Makindo Medical Notes

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Reflex anoxic attacks (RAA) are paroxysmal, self-limited episodes of brief asystole, typically lasting around 15 seconds. They are commonly triggered by emotional stressors such as pain, fear, or anxiety, and typically occur in children aged 6 months to 2 years. These attacks are often mistaken for seizures but are distinct due to their trigger and characteristics. The condition is generally benign, and most children outgrow it without any long-term effects.

Introduction

• Reflex anoxic attacks are a benign condition that commonly affects young children, often triggered by emotional stress.
• Brief episodes of pallor, muscle stiffness, and impaired consciousness, followed by rapid recovery.
• While often confused with epilepsy, RAA episodes are self-limiting and typically resolve as the child grows older.
• Reassurance and monitoring are key aspects of management. Some requiring medications or pacemaker intervention.

Clinical Features

• Duration: The attacks typically last for 15 seconds, but some can be longer (up to a few minutes).
• Triggers: Common triggers include pain (e.g., during venepuncture), fear, or anxiety.
• Symptoms:
  • Deathly pallor (paleness)
  • Hypotonia (weakness in muscle tone)
  • Rigidity (stiffness in muscles)
  • Upward eye deviation
  • Clonic movements (muscle jerking)
  • Urinary incontinence
• Age Group: Primarily affects children between the ages of 6 months to 2 years, but can occur in older children as well.
• Prevalence: Occurs in approximately 0.8% of preschool-aged children.

Misdiagnosis and Differentiation from Epilepsy

• RAA can be confused with epilepsy due to the similar features of impaired consciousness and muscle jerking. However, key differences include:
• Trigger: RAA episodes are typically preceded by a known trigger such as pain, fear, or anxiety, while epileptic seizures can occur without a clear trigger.
• Absence of Postictal Phase: RAA episodes do not have the prolonged recovery phase seen in epilepsy.
• No Tongue-Biting: Unlike seizures, reflex anoxic attacks do not involve tongue-biting or incontinence.
• If there is uncertainty in diagnosis, referral to a specialist for vagal excitation tests under continuous EEG and ECG monitoring may be necessary.

Management

• Ferritin Level: Check ferritin levels to ensure they are above 50 ng/mL, as iron deficiency may exacerbate RAA.
• Medications: Generally, medication is not required. However, atropine has been tried in some cases to reduce sensitivity to vagal influences.
• Pacemaker: In rare, severe cases with frequent or prolonged episodes, a pacemaker may be considered to regulate heart rhythm.

Parental advice

• Avoid the Term "Seizure": It's important not to refer to the episodes as "seizures," as this could cause unnecessary concern. Use the term "white breath-holding attacks" instead, which is a less alarming phrase.
• Benign Nature: Reassure parents that reflex anoxic attacks are benign and that children typically outgrow the condition by the age of 4 or 5. However, it can recur later in life or in siblings.
• No Long-Term Effects: Emphasize that there are no long-term health effects or brain damage associated with these attacks.