Breath-Holding Spells
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Breath-Holding Spells
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Breath Holding Spells header

Author: Sonal Bhatia MBBS, MD
Medical University of South Carolina  

Reviewed: June 2021 

SUMMARY

Breath-holding spells are short spells of time during which a child stops breathing. They are commonly mistaken for seizures 

Spells usually occur in an otherwise neurologically healthy toddler. The most common age for a spell is between 12 and 18 months old. Some children with breath-holding spells can be younger.  

This condition is seen in about 1 in 25 children during the first few years of life.  

There are two types of breath-holding spells. Both types may occur in the same child at different times. They are defined based on the child’s color during the spell: 

  • Cyanotic Breath-Holding Spell. A child turns blue during this type of spell. “Cyanosis” is the medical term for taking on a bluish or purplish tone. This coloring is due to lack of oxygen in the blood.  
  • Pallid Breath-Holding Spell. A child appears pale rather than blue during this type of spell. 

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Disorder Overview

DESCRIPTION/SIGNS & SYMPTOMS 

Cyanotic Breath-Holding Spells 

These are also called:  

  • Blue breath-holding spells 
  • Cyanotic infantile syncope 

These are the most common type of breath-holding spells. They are seen in more than half of cases. 

They are provoked and preceded by crying. Sometimes, the crying is not intense. For instance, cyanotic spells can be provoked by mild sobbing.  

Triggers involve an emotional upset of some kind. An example might be an older sibling taking away a toy.

Emotions can include: 

  • Fear 
  • Anger 
  • Frustration

Sequence of events seen during a cyanotic spell

  1. Child cries inconsolably and vigorously.  
  2. Child appears to take a deep breath. Child stops breathing during the process of releasing air from the lungs. In other words, breathing stops during expiration. 
  3. Child turns blue and passes out. This is likely due to a temporary cut-off of oxygen to the brain. 
  4. Child becomes stiff. Child then might lose muscle tone. Or the child might show brief, abnormal jerking movements of the limbs. These movements can be quick or repetitive. This stage may resemble or be mistaken for a seizure.  
  5. As the episode ends, the child takes a deep breath. The child regains consciousness. 
  6. The child then has a quick return to baseline activity. There are usually no physical consequences. 

A typical spell like this lasts less than a minute. 

This is usually only a respiratory event. It usually does not cause any change in heart rate or rhythm.  

Note: These spells are not done on purpose by the child. Crying during a tantrum could provoke a spell. However, spells themselves are not self-induced temper tantrums.  

Breath Holding Spells

Pallid Breath-Holding Spells 

These are also called: 

  • White breath-holding spells 
  • Reflex anoxic seizures 

These are a less common type of breath-holding spell than cyanotic spells. However, they are more commonly mistaken for epileptic seizures. 

Syncope is a loss of consciousness, or fainting. Pallid breath-holding spells  resemble fainting. They can mimic other kinds of syncope. For instance, they can look like vasovagal syncope. Vasovagal syncope happens because of an emotional trigger, such as the sight of blood. 

Pallid spells can be caused by a sudden fright. They can also be caused by pain from a relatively trivial trauma. For instance, a trivial trauma might look like a bump to the head or a fall on the sofa cushion. 

Sequence of events during a pallid spell

  1. Intense crying is absent. A brief, feeble cry be present. 
  2. Child gasps. Child then suddenly turns pale and looks dead. This can be very scary. 
  3. Child can have some extremity jerking. Sometimes abnormal eye movements maybe seen. Caregivers or observers might think this is an epileptic seizure.  
  4. Child quickly returns to baseline activity. Tiredness and sleepiness may be seen in some.  

These spells may last longer than a minute. 

During an attack, the child’s pulse slows significantly. This may frighten an observer.  

Note: The term “seizure” in reflex anoxic seizure does not make this a true epileptic seizure. It is a syncope (fainting). Seizure-like movements are caused by the loss of oxygen. 

Features Similar to Both Spells 

Some characteristics are the same in both types of breath-holding spells. These include: 

  • Variance. Spells can vary in frequency, severity, intensity, and duration. This can be true even in one same child with recurrent events.  
  • Recurrence. Spells can recur. In some, this can happen even on the same day.  
  • Wakefulness. Spells always occur while a child is awake. 

Breath-Holding Spells Versus True Epileptic Seizures 

These spells and epileptic seizures can look similar. However, there are some important differences. 

  • Provocation. Breath-holding spells are always provoked. This means they have a trigger. True epileptic seizures are not always provoked. 
  • Return to baseline. Returning to baseline means returning to a child’s state before the incident. There is a quick return to baseline after a breath-holding spell. There is usually a delayed return to baseline after a true epileptic seizure. 
  • Color change. Color change precedes seizure-like movements in a breath-holding spell. A child may turn blue only during or after a true epileptic seizure. 
  • Eyes. Eyes always remain closed in breath-holding spells. Eyes are always open in a true epileptic seizure. 
  • Wakefulness. Breath-holding spells always occur while awake. True epileptic seizures can occur while awake or asleep.  
Breath Holding Spells 2

CAUSES

Cyanotic Breath-Holding Spells 

The exact mechanism of these is not clearly understood. It is somewhat complex. 

Consciousness requires a steady flow of blood and oxygen to the brain. This gets interrupted when a child is holding their breath. As blood and oxygen stop flowing to the brain, a child can pass out and turn blue.  

Pallid Breath-Holding Spells 

These are believed to be a vasovagal response to pain caused by a relatively trivial trauma. The vagus nerve controls the heart rate. Sometimes it is overactivated. This is called a vasovagal response. This overactivation can result in a decrease in the heart rate. A decrease in heart rate can lead to a reduction in blood and oxygen supply to the brain. This reduction, in turn, can cause a child to lose color and pass out. 

Causes Common to Both Types 

Sometimes, parents or siblings have also experienced breath-holding spells. This supports a genetic basis for the condition.  

Iron deficiency and iron-deficiency anemia may also be associated with breath-holding spells. 

Breath Holding Spells 1

LABORATORY INVESTIGATIONS 

Making a Diagnosis 

No laboratory investigations are needed to make an initial diagnosis. 

A detailed history of the event and the provoking triggers is enough to make a clinical diagnosis. A detailed history can also help to differentiate breath-holding spells from: 

  • Epileptic seizures 
  • Cardiac phenomena, such as syncope or abnormal heart rhythms (arrhythmias) 

Video recording the spells with a cellphone camera is another quick and inexpensive way of arriving at a diagnosis. 

Further Testing 

Blood labs are sometimes necessary. A complete blood count and iron study may be done to rule out iron-deficiency anemia. 

An electroencephalogram (EEG) is a test that can record brain waves to assess someone’s risk of having a seizure. An EEG may be ordered in rare cases for events that might be breath-holding spells. They are ordered if: 

  • The history of an event cannot be clearly recalled 
  • The event had atypical features 
  • The event was prolonged  

If a breath-holding spell is captured on an EEG, it does not show features that are seen during a true epileptic seizure. Instead, it shows transient slowing of the brain waves. This occurs due to a decrease in the blood and oxygen supply to the brain during a spell. If an EEG is done outside a spell, largely, it does not show the presence of waveforms that suggest someone maybe at an increased risk for seizures.  

In rare cases, a cardiologist referral may be placed. This can happen if there are atypical features of the spell, or if a cardiac condition is suspected. 

TREATMENT AND THERAPIES 

No treatment is needed for isolated, rare, or infrequent events.  

It is important to reassure and counsel parents. They should understand the benign nature of these spells. Parents may avoid disciplining their child for fear of provoking an event. Decreasing parents’ emotional reaction to the spells allows for age-appropriate discipline. 

Oral iron supplementation tends to improve spells. This helps especially if the child is iron deficient. Iron is usually given for between 1 and 4 months. 

Extremely severe cases sometimes require a heart pacemaker. A pacemaker is an electrical device used to stimulate or steady the heartbeat. It requires surgery to implant. A pacemaker is used when the spells involve: 

  • Significant bradycardia. Bradycardia is a decrease in the heart rate below what is normal for one’s age. 
  • Asystole. Asystole is an arrest of cardiac activity (stopping of the heart). 

The use of antiseizure medications is almost never recommended for breath-holding spells. This is true even in cases where the child shows brief convulsive movements during a spell. In rare cases, a breath-holding spell may evolve into an actual epileptic seizure. Still, this typically does not warrant the use of an antiseizure medication.  

Breath Holding Spells 3

 What to Do During a Breath-Holding Spell 

  • Do not panic. This is true for both parents and onlookers. 
  • Place the child sideways. 
  • Ensure the child is in a safe location. 
  • Avoid picking the child up during a spell. This may prolong the spell.  
  • Do not perform mouth to mouth breathing or cardiopulmonary resuscitation. Spells are brief, with quick recovery.  

LONG TERM 

No long-term neurological or health issues occur as a consequence of having breath-holding spells in childhood. 

There is not an increased risk of having epileptic seizures associated with breath-holding spells. This is true even if the child shows convulsive movements during the spell.  

Children with pallid breath-holding spells as a toddler may continue to experience vasovagal syncope as they grow older.  

In rare cases, children may develop transient or long-term behavior issues or temper tantrums.  

OUTLOOK

Breath-holding spells do not harm the child. However, they are very scary for a parent to watch. 

They are age-dependent which means they are related to brain maturity. They resolve over time, usually by 5 to 7 years of age.  

Children with pallid breath holding spells may develop vasovagal syncope as adolescents and adults. Again, this is due to an “overactive” vagus nerve. 

Overall, outlook is excellent for both types of breath-holding spells. 

Breath Holding Spells 4

Research 

ClincalTrials.gov for breath-holding spells are clinical trials that are recruiting or will be recruiting. Updates are made daily, so you are encouraged to check back frequently.  

ClinicalTrials.gov is a database of privately and publicly funded clinical studies conducted around the world. This is a resource provided by the U.S. National Library of Medicine (NLM), which is an institute within the National Institutes of Health (NIH). Listing a study does not mean it has been evaluated by the U.S. Federal Government. Please read the NLM disclaimer for details.  

Before participating in a study, you are encouraged to talk to your health care provider and learn about the risks and potential benefits. 

The information in the CNF Child Neurology Disorder Directory is not intended to provide diagnosis, treatment, or medical advice and should not be considered a substitute for advice from a healthcare professional. Content provided is for informational purposes only.  CNF is not responsible for actions taken based on the information included on this webpage. Please consult with a physician or other healthcare professional regarding any medical or health related diagnosis or treatment options. 

References

Flodine TE, Mendez MD. Breath Holding Spells. [Updated 2020 Oct 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539782/  

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