Breath holding spells —  Super Scary for parents, not a big deal for kids

The Pediatric Insider

© 2017 Roy Benaroch, MD

Lemelon wrote a topic suggestion: “Breath holding spells. My toddler had a cyanotic breath holding spell after a bad fall where he struck his head on concrete from a height of about 4-5 feet. I didn’t know about breath holding spells and was pretty sure he was going to die. Thought maybe other parents would like to learn about them and their prevalence. Thanks!”

Near the top of a list of super-scary things for parents to see are breath holding spells. Your kiddo, typically a toddler, bonks his head or gets really mad about something. Then he stops breathing, turns white, and collapses on the floor. And looks dead. Really. Dead. It’s quite dramatic. I can say this, calmly now, because the child of mine that used to have them hasn’t had one in over 10 years. I’m a doctor, but with your own kid breath holding spells are freaky and scary.

But they aren’t freaky and scary to the children. After a few moments, they start to breathe again, and they might be a little tearful or clingy for a few minutes, and then they’re fine. Mom and dad need a long lie-down and a few glasses of Chablis, but the kiddos, I promise, they’re fine.

So what are breath holding spells? They’re kind-of-sort-of like a faint. They usually happen in toddlers, say from 6 to 18 months of age, and usually start with either a painful stimulus or less-often a very frustrating or fearful sort of event. The child might then gasp, and stop breathing, and almost immediately turn very pale or sometimes blue. Here’s a weird thing: even though their skin can look blue, there’s still plenty of oxygen in their blood. This happens way too fast to drop blood oxygenation. They look like they’re blue and dying, but they’re not. And: breath holding spells are entirely, 100%, involuntary. These are not kids who decide to hold their breath until they pass out.

During this period, what’s basically happening is that the autonomic nervous system – that’s the involuntary, behind-the-scenes part of the nervous system that you don’t think about much – slows down the heart, and clamps down the blood vessels, and, well, shuts off the brain. The kids go limp, and collapse breathless on the floor. Sometimes, there can be just a few little muscle jerks or spasms right there at the end, too, to further freak you out.

But just a few seconds later, everything resets. The heart resumes normal beating, circulation returns, and Junior wakes up. Crazy, I know, but leave it to kids to come up with something like this. Look mom, I’m dying! Just kidding!

(If the child doesn’t wake up and start breathing within 3 minutes, start CPR and call 911. I’ve not seen or heard of that happening, and I don’t think any parent would even wait that long, but I don’t want parents to not call 911 if they’re worried!)

Breath holding spells are fairly common – they happen in 4-5% of children, maybe a little more commonly in girls. Though they typically start at 6-18 months, some babies will start younger. They usually stop by age 4 years or so, though some kids go on to have more-ordinary fainting spells from there.

Bottom line: as scary as they are, breath holding spells are harmless. The main thing is to diagnose them correctly (which is 100% entirely by the history, there are no tests or scans or anything) and to avoid a huge, expensive, painful, and misleading diagnostic odyssey. These kids do not need a bunch of tests. If the diagnosis isn’t clear from the history (say, the events are unwitnessed or atypical), sometimes a few tests can rule out other things.

There are a few off-label medicines that are rarely prescribed to prevent breath holding spells, especially if they’re happening very frequently. There’s some evidence, not great, that iron supplementation may sometimes be helpful. But that’s it in terms of medical therapy. (That, and the Chablis)

With breath holding spells, the doc’s job is to listen and get the diagnosis right, without unnecessary tests; the parents’ job is to leave the kiddo alone until he wakes up, and try not to freak out; and the child’s job is to outgrow them before Daddy has a heart attack, OK?

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5 Comments on “Breath holding spells —  Super Scary for parents, not a big deal for kids”

  1. Olivia Says:

    My daughter fell at day care when she was in the 1 year old room and hit her head and then had what we learned the next day from her pediatrician was a breath holding spell. Daycare called an ambulance and we met it and had a trip to the ER, where she was totally fine so they checked vitals, gave her a popsicle and after a while we all went home. I stopped by pediatrician to inform them the next morning, because despite the Chablis, I was still a bit freaked out, during their walk in hours and he immediately diagnosed this and said they see them all the time with vaccinations, wasn’t surprised ER docs and EMTs had no clue. Luckily she never had them again. Moved on to night terrors to freak us out, another thing I’ve never heard of till after we experienced the first ones. Yikes.


  2. Dr. Roy Says:

    Yup, night terrors are big-time freaky, too!

    I haven’t seen breath holding after a vaccine — I think because these kinds of spells usually start to peter out by 3 or 4 years, and it’s the 4 year olds who are most upset/scared by the shots. I’m sure it could happen, but I haven’t seen it.

    Sometimes teenagers faint after vaccines or finger-sticks, but that’s a little different.


  3. wzrd1 Says:

    I wonder if breath holding, pallor/cyanosis effect isn’t a survival trick, akin to that which an opossum uses?
    Stranger things have happened in nature.


  4. INTP mom Says:

    Thank you for explaining this so thoroughly. My daughter had a breath-holding spell a few years ago when she was 2, after tumbling down a flight of stairs. She cried for a few seconds and then became quiet and looked at me with a blank stare, before her eyes rolled into the back of her head and her arms curled into her chest and went stiff. It was the scariest moment of my life and like you said, I thought she was dying. We went to the ER and they said it was a breath-holding spell, but they didn’t explain it half as well as this blog post.

    Now, my 1-year-old son sometimes cries so hard that he can’t catch his breath and turns blue, and once or twice has passed out. Our pediatrician said these are breath-holding spells, and they happen either when he gets hurt or when he’s really upset about something. She also said that some toddlers hold their breath on purpose to the point of passing out when they’re upset with their parents, and my son used to do this every time I wanted to cut his nails. So I’m curious, since you said breath-holding spells are completely involuntary, whether this is something different.


  5. Dr. Roy Says:

    INTP, I do not think it is possible for anyone to voluntarily hold their breath until they pass out. The drive to breathe is too strong (unless you’ve done something to manipulate your carbon dioxide excretion, but that’s a completely different thing — see “troublemaking teenagers”). Breath holding spells are not voluntary events.

    This ABC news story makes the point well, and shows how parents sometimes feel “hostage” to the breath holding, because it’s scary. But that doesn’t mean it’s voluntary or the child’s fault or the parents’ fault:

    Liked by 1 person

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