Breath-holding spells in toddlers

Pediatrics for Parents, June, 2007 by Angela M. Simpson

Your toddler is happily playing when suddenly she becomes frustrated and upset. She lets out a brief, loud cry with a forceful expiration ... and then silence. She looks as though she's crying because her face is strained, but no sound comes out. She doesn't take another breath. She begins to turn blue. You watch, terrified, but she still won't breathe in. You feel your own heart start to pound as her body becomes limp Then she becomes unconscious. Her arms and legs begin to jerk ...

Breath-holding spells are one of the most frightening and unnerving behaviors that a parent may witness. Despite their dramatic appearance, they are benign and harmless to the child. These episodes always occur in response to an emotional trigger, such as anger, agitation, pain, or frustration. The child will begin to cry, but then stops mid-cry in a "noiseless expiration." This is followed by a dramatic facial color change from red to blue. The episode ends spontaneously, without any intervention, when the child takes a sudden, deep inspiration. In more severe cases, the child may become limp or pass out. Real seizure activity may occur as part of the spell, but this is not harmful, and there is no increased risk of subsequent seizure disorder. Breath-holding episodes may last several seconds to more than a minute.

There is another, far less common, type of breath-holding episode called a pallid spell. During this type, the child will turn very pale. These are brought on by a sudden startle, such as a minor bump on the head. The child will stop breathing, go limp, become unconscious, and become dramatically pale. This type of breath-holding episode also resolves spontaneously.

Breath-holding spells are fairly common. Simple spells, in which there is no associated loss of consciousness, occur in up to 25% of healthy kids. Severe episodes, which include limpness, loss of consciousness, and/or seizure activity, occur in about 5% of children. Up to 20% of children with breath-holding episodes have family members who were similarly affected during childhood. Breath-holding spells typically begin in the age range of six to eighteen months. These episodes may occur as often as several times a day, or as rarely as once a year. They occur with greatest frequency in the second year of life. Once parents have witnessed one breath-holding spell, often they can predict when another is about to happen. Children outgrow this behavior, usually between the ages of four to six years.

After a first breath-holding spell occurs, a pediatrician should evaluate your child. Breath-holding spells share some features in common with other more serious disorders, such as seizures, cardiac problems, and rhythm disturbances. A detailed description of the circumstances and sequence of events at the time of the episode may be all that the doctor needs to confirm the diagnosis of breath-holding. For instance, breath-holding spells are always triggered by an emotion, such as frustration or pain. In contrast, generalized seizures and cardiac disturbances usually do not have a precipitating emotional event. In breath-holding spells, children will turn blue before they pass out and before seizure activity occurs. The sequence of events is different in a child with an epileptic seizure disorder, where the child may turn blue during or after the seizure, but not before. In addition to a detailed history, your pediatrician will perform a physical exam of your child, with close attention to the cardiovascular and neurological systems.

If your your child's doctor confirms that the episode was indeed a breath-holding spell, your child may be checked for anemia. There is an association between iron deficiency anemia and breath-holding spells, and treating the anemia will often decrease the frequency of passing out.

Breath-holding episodes are harmless, in the short run as well as the long run. Children outgrow breath-holding spells without any increased risk of epilepsy or other neurological problems. The only significant finding on follow-up of kids with breath-holding spells is a mildly increased incidence of syncope (passing out) in later childhood and adolescence.

What should you do when your child is holding her breath and turning blue? First, do not panic. Keep in mind the episode will resolve spontaneously, usually within a minute or so. Many parents will try splashing water on their child or blowing in their face, but this is not necessary. You should not start CPR or shake your child. The best thing to do is to lay your child down on her side. This will prevent injury should your child pass out. As soon as she loses consciousness, she will begin to breathe on her own within seconds. She may be a little sleepy after the episode, but then will resume her usual activity.

How to react to a child's breath-holding spells can be a big challenge for parents. Giving your child extra attention after an episode, showing excessive worry, or bending to your child's will are all tempting and natural responses as a parent, but will only serve to reinforce the breath-holding behavior. Some parents avoid disciplining a child, fearful of the very real possibility that conflict or disappointment will provoke another spell. Try not to fall into this trap. You still need to set limits with your toddler, even if she gets so frustrated that she holds her breath until she passes out.