured. In a random order a sham-compression was also carried out on the fetal head. In normal fetuses 21/28 real compressions were followed by an apnea in 1F, while this was only the case in 3/21 sham-compressions (P < 10(-4)). For 2F these results were 47/57 and 7/51, respectively (P < 10(-4)). In IUGR-fetuses 43/51 real compressions (1F and 2F together) and 7/46 sham-procedures provoked an apnea (P < 10(-4)). These results prove the existence of the IPIR in normal and IUGR-fetuses. The mean (+/- S.D.) duration of apnea in the IUGR-fetuses was 15.8 s (+/- 4.0) (range 4-80 s) and 15.2 s (+/- 4.3) (range 4-106 s) in the normal group.(ABSTRACT TRUNCATED AT 250 WORDS)

Apnea in postsurgical hypnotherapy of an esophageal cancer patient: a brief communication.

Use of clinical hypnosis in the postsurgical psychotherapy of an esophageal cancer patient who could not swallow involved reenactment of the successful surgery and producing hallucinations of taste and smell, as well as working through emotions relations to the surgery and her disease. An apnea that occurred in a late phase of the treatment was addressed with the familiar arm pumping technique that had been used as a deepening technique, resulting in the patient's resuming normal breathing. The experience reminds the practitioner of the possible unexpected professional demands when working in a medical environment. It also provides clues as to the underlying psychological mechanisms and their role in successful symptom removal. A 6-year follow-up confirmed the lasting effect of this brief psychotherapy.

Conditioned hyperventilation as a factor in animal, infant, and adult apnea: a theoretical analysis of experimental and clinical data.

An apnea hypothesis is proposed termed Conditioned Hyperventilation. An organism (animal, infant, or adult) can become conditioned to anticipate traumatic terminal breathing. The resulting hyperventilation produces excessive oxygen, which triggers apnea, allowing an increase in carbon dioxide. This apnea serves as an additional unconditioned stimulus (UCS) causing the hyperventilation (apnea) to increase. Organic blockage can also serve as the UCS. Apnea may be reduced or prevented by monitoring and extinguishing hyperventilation through the use of behavioral modification techniques, or biofeedback. Infant lung collapse during the first six months is suggested as one UCS in infants.

Piracetam in severe breath holding spells.

BACKGROUND: Breath holding spells (BHS) are apparently frightening events occurring in otherwise healthy children. Generally, no medical treatment is recommended and parental reassurance is believed to be enough, however, severe BHS can be very stressful for the parents and a pharmacological agent may be desired in some of these children. OBJECTIVE: In this prospective study aim was to determine the usefulness of piracetam as prophylactic treatment for severe BHS. METHODS: Children were recruited from Neurology Clinic in Children's Hospital, Islamabad between January 2002 to December 2004. Diagnosis of BHS was based on characteristic history and normal physical examination. Piracetam was prescribed to those children who were diagnosed as severe BHS in a dose ranging from 50-100 mg/kg/day. Iron supplements were added if hemoglobin was less than 10 gm%. Patients were seen at 2-4 weeks interval and follow-up was continued until 3 months after the cessation of drug therapy. RESULTS: Fifty-two children were enrolled in the study, 34 boys and 18 girls. Ages ranged from 4 weeks to 5 years with mean age of 17 months. In 81% of children, spells disappeared completely and in 9% frequency was reduced to less than one per month and of much lesser intensity. Prophylaxis was given for 3-6 months (mean 5) duration. CONCLUSIONS: Piracetam is an effective prophylactic treatment for severe BHS.

Cyanotic episodes in a male child with fragile X syndrome.

A 9-year-old male with a diagnosis of fragile X syndrome (FXS) was evaluated for cyanotic episodes of unknown etiology. Clinical observation revealed frequent episodes of hyperventilation lasting several minutes, only while the patient was awake. This was followed by apnea associated with cyanosis and oxygen desaturation. Polysomnogram confirmed episodic central apnea temporally associated with hypocapnia, only during the awake state. Extensive evaluation failed to reveal other neurological, cardiac, gastrointestinal, or pulmonary etiologies for the events. The clinical observations and investigations allowed us to conclude that the patient's cyanotic episodes were caused by primary behavioral hyperventilation in the awake state. Similar behaviors have been reported in children with a variety of diagnoses but to our knowledge have not been previously reported in children with FXS. Treatment for this unusual behavior in FXS consists of reassurance and behavior modification to decrease the frequency and severity of the cyanotic episodes.

Metabolic rate, respiratory exchange ratio, and apneas during meditation.

We tested the hypothesis that a drop in metabolic rate (MR) causes the apneas observed in some subjects during transcendental meditation (TM). We measured O2 consumption (VO2) and CO2 production (VCO2) in three groups of experienced meditators and one group of nonmeditating controls. Measurements were made before, during, and after TM for the meditators and before, during, and after eyes-closed relaxation for the nonmeditating controls. The three groups of meditators consisted of 1) those showing little change in the frequency of ventilation (f) with meditation, 2) those showing a marked decline in f, and 3) those showing numerous apneas and a marked fall in f. There were significant trial effects but no group or interaction effects for the decline in VO2. Thus we concluded that a drop in MR is not the cause of the apneas. However, there were significant trial and interaction effects for the changes in VCO2 and the respiratory exchange ratio (R), with a significant drop in R for the meditators but not for the controls. We report additional evidence and speculate that the drop in R is a consequence of mild hypoventilation.

[Hypochromic anemia in children with affective breath-holding spells]. / Hipohromna anemija kod djece sa respiratornim afektivnim krizama.

Breath holding attacks are most common in children aged 6 months to 6 years, in 76% of cases between 6 and 18 months of age. Very often they are misinterpreted as tonic epileptic seizures. They are provoked by frustration, anger or sudden injury. Child starts to cry, then holds the breath at the end of expirium. After a few seconds it becomes cyanotic, and losses consciousness. It is usually floppy, but sometimes stiffness, and clonic seizures can be present, and child can be diagnosed as having epilepsy. The form in which child is pale is less frequent, and crying is usually brief or even absent in this type. Breath holding attacks usually do not last more then one to three minutes. Good heteroanamnesis is essential for diagnosis, revealing provoking factors for each attack. Interictal EEG registration is usually normal. Attacks often spontaneously cease after 5 or 6 years of age, and do not require any medical treatment. In more severe cases behavioral therapy has shown good results. It has been noticed that those children in adolescence have syncope more frequent then rest of population. Seventeen children (12 male and 5 female) were investigated at Pediatric Hospital in Sarajevo as breath holding attacks in period from June 1997 to June 2000. Age of patients was between 5 months and 5.5 years (median was 11 months). Hypochromic anemia was present in 12 patients (76%), with average hemoglobin value of 8.2 g/dl (5.9-11.0 g/dl). All children had normal EEG recording. Iron therapy gave positive response in 8 out of 9 patients that were followed (88.9%). Three patients had not come for follow up. It is concluded that hypochromic anemia is often a part of clinical presentation of breath holding attacks in children, and iron therapy can stop them.

[Conditioning of affect-induced breath-holding spells]. / Zur Konditionierbarkeit respiratorischer Affektkrämpfe.

Breath holding spells often arise in the context of affectively dramatic conflict situations between mother and child. Assessment by psychopathological screening instruments, however, has not given empirical evidence of an increased psychiatric morbidity in these children. Therefore, in our study we did not concentrate on basic psychopathology but on behavioral variables that might be effective during the ongoing attack episode and, hereby, exert an influence on the risk of chronification (relapse rate). The main goal of this approach is to examine secondary reinforcement effects on the attack behavior according to the learning principle of operant conditioning. Our sample consisted of 28 children and ten siblings as control group. To control for effects of behavioral disorders in the sample, we applied the Marburger Verhaltensliste (MVL) on the level of the child, and the Familienfragebogen (FFBO-III) on the level of family adaptation. The main assessment instrument, however, was the Functional Behavior Analysis (FBA) in order to measure the trigger, reaction and consequence conditions in the course of given attack episodes. MVL and FFBO-III results confirm the lack of basic psychopathology in the patients and their families. The individualized FBA's can be transformed in a taxonomy of five distinct types. All the first three types are triggered by intensive conflict situations and show a high relapse rate (type 1) if the mother reacts in a rewarding manner with positive consequences for the child (reinforcement condition), a dramatically reduced rate (type 2) if the mother reacts neutral (extinction condition), or a heterogeneous pattern (type 3) if the mother reacts punishing (punishment condition). In type 4 (pallid type) and type 5 (triggered spontaneously), respectively, no responsiveness to conditioning effects can be recognized. With respect to parent counselling, a recommendation for a quiet and consequent reaction can be concluded, especially in the case of a preceding conflict situation. The empirical results are integrated into a hypothetical model on pathogenesis that delineates the interaction of neurophysiological and behavioral factors in the maintenance of breath-holding spells.