Toddlers Fight for Their Right to Party: Breath Holding Warfare Rages

Small boy pipe one's eyeA battle of wills. You know how this ends. You know she doesn’t (cue Cartman voice from South Park) respect your authorit-ay. Yet, you’re determined this time to stand your ground. It’s time to come in for dinner. She thinks it’s not: her swing set, her decision when she’s done with the slide. There’s a glint of defiance in her eye. The camera pans from her face, to yours, and back again. That familiar cowboy whistle rings out, tumbleweeds blow through the backdrop of this scene. Sweat drips from your face.
Then, it happens.

Your 18-month-old daughter hasn’t been staring you down so much as she’s been not breathing mid temper tantrum. Her lips turn blue. Her legs buckle, and there you go, swooping in to save her from certain head injury as she starts to pass out. She wins. She always does.

What you’ve just witnessed is a good, old fashioned breath holding spell. Although you’ve witnessed it before, it always takes your breath and quickens your pulse.

There is a silver lining: while scary to parents as they witness this fainting episode, these are very benign disorders. In fact, this scenario is so classic, that if you bring your kid to see me in the emergency department with this exact story, I’m probably going to offer you some reassurance and teaching on the subject, then discharge you and your princess home.

There are a number of things that precipitate this toddler equivalent of a fainting goat show. Usually either little Johnny is upset because you didn’t give him what he wanted, or your little girl got hurt so bad it made her cry and then be unable to take that next breath. In the great state of Indiana, parents are sometimes known to blow in the face of the blue infant. We call that Hoosier CPR. Yes, we’re keeping it classy.

We used to think that this was a volitional act of defiance. What’s actually thought to be the cause is something caused autonomic dysfunction. The autonomic nervous system is the part of us that we don’t have to think about. It controls our heart rate, respiratory rate, and blood pressure. It’s also responsible for the fight or flight response to perceived bad things. So, as you can see, dysfunction in this arena can make kids hold their breath to the point of not being able to take another breath and then passing out, or even slowing the heart rate so severe that also leads to fainting. Most kids will outgrow these, a small number will go on to be adults who pass out at the site of blood or with some other tragic stimulus.

Let’s break down for a second what happens when a child has one of these episodes. With this “autonomic dysfunction,” there is either a halt in breathing, or just a very slow heart beat. This results in a decrease in blood and oxygen going to the brain, which the brain does not like so much. As a result, the child passes out, which, if you think about it, causes breathing to start up again, and it increases the blood flow to the brain (easier to push blood to a brain on a flat body than pushing it uphill when one is upright). And, voila! The universe is once again right and in order. Occasionally these episodes are so severe that there is a brief seizure or seizure-like activity at the end.

If your child does have one of these episodes, by all means feel free to go see your doctor, or at least place a phone call. There are many nuances to the practice of medicine and, as such, it’s always a good idea to run your specific case by a provider. Just don’t be surprised if your doctor doesn’t launch into an exhaustive series of tests.

There is an association between iron-deficiency anemia and breath-holding spells. So, screening for this with a complete blood count is reasonable for your doctor to do. If this diagnosis is made, iron replacement can be helpful.

Most patients outgrow these episodes by age 5. It’s important to remember that, unlike the perception in the story at the beginning, this is not an attempt by your child to undermine your parenting prowess. It also doesn’t mean that your descendant should enjoy a life without boundaries. What it does mean is that it’s an opportunity to love this child through a brief tantrum or fit, and keep her safe while she passes out. When she wakes up, you tell her she’s still not going down the slide again. Dinner is almost ready. She probably won’t have the nerve to pass out on your twice in a row.

What scary experiences have you had with a child who tortured you with these?

Should I Stay Or Should I Go? An emergency physician as an emergency patient… again.

Should I stay or should I go?iStock_000026176395_Medium

That’s the question I faced yesterday as I pondered whether I was sick enough to go to the emergency department for care. Yes, me. The emergency physician. You’d think such questions would be fairly easy, but they are far from such.

I’m sure people outside of my profession find themselves in similar conundrums when deciding whether or not they should seek care emergently or just wait to see if their illness is self-limited, as most are. Self limited means it’s going to get better on its own, so, basically, suck it up cupcake.

But, for those of us who work in the ED, actually venturing through the sliding glass doors as a patient is a little more complicated. We don’t try to make it that way, it just is. As providers, we see all those people who come in for our care in search of some magic therapy that will cure all their ills. As we assess them, our primary goal is to just make sure the afflicted soul doesn’t have some life-threatening malady. In addition, we try to offer them some symptomatic relief, most of which could be attained to a similar degree with over-the-counter medication and some bedrest.

Now, the last time I did a post about my own experience in the patient bed (Wearing the patient gown), I had gone to the hospital for chest pain and EKG changes. That was rather straightforward. No pondering needed.

Yesterday, however, my two days of a summer cold took a rather abrupt change. Driving 2 hours to take the minions to the Children’s Museum, I started off just a bit achy, thought my cold was just getting worse, but nothing bad enough to cancel the trip. Right around noon, I had some increase in the muscle aches (we call that myalgias), and felt like I was starting to run a fever. Also, not the end of the world. We stopped for some Tylenol and ibuprofen to treat the fever and the pain. Even with these wonder drugs, I actually had to leave the museum to lay down in the car while my emergency nurse fiancée weaved the children through dinosaurs and train displays. Still, going to the ED was not on my radar.

As we drove home, my thoughts shifted from, “Wow, I don’t feel well,” to “I bet this is what death feels like…”

I watched my heart rate hover in the 130s on my Apple Watch (yes, I’m an early adopter), even after my fever broke. At home, I laid down, my heart rate still in the 120s, then up to 148 if I stood up. Now, those vital sign changes can occur with fluid loss, such as working out in the heat, or vomiting and diarrhea, but I had none of those insults to my body. My respiratory rate was 22, which is also a bit elevated.

I provide you with all this background to say this. I have an entirely new respect for this entity known as SIRS (Systemic Inflammatory Response Syndrome). SIRS plus a source of infection is sepsis, which essentially means your body is really reacting to whatever infection it’s battling. Since one of my goals is to educate the public, I’ll teach you what the SIRS criteria are. You need 2 of these plus a source of infection to qualify as sepsis. Heart rate > 90, respiratory rate > 20, temperature > 100.4, white blood cell count > 12,000 or < 4,000.

Yet, despite all I know, my abnormal vital signs, and feeling like I had just been pummeled by Tito Ortiz in the octagon, I still debated whether or not I should go to the ED. Riding to the hospital, I wondered if I were overreacting. In the end, it was my rapid heart rate and my belief that some intravenous fluids would help me feel better that convinced me to enter under the sign titled: EMERGENCY.

Once inside, my heart rate did not magically improve (that was honestly my concern, because then I would have been declared a fraud!). My initial labs showed a white blood cell count of 25,000. Most of these were neutrophils, the subset of white blood cells that crank up in the presence of bacterial infection. While my x-ray was negative, my CT scan showed a pneumonia. Yes! I told you I was sick! So, pneumonia was my “source” of infection. That, coupled with my SIRS criteria, meant I had sepsis.

Two liters of iv fluids and some iv antibiotics later, I was on my way home. Did I feel better? Only ever so slightly that I was willing to rescind my DNR status (I’m joking). Actually, my fever and chills came back as I returned home, and I felt like death again. But, at least this time I had a diagnosis, and not a sissy diagnosis, either. Full-fledged pneumonia. Can you tell I revel in being validated as a “legit” patient? I woke up today markedly better.

There is a point to this story. Basically, when you feel so terrible, worse than you ever have, it’s probably time to be evaluated, even if you have the initials “MD” after your last name. Our bodies are remarkable at screaming at us when something is wrong. We just have to listen. What I had was early sepsis, something that is fairly easily treatable. But, without the fluid and the antibiotics, this would have progressed to severe sepsis or even septic shock. I’m convinced if I had not sought care from a colleague last night, I would have worsened to the point that I would be in the ICU today being treated for severe sepsis rather than sharing my good fortune with you.

What experiences have you had that left you with the thought you were glad you went to the hospital when you did?