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 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. Breath-holding spells can take one of two forms.
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 2 years and are rare after 5 years. 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, the parents must try to avoid reinforcing the initiating behavior. 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 respond to treatment with iron supplements, even when the child does not have iron-deficiency anemia, and to treatment for obstructive sleep apnea.
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 is rare, further diagnostic evaluation and treatment may be needed if the spells occur often.
Last full review/revision February 2009 by Stephen Brian Sulkes, MD