Breath-holding Spells

Breath-holding spells are fairly common in young children. In fact, between 5% and 25% of children have these by the time they are 2 years old. These frightening episodes are not actually "breath-holding" that is under a child’s control. They are also not seizures, although in a small number of children they can cause seizures. The best evidence is that breath-holding spells are related to fainting spells in older children and adults. They are episodes in which the primitive part of the nervous system (the "autonomic" nervous system) gets out of balance. They seem to run in families.

Most children with breath-holding spells develop them between the ages of 6 and 18 months. They can start much earlier, but this is unusual. The spells peak in frequency by around 18 months in boys and 2 years in girls. Children who have these spells may have them infrequently at first, but at their peak they usually happen several times a week. Some children have them several times a day. Most children have outgrown their spells by the time they are 4 to 6 years old.

Breath-holding spells almost always scare the daylights out of parents and others who see them. They come in three types, in all cases they begin with some kind of emotional upset and end in unconsciousness:

• Cyanotic (blue) spells are the most common. About half of children who have spells have blue spells. Blue spells tend to be set off by anger or frustration. People often mistake blue spells for tantrums, but they are not something the child can control. Children usually cry or scream to the very end of a breath, and then stop breathing. They may turn dusky or blue, especially around the mouth and eyes. After turning dusky or blue, the child becomes limp and loses consciousness.
• Pallid (pale) spells happen in about one fourth of children who have spells. Unlike blue spells, pale spells may not usually involve much crying. Pain or fear can be what sets off a pale spell. Children with pale spells become gray or white and then lose consciousness very quickly
• Combination spells happen in the remaining one fourth of children. These children may turn blue first and pale later, or vice versa.

The spell lasts from a few seconds to about a minute. When it is over, children may wake right up and be normal, or they may be sleepy for a few hours.

Although these spells can look different from each other, there does not seem to be any long-term difference in outcome. Up to 15% of children with breath-holding spells can have seizures at the end of the spell. The longer the spell lasts, the more likely it is that a child will have a seizure. Children who have a seizure as part of a breath-holding spell do not have a lifelong seizure disorder (epilepsy).

The first time they see a breath-holding spell, most parents are terrified that their child has stopped breathing and might die. The first spell often prompts a trip to the emergency room. After the diagnosis of breath-holding spells is known, many parents become concerned that their child is doing them on purpose or is having a tantrum. It is very important to understand that these spells are not in the child’s control at all. They are not manipulating you or punishing you in any way. It is equally important to explain this to other people who care for your child.

The unconsciousness in these spells is the result of not enough oxygen reaching the child’s brain for just a few moments. Of course everyone is concerned about this, but there is no evidence that these spells cause brain damage or mental retardation. If the period of not breathing lasts long enough, children may develop a seizure. These can be as frightening as the spells themselves, but also do not cause brain damage or retardation. Children who have a seizure during a breath-holding spell are not more likely to develop a seizure disorder (epilepsy) than any other child.

Your doctor will have done a complete physical examination and listened to you describe the spells (or s/he may have seen one him or herself). This is usually enough to make the diagnosis. Your doctor will probably check your child for iron-deficiency, and may prescribe an iron supplement, especially if your child has iron-deficiency anemia (read iron-deficiency anemia Aftercare Instruction). Once we are sure of the diagnosis of breath-holding spells, the best treatment is to learn about them, be prepared for them to happen, and wait for your child to outgrow them. This can be very hard to do. Many parents think that they should try to avoid any situation that would make their child angry, upset, or frightened. Of course, there is really no way to do this all the time, and these feelings are a normal part of a child’s development, so they really should not be avoided all of the time. It is also important to explain this to others who take care of your child, like grandparents and daycare providers. Most professionals who deal with children understand about breath-holding spells, but people who do not recognize that the child cannot help him or herself may either coddle or punish a child inappropriately.

In the past some doctors tried using seizure medications for breath-holding spells, but we no longer think that they are helpful, even to prevent seizures at the end of the spell. In very extreme cases, when children have dangerously low heart rates, doctors have used implantable pacemakers. These can sense a low heart rate and stimulate the heart to beat faster. Pacemakers are effective at making breath-holding spells less common and less severe, but they require one or more operations to put them in and maintain them. Very few children need cardiac pacemakers.

Once we are sure of the diagnosis, there is actually very little to worry about with breath-holding spells. Again, it is important to be sure you help everyone who cares for your child to understand this. Rarely, some other condition is present either in addition to or instead of breath-holding spells. Here are a few things that might be concerning:

• Spells that occur in a child younger than 4-6 months – these can happen but it is less common, and worth checking for other causes such as seizures
• Spells in a child older than 3-4 years old who has never had them before – again, worth checking for other causes
• Spells with unconsciousness that lasts more than a minute
• Seizure at the end of a spell, unless this has happened before and you have discussed it with your doctor
• Vomiting during a spell
• Noisy breathing or trouble breathing after a spell
• Fever after a spell
• Loss of bowel or bladder control during a spell (but before a seizure, if one occurs)
• Spells continuing past the age of about 6 years old

We can all remember the phrase from the old TV shows, "I'm going to hold my breath until I turn blue!" – usually said by a "bratty" or spoiled child. Many people still react to a child with a breath-holding spell the same way, and assume that the parents have spoiled the child. Sometimes people punish children with breath-holding spells. Of course, this is not fair because the child absolutely cannot control them, and is not doing them on purpose. Please be sure everyone who takes care of your child understands this. You may want to give them a copy of this Aftercare Instruction for reference. It is important to learn the kinds of things that trigger a spell in your own child so that you can prevent an injury. For example, if your child is in a swimming pool and gets angry or frustrated, you’ll want to be right by his or her side to prevent a serious accident. Children at this age often have things in their mouths – if you see your child winding up for a spell, be prepared to remove whatever s/he was preparing to put in his or her mouth.

People often mistake breath-holding spells for seizures, and vice versa. Here are some ways to tell them apart:

• Breath-holding spells almost always have a consistent trigger, like anger or frustration; seizures do not
• Breath-holding spells never happen during sleep; seizures often do
• Breath-holding spells never cause bowel or bladder "accidents;" seizures often do
• Children with breath-holding spells have normal EEG (brain-wave studies); children with seizures usually have abnormal EEG studies.

Having a child with breath holding spells can be tiring and frustrating. As badly as you feel for your child, you yourself may feel out of control, inadequate, or even angry – these are normal feelings. Parents often feel stressed to the breaking point, especially when there are other children or adults to take care of. One of the best things you can do for your child is to be sure you take care of yourself. If possible, try to have other adults take care of your child for an hour or two each day so you can get some rest or just some quiet time. If you get so stressed that you are worried about your baby’s safety, call your local Parents’ Anonymous Hotline or visit the Parents Anonymous website  to find a group near you.