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Table of Contents
Year : 2017  |  Volume : 33  |  Issue : 4  |  Page : 562-563

Breath-holding in Vitamin D deficiency rickets: A dilemma for the anesthetist

1 Department of Anaesthesia, Kasturba Medical College, Manipal, Karnataka, India
2 Department of General Surgery, Kasturba Medical College, Manipal, Karnataka, India

Date of Web Publication9-Jan-2018

Correspondence Address:
Kush Ashokkumar Goyal
Department of Anaesthesia, Kasturba Medical College, Manipal - 576 104, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-9185.173387

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How to cite this article:
Rao M, Shetty D, Goyal KA, Budania LS. Breath-holding in Vitamin D deficiency rickets: A dilemma for the anesthetist. J Anaesthesiol Clin Pharmacol 2017;33:562-3

How to cite this URL:
Rao M, Shetty D, Goyal KA, Budania LS. Breath-holding in Vitamin D deficiency rickets: A dilemma for the anesthetist. J Anaesthesiol Clin Pharmacol [serial online] 2017 [cited 2020 Nov 29];33:562-3. Available from:


Vitamin D deficiency rickets presents profound anesthetic concerns ranging from impaired neuromuscular function, risk of fractures, difficult airway to electrolyte imbalance causing laryngospasm, seizures, arrhythmias, and tetany.[1] Breath-holding secondary to hypocalcaemia is rare and mostly seen in neonates or infants and hardly reported in older children.[2],[3]

Two children of 3 months and 8 years, diagnosed previously as Vitamin D deficient rickets on daily calcium, phosphorus, and monthly Vitamin D3 depot injections, were posted for herniotomy with orchidopexy. Both gave a history of breath holding spells associated with cyanosis and drowsiness but recovering immediately without active interventions. Records revealed need for hospitalization and intravenous calcium gluconate during one such episode in the older child at 4 months of age. His clinical assessment prior to surgery showed craniosynostosis, pigeon chest, genu varum, frontal and parietal bossing, serum calcium of 8.1 mg/dL (normal 8.8-10.8), and phosphate 4.8 mg/dL (normal 4.5-5.5). The infant's examination was unremarkable but calcium and phosphate were 7.2 mg/dL and 4.0 mg/dL. In view of anticipated difficult airway, general anesthesia with endotracheal intubation for the child and laryngeal mask airway for the infant along with ilioinguinal, iliohypogastric nerve block was planned. The intraoperative period was uneventful. Twenty minutes into the postoperative period, the older child's respiration became irregular with diminished chest expansion and brief apnea of 10-15 s, and drop in oxygen saturation to 91%; however, cyanosis, dyspnea, stridor, or loss of muscle tone was not observed. The episode repeated after 10 and 20 min. First, oxygen was supplemented via facemask at 6 L/min that improved the saturation to 98% briefly. Common causes of breath holding in postoperative period such as laryngospasm, opioid overdose, seizures, inadequate reversal, and analgesia were excluded. When subsequent episodes occurred and saturation dropped while still on oxygen, considering hypocalcemia as a probable cause 10 ml of 10% calcium gluconate was administered over 10 min. After discussing with pediatrician, Vitamin D3, 6 lakh units was also given. After these interventions, saturation improved and there was no relapse. In view of the emergency, calcium gluconate was administered immediately without waiting for a serum calcium value. However, once the child was stable, blood investigation revealed serum calcium of 8.3 mg/dL. We accepted this almost low normal value as his symptoms had subsided, noting his preoperative baseline value of 8.1 mg/dL and keeping in mind his underlying disease pathology. Intubation was deferred as the episodes though recurrent, lasted for only 20 s. He was observed for 8 h, shifted after ensuring regular breathing. He was discharged the following day with oral supplements and a follow-up after 1 month revealed normal values of serum calcium. The infant had an uneventful hospital stay.

Breath-holding in rickets may be seen in infants as reported by Buchanan et al. where hypocalcaemia, accentuated by stoppage of calcium produced recurrent apnea that necessitated intubation and intensive care in a seven-week baby who later responded dramatically to intravenous calcium.[3] Bonnici added that this line of treatment with intravenous calcium alone produces transient recovery and should be supplemented with regular Vitamin D supplements.[2] The complex relationship between low calcium and apnea may be attributed to increase in production of sleep-regulating substances such as tumor necrosis factor-α and prostaglandin D2 in Vitamin D deficiency. Airway hypotonia causing obstructive sleep apnea has also been postulated.[4] Knowledge of this complication is important in postoperative period to anesthetists especially in developing countries where rickets is endemic.[5] However, ruling out other causes of postoperative apnea is prudent. Early identification and initiation of treatment at young age may avoid problems as seen in the infant who had an uneventful perioperative period.

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  References Top

Garg R, Khanna P, Pandia M. Anaesthetic considerations in a child with rickets and craniosynostosis for linear strip craniectomy and frontal advancement. Indian J Anaesth 2010;54:350-1.  Back to cited text no. 1
[PUBMED]  [Full text]  
Bonnici F. Functional hypoparathyroidism in infantile hypocalcaemic stage I vitamin D deficiency rickets. S Afr Med J 1978;54:611-2.  Back to cited text no. 2
Buchanan N, Pettifor JM, Cane RD, Bill PL. Infantile apnoea due to profound hypocalcaemia associated with vitamin D deficiency. A case report. S Afr Med J 1978;53:766-7.  Back to cited text no. 3
McCarty DE, Marino AA. Vitamin D deficiency, sleep, sleep disruption, and daytime neurocognitive impairment. In: Preedy VR, Patel VB, Le LA, editors. Handbook of Nutrition, Diet and Sleep. 1st ed. Wageningen: Wageningen Academic Publishers; 2013. p. 353-68.  Back to cited text no. 4
Pettifor JM. Vitamin D &/or calcium deficiency rickets in infants & children: A global perspective. Indian J Med Res 2008; 127:245-9.  Back to cited text no. 5
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