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.
(See also Overview of Behavioral Problems in Children.)
Breath-holding spells occur in 0.1% to 5% of otherwise healthy children (1). They usually begin in the first year of life and peak at age 2. They resolve by age 4 in over 50% of children and by age 8 in almost all children (2). The remainder may continue to have spells into adulthood.
Breath-holding spells do not appear to be risk factors for true epilepsy (3) but may be associated with an increased risk of fainting spells in later life (4).
Almost all breath-holding spells occur secondary to a precipitating external trigger that is either physical (eg, trauma) or mental (eg, emotional outburst due to anger or panic).
There are 2 forms of breath-holding spells:
Cyanotic form: This form is the most common, and although the breath holding is involuntary, it 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 voluntary episodes that sometimes occur in children, in which they hold their breath to demand something from an adult (eg, candy, staying at a party); invariably, children who voluntarily hold their breath resume normal breathing when they become uncomfortable.
Both voluntary and involuntary forms of breath-holding spells may range in duration from 10 to 60 seconds (1).
References
1. Leung AKC, Leung AAM, Wong AHC, Hon KL: Breath-holding spells in pediatrics: A narrative review of the current evidence. Curr Pediatr Rev 15(1):22–29, 2019. doi: 10.2174/1573396314666181113094047
2. DiMario FJ Jr. Prospective study of children with cyanotic and pallid breath-holding spells. Pediatrics. 2001;107(2):265-269. doi:10.1542/peds.107.2.265
3. Hellström Schmidt S, Smedenmark J, Jeremiasen I, Sigurdsson B, Eklund EA, Pronk CJ. Overuse of EEG and ECG in children with breath-holding spells and its implication for the management of the spells. Acta Paediatr. 2024;113(2):317-326. doi:10.1111/apa.17020
4. Shen WK, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society [published correction appears in Circulation. 2017 Oct 17;136(16):e271-e272. doi: 10.1161/CIR.0000000000000537.]. Circulation. 2017;136(5):e60-e122. doi:10.1161/CIR.0000000000000499
Cyanotic Breath-Holding Spell
During a cyanotic breath-holding spell, an involuntary sequence of events occurs in children until they lose consciousness.
Typically, the child cries out, exhales, and involuntarily does not inhale. Shortly afterward, the child begins to turn blue and unconsciousness ensues. Rarely, a brief self-limited 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. If spells are recurrent, parents should attempt to avoid situations that trigger episodes.
Children with cyanotic breath-holding have been found to respond to iron therapy (1), even in the absence of anemia, and to treatment for obstructive sleep apnea (when present).
Cyanotic spell reference
1. Hamed SA, Gad EF, Sherif TK: Iron deficiency and cyanotic breath-holding spells: The effectiveness of iron therapy. Pediatr Hematol Oncol 35(3):186–195, 2018. doi: 10.1080/08880018.2018.1491659
Pallid Breath-Holding Spell
During a pallid breath-holding spell, vagal stimulation severely slows the heart rate.
The child involuntarily does not inhale, 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 intervention.
Because this form is rare, further diagnostic evaluation and treatment may be needed if the spells are recurrent. Simultaneous ECG and electroencephalography can help differentiate cardiac and neurologic causes.
