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Breath-Holding Spells

by Stephen Brian Sulkes, MD

A breath-holding spell is an episode in which the child stops breathing and loses consciousness for a short period immediately after a frightening or emotionally upsetting event or a painful experience.

  • Breath-holding spells usually are triggered by physically painful or emotionally upsetting events.

  • Typical symptoms include paleness, stoppage of breathing, loss of consciousness, and seizures.

  • Despite the dramatic nature of the symptoms, the spells are not dangerous.

  • Tantrums, often a component of breath-holding spells, may be prevented by distracting the child and avoiding situations known to trigger the spells.

Breath-holding spells occur in 5% of otherwise healthy children. They usually begin in the first year of life and peak at age 2. They disappear by age 4 in 50% of children and by age 8 in about 83% of children. A small percentage of these children may continue to have spells into adulthood. Breath-holding spells can take one of two forms:

  • Cyanotic

  • Pallid

The cyanotic form of breath-holding, which is most common, is initiated subconsciously by young children often as a component of a temper tantrum or in response to a scolding or other upsetting event. Episodes peak at about age 2 and are rare after age 5.

Typically, the child cries out (without necessarily being aware they are doing so), breathes out, and then stops breathing. Shortly afterward, the skin begins to turn blue, and the child becomes unconscious. A brief seizure may occur. After a few seconds, breathing resumes and normal skin color and consciousness return. It may be possible to interrupt the episode by placing a cold rag on the child's face when the spell begins. Despite the frightening nature of the episode, children do not have any dangerous or long-term effects. Parents must try to avoid reinforcing the initiating behavior. At the same time, parents should not avoid providing appropriate structure for children out of fear of causing spells. Distracting children and avoiding situations that lead to tantrums are the best ways of preventing and treating these spells. Cyanotic breath-holding spells may respond to treatment with iron supplements, even when the child does not have iron-deficiency anemia.

The pallid form typically follows a painful experience, such as falling and banging the head or being suddenly startled. The brain sends out a signal (via the vagus nerve) that severely slows the heart rate, causing loss of consciousness. Thus, in this form, the loss of consciousness and stoppage of breathing (which are both temporary) result from a nerve response to being startled that leads to slowing of the heart.

The child stops breathing, rapidly loses consciousness, and becomes pale and limp. A seizure and incontinence may occur. The heart typically beats very slowly during a spell. After the spell, the heart speeds up again, breathing restarts, and consciousness returns without any treatment. Because this form causes symptoms similar to those of certain heart and brain disorders, doctors may need to do a diagnostic evaluation if the spells occur often.

Both forms are involuntary, which means that children are not intentionally holding their breath and have no control over the spells. Breath-holding spells are easily distinguished from uncommon, brief episodes of voluntary breath-holding by some children. Children who voluntarily hold their breath do not lose consciousness and go back to breathing normally after they get what they want or after becoming uncomfortable when they do not get what they want.