Breath Holding Spells

Question

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

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.

Last medical review on: August 10, 2010
About the Author
Photo of Alan Greene MD
Dr. Greene is a practicing physician, author, national and international TEDx speaker, and global health advocate. He is a graduate of Princeton University and University of California San Francisco.
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