Breath Holding Spells

My daughter will be two years old in August. For a year she has had occasional periods when she passes out when crying too hard. It is always brought on from her being angry or upset. She holds her breath, her face becomes purple and her tongue looks purple, also. The whole breath-holding and passing out lasts only a few seconds. Afterwards, she will be sleepy and cry for 5 – 10 minutes. Then she is back to normal. Is she harming herself? Is this normal? Is this more serious than simply holding her breath? Her baby-sitter suggested that these may be seizures.
Sara Silva – Porterville, California

Breath Holding Spells

Dr. Greene’s Answer:

This is a typical scene: A little child is playing happily, something upsets her, she exhales forcefully with a brief, shrill cry — but she doesn’t take another breath. You wait, but she still doesn’t breathe. She looks as if she’s crying, but no sound emerges. She begins to turn blue, her face strained, and still she is not breathing. Now she is unconscious, unresponsive, limp; the sight of her lifeless body is terrifying. Now her back arches, and her blue arms and legs begin to jerk uncontrollably. Your heart is pounding, frantic…

Breath-holding spells are perhaps the most frightening of the common, benign behaviors of childhood. Desperate parents often want to splash cold water on the child’s face, start mouth-to-mouth resuscitation, or even begin CPR. Thankfully, breath-holding spells resolve spontaneously soon after the child passes out, and unless the fall hurts the child, she will be fine afterwards. The spell usually resolves within 30 to 60 seconds, with the child catching her breath and starting to cry or scream. Sometimes children will have real seizures as part of breath-holding spells, but these brief seizures are not harmful, and there is no increased risk of the child’s developing a seizure disorder. Breath-holding spells occur in about 0.1 to 5% of children, usually between ages 6 months to 6 years old.

These spells are provoked by the child’s not getting her own way. While they are triggered by a child being angry or surprised, they are thought to be reflexive, not intentional behaviors. Breath-holding is quite rare before 6 months of age. It peaks as children enter the twos, and disappears finally by about age five. The spells occur sporadically, but when they do occur, it is not uncommon for there to be several spells within a single day. Once parents have witnessed one breath-holding spell, they can often predict when another one is about to happen.

The first time a spell occurs, the parents should have the child examined by a doctor. Because breath-holding spells do share several features in common with seizure disorders, the two are often confused. In epileptic seizures, a child may turn blue, but it will be during or after the seizure, not before. Rarely, other medical conditions may look like breath-holding spells and a visit to the doctor’s will help clarify the situation.

If your doctor confirms that the event was indeed a breath-holding spell, it is a good idea to check for anemia since there is an association between the two. Treating the anemia, if present, will often decrease the frequency of passing out. The parents’ most important job, however, is to not reinforce the breath-holding behavior — either by bending to the child’s will or by paying more attention to her when she has these spells. Instead, if you are certain she hasn’t choked on something, place her in a safe spot (without giving in to whatever she held her breath to achieve), and ignore her behavior.

There is another, far less common, type of breath-holding spell, where the child turns deathly pale instead of blue or purple. These pallid spells are involuntary and unpredictable. They are brought on by a sudden startle, such as falling and striking the head. The child stops breathing, goes limp, passes out, and rapidly drains of color. Pallid breath-holding spells also resolve spontaneously. These children should be examined by a doctor, both to confirm the diagnosis, and to prescribe a preventative medicine if the spells are frequent or severe. There is an even less common type of breath-holding spell associated with a rare genetic condition called familial dysautonomia (Riley Day Syndrome); these involuntary spells occur in children who are already acting seriously ill.

Breath-holding spells shine a brilliant spotlight on one of the biggest challenges of parenting. We do not like to disappoint the little children that we love so much. Moreover, we don’t want to get into yet another battle with our children — in the short run it is always easier to give in to a tantrum than to do what we instinctively feel is best. For parents of breath-holding children, this crucial struggle of parenthood is powerfully amplified.

Most would expect that a breath-holding spell would be difficult. Most are surprised, however, to find that in many ways, the biggest challenge is life between spells. Parents become timid about setting limits or disappointing their children because of the very real possibility of provoking another spell. For all of us, love consists of having the courage to act in spite of our fear.

Dr. Alan Greene

Dr. Greene is the founder of DrGreene.com (cited by the AMA as “the pioneer physician Web site”), a practicing pediatrician, father of four, & author of Raising Baby Green & Feeding Baby Green. He appears frequently in the media including such venues as the The New York Times, the TODAY Show, Good Morning America, & the Dr. Oz Show.

  1. Renata

    There is NO way that behaviour is normal. A well nourished, emotionally healthy child will not do such breath holding. Parents must look at themselves and research child development, nurture their kids and they will be all fine.

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    • Caleo

      Are you kidding me?!? My 4 yr old has had these episodes 3 times in her life. All of which happened after a sudden fall. She was not upset because of not getting her way, she was upset because she was in pain! You can not seriously be telling me that I need to be a better parent! She is very emotionally healthy and strives in life!! I do not believe that holding her breath is in any way something that she chooses to do.

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  2. Catherine madejczyk

    Help 3 month old grandson is in NICU in a PA children’s hospital. Sunday night parent feeding him and he looked to be choking and stopped breathing. CPR was done by parent and EMS. He got to a hospital and now has fluid and blood on the brain. Can this be from a seizure or holding breath or CPR. We need help.

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  3. frank hood

    Can a child’s breath holding spells lead to adult sleep apnea?

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  4. Patrick Movsessian

    It would be interesting to investigate to see if children who have breathholding spells are at higher risk for developing sleep apnea as adults. Maybe there is a genetic link between these two disorders involving a dysautonomia. I know of a brother and sister, one of whom had breathholding spells and the sister had POTS which is an autonomic dysfunction. Breathing is controlled by the autonomic nervous system.
    Patrick Movsessian

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  5. Stephanie

    Hi, I am experiencing this same situation with my 12 month old daughter and it has been occuring for several months. I am repeatedly told that these spells are normal, however I am becoming more concerned. The spells are not becoming more frequent but when they do occur they are longer and worse. As a side note, my daughter was diagnosed with SVT at 7 weeks old and has had two episodes, she is on atenolol. The first breath holding episode was when she was 6 months old (in June of this year). (A week prior to this episode she was diagnosed with pneumonia). We went to the ER and they did several tests including a EEG, EKG ect. and everything came back normal. After this I was told that children do this to get their way and it is somewhat normal. The spells continued and in the past two months have become worse. About 1.5 months ago (In November 2014) she had a swallow study because she had been so congested for almost 3 months and we found out she was aspirating on thin fluids so now she is restricted to thickened fluids only and mashable foods. Two days ago (Dec. 27, 2014) she had a horrible breath holding spell that lasted at least two minutes. She got mad started crying held her breath and turned purple/blue. I picked her up and her whole body was arched back and completely stiff and doing like a fine shake, shiver type movement. Her face was like it was stuck in the crying position with no air coming out no crying nothing just froze. We took her into the kitchen and put ice on her face (as this has worked before) and then started rubbing ice all over her body because she was not coming out of it. Then she went into a calm state where it was like she was almost sleeping and just very calm and out of it, not alert. Then when she finally woke up she cried a little bit and just looked confused. We called 911 during the whole episode and by the time they got there she was fine. We took her to the ER anyways to have her checked out and her vitals remained normal. They did urine and blood cultures and everything came back normal. However they did not do an EEG for seizures. I am just concerned that this is not normal with her other issues and that all of this is related to some underlying issue. I have been researching tracheomalacia, but she does not have the stridor that seems to accompany this. Also, Im wondering if she should be tested for seizures again since the EEG was 6 months ago now. She also has a slight murmur (I can’t remember was type). She had an echocardigram done in August of this year when she was 8 months old and it had not appeared any larger from when she was 7 weeks. Her cardiologist suggested she may outgrow it and we are scheduled to go back in february. When she had the swallow study done in November 2014 (5 weeks ago) the speech pathologist suggested speech therapy to help her learn how to swallow correctly and suggested she see a pulmonologist. However, her pediatrician said lets start with the speech therapy and see if we can get that resolved and then go on to the pulmonologist. We are still waiting for the speech therapy to start. I am just at a loss with all of this and have a really hard time thinking that the breath holding spells are normal when she has all of this issues. I need a direction/advice because I just feel as if something is not right. I appreciate any feedback. Thank you for your time!

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  6. Alana

    My daughter is 4 and had her first episode 3 days ago. She has also been diagnosed with Complex Partial Seizures last year. I can’t find any information regarding a child STARTING with these episodes this late in life. Everything I read says that they outgrow it between 4-6. Does it seem odd that she had her first one at age 4?

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  7. Alessandra

    Im from peru and yesterday mi one year son had an episode. He fell down and it wad lime he couldnt cry…let the air come out. He past out and we didnt know what to do so we starter to shake him. He woke up kindergarten of dizzy and vomit. We went to the er imediately and they did a scan and everything was ok. Im Nervous because he vomites…..is this normal?

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  8. Heather Guynell Pritchard

    My one month old has something similar to this but it only happens when shes sleeping. She doesn’t go pale but she stops breathing and goes limp. I had to smack her back and she started breathing again. It scared both my boyfriend and me. She has done it twice already. My older daughter only did it once but it still scares me. I don’t know if it is relevant but I used to have seizures as an infant. Could this be what she is going through?

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  9. Leah

    is there a adult or teen version of this?

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    • Alan Greene

      Leah, one of my biggest concerns for adults and teens with breath holding is some version of ‘the choking game’ – which is anything but a game. It goes by many names, including air planing, black hole, blackout, funky chicken, and ghost. By whatever name, it’s the voluntary choice to deprive the brain of oxygen, which – unsurprisingly – is not good for the brain.

      There are also seizures and pseudo-seizures that can cause similar spells in adults or teens.

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      • Leah

        one of my friends daughter has this, she is 16 and i constantly see her having one of these, i think maybe she should get it checked out. she never remembers doing it, after she has an episode we get her face in front of a fan or a cold place. this usually makes her breathe better and continue breathing.

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  10. rita

    how can i contact you Dr. Green? i have familly in Canada with a baby boy who was born with that disease. They are willing to come to USA in order to know how to cure, if there is a cure, for the problem. I would really appreciate your answer.

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    • Alan Greene

      Rita, our website office number is 925 964-1793. There you can get information about seeing me or about making an appointment at Stanford’s Packard Children’s Hospital.

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