Breath Holding Spells


February 26, 2018 by: Roy Benaroch, MD Article Tags:

Q My toddler had a cyanotic breath-holding spell after a bad fall where he struck his head on concrete from a height of about four to five 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!

A 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 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, 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 three 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?

Roy Benaroch

Roy Benaroch, MD

Roy Benaroch, MD, FAAP is an Associate Adjunct Professor of Pediatrics with Emory University. He has produced several courses exploring medical cases for laymen in his "Medical School for Everyone" lectures, available from The Great Courses, and has also written books for parents and chapters in medical textbooks. He is also on the Board of Directors of The Children's Care Network, one of the largest clinically integrated pediatric care networks in the country. Dr. Benaroch practices general pediatrics near Atlanta, GA.