Breath Holding Spells
The typical call to the pediatrician is “My 15 month-old just had a ‘blue spell’!" The parent usually reports their child was playing quietly and then suddenly collapsed on the ground, his/her lips turning blue. A few moments later, the child takes a big breath and wakes up. By the time we talk to the parent, the child appears comfortable, alert, calm, and is playful. And although we often will ask more questions, perform a detailed exam and possibly do a few tests, the diagnosis 99 out of 100 times is “a breath-holding spell”.
What does a breath-holding spell look like?
Breath-holding spells follow a very scripted sequence. They are usually provoked by something that causes anger, frustration, pain, or surprise which is quickly followed by crying. The child then becomes quiet, exhales, and stops breathing. The skin color changes quickly (becoming pale or bluish) and then the child loses consciousness and becomes stiff or, less often, limp. Usually breathing stops for about 10 seconds. From start to finish breath-holding spells usually lasts from two to 20 seconds. The child will usually return to consciousness fairly rapidly, remaining drowsy only briefly before resuming normal activity. These spells are totally involuntary since the breath is held after exhalation (breathing out), not after inhalation (breathing in).
There are 3 types of breath holding spells:
- Cyanotic (bluish) spells (which account for 62% of the total) are usually precipitated by an event that makes the child frustrated or angry. The child cries vigorously and quickly develops cyanosis or facial blueness.
- Pallid spells (19% of the total) are more often provoked by a sudden, unexpected event that frightens the child, such as a bump to the head or a scary surprise. The child cries only a little, becomes pale and limp, and may posture or show convulsive movements before regaining consciousness. These spells are sometimes called "white breath-holding.”
- Combination spells (19% of the total) include both cyanosis (blueness) and pallor (whiteness).
The most important thing to remember about all breath-holding spells is that they are not dangerous and have nothing to do with epilepsy.
Who has breath-holding spells? The child with a family history of breath-holding spells may be at higher risk of having spells than other children, perhaps because of an underlying, as yet, unknown, genetic predisposition. Most children who have breath-holding spells have the first spell between 6 and 18 months of age. The number of times can vary from several times a day to once a year or many times in a single day. 1/3 of affected children have two to five spells each day, while another 1/3 have only one a month. In most children, the spells peak between age one and two years and then gradually become less frequent. The breath-holding spells in 50% of children resolve by age 5 years, 90% resolve by age 6 years, and 100% by age 7 years. Breath-holding spells are equally common in boys and girls. It is likely that for the same reason that children have breath-holding spells, they have head banging and bulimia (forceful vomiting) episodes. These “behaviorisms” all occur around the same age and disappear around the same age.
Why do breath-holding spells occur? Breath-holding spells represent interplay among the respiratory control center in the brain, the autonomic nervous system that helps us respond to the environment (“fight or flight” response), and the cardiovascular system (heart). They reason why children with breath-holding spells respond differently to environmental situations than other children is not clearly understood although genetics seems to be a factor.
What do I do if my child has a breath-holding spell? First and foremost, remember that these spells are harmless and always stop by themselves. Time a few spells using a watch with a second hand, since it's difficult to estimate the length of an attack accurately. Have your child lay flat on his back to increase blood flow to the head (this position may also prevent some muscle jerking). Don't start resuscitation—it is unnecessary. Also, please don't put anything in your child's mouth; it could cause choking or vomiting.
Treatment after a breath-holding spell. When the spell is over, give your child a brief hug and go about your business. A relaxed attitude is best. If you are frightened, don't let your child know it. If your child had a temper tantrum before the spell because he wanted his way, please don't give in to him after the spell.
Prevention of breath-holding spells. Spells that result from a fall or a sudden fright can't be prevented. Most spells that are triggered by anger also are involuntary. If your child is older than 2 years and is having daily spells, however, he probably has learned to trigger some of them himself. This often happens when parents run to the child and picks him up every time he starts to cry or give him his way as soon as the spell is over. If you avoid these responses, your child won't have an undue number of spells.
It is very difficult for parents to set limits when their child has breath-holding spells, especially if the spell is precipitated by frustration when their parents says “no.” It is important to remember that children who react to frustration with breath-holding need well- defined limits even more than other children do. Once they learn the rules, they will experience less frustration and cry less often than they did when limits were unclear, thereby initiating fewer breath-holding episodes.
Even though breath-holding spells can be scary, remember that they are over quickly and are not harmful. Please call us if your child holds their breath for more than one minute, is older than 6 years and having their first spell, or you are unsure whether or not your child is having a breath-holding spell.