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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 involuntarily and loses consciousness for a short period immediately after a frightening or emotionally upsetting event or after 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. The remainder may continue to have spells into adulthood. Breath-holding spells do not appear to be risk factors for true epilepsy but may be associated with an increased risk of fainting spells in adulthood. There are 2 forms of breath-holding spells:

  • Cyanotic form: This form is the most common and often occurs as part of a temper tantrum or in response to a scolding or other upsetting event.

  • Pallid form: This form typically follows a painful experience, such as falling and banging the head, but can follow frightening or startling events.

Both forms are involuntary and readily distinguished from uncommon brief periods of voluntary breath-holding by stubborn children, who invariably resume normal breathing after getting what they want or after becoming uncomfortable when they fail to get what they want.

During a cyanotic breath-holding spell, children hold their breath (without necessarily being aware they are doing so) until they lose consciousness. Typically, the child cries out, exhales, and stops breathing. Shortly afterward, the child begins to turn blue and unconsciousness ensues. A brief seizure may occur. After a few seconds, breathing resumes and normal skin color and consciousness return. It may be possible to interrupt a spell by placing a cold rag on the child’s face at onset. Despite the spell’s frightening nature, parents must try to avoid reinforcing the initiating behavior. As the child recovers, parents should continue to enforce household rules. Distracting the child and avoiding situations that lead to tantrums are good strategies. Cyanotic breath-holding has been found to respond to iron therapy, even in the absence of anemia, and to treatment for obstructive sleep apnea (when present).

During a pallid breath-holding spell, vagal stimulation severely slows the heart rate. The child stops breathing, rapidly loses consciousness, and becomes pale and limp. If the spell lasts more than a few seconds, muscle tone increases, and a seizure and incontinence may occur. 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. Simultaneous ECG and EEG can help to differentiate cardiac and neurologic causes.

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