Breath-holding spells are temporary episodes, especially seen in infancy and early childhood, that progress with breath-holding and loss of consciousness after crying. Although they are generally benign, they are a worrying condition for families.

Breath-holding spells in children usually develop after emotional reactions such as falling, anger, or fear. During the spell, the child may experience cyanosis, convulsions, or short-term loss of consciousness. This condition should not be confused with epilepsy, and differential diagnosis is important.

Breath-holding spells mostly end spontaneously and do not leave a permanent mark on the child’s neurological development. However, injuries related to falls may be seen in recurrent attacks. Properly informing families and helping them remain calm is an important part of the treatment process.

Treatment is not necessary in most cases, and only information and regular follow-up are sufficient. Rarely, if there is iron deficiency or another underlying cause, these need to be treated. Doctor follow-up is necessary both for confirming the diagnosis and ensuring safety.

What Are Breath-Holding Spells?

Breath-holding spells are an involuntary pause in breathing seen in children. It is just like a sudden reflex; just as we pull our hand back without thinking when it gets burned, this is a similar reaction and is not under the child’s control. Although it may occur during temper tantrums, it is not intentional behavior. Children do not deliberately hold their breath during this time. Generally, events that affect them deeply or intense emotions lead to this condition. Understanding that these spells are involuntary is very important for parents to approach their children with support and understanding.

What Types of Breath-Holding Spells Are Seen in Children?

There are basically two main types of breath-holding spells: cyanotic and pallid. In some children, mixed spells carrying the characteristics of both types may also be seen.

Cyanotic Spells: These are the more common type of breath-holding spells. They usually occur as a result of children’s emotional reactions such as anger, frustration, irritability, or sadness. The typical scenario is as follows: the child begins to cry intensely, then becomes silent and the breath stops. During this time, due to lack of oxygen, the face and lips may turn purple or blue. You can think of it like the color of our lips changing when we get very cold. In some cases, the child may also lose consciousness for a short time.

Pallid Spells: These types of spells generally occur as a result of sudden fear, pain, or a traumatic event. Unlike cyanotic spells, in pallid spells the child’s heart rate slows down. After the triggering event, the child either does not cry at all or lets out a short scream, then the breath stops and consciousness is lost. The skin typically takes on a pale color and may even appear sweaty or moist. Sometimes, twitching in the body or urinary incontinence may also be seen in children experiencing pallid spells.

What Happens During Breath-Holding Spells?

During a breath-holding spell, the child first takes a short breath in and out, then the breathing stops. The change in skin color is an important clue for understanding the type of spell. In cyanotic spells, the skin turns purple or blue, while in pallid spells it becomes pale. Fainting or loss of consciousness may also be seen, and this usually lasts less than one minute, at most one to two minutes. In approximately one out of every three children, convulsion-like, involuntary movements may also be observed during the spell. Fortunately, shortly after the loss of consciousness, normal breathing returns spontaneously and the child’s color improves with the first breath. This entire event usually lasts less than one minute, but for anxious parents this time may seem much longer. After the spell, the child usually recovers completely within a few minutes. Understanding this typical course may help parents know what to expect and distinguish these spells from more serious conditions.

When Do Breath-Holding Spells Occur?

Breath-holding spells usually begin between 6 months and 2 years of age, but in some cases they have been seen even in infants as young as 2 months. As the child grows, these spells decrease and usually disappear completely by the ages of 4 to 6. In some cases, this age may extend to 8. The age range in which these spells are most frequently seen is generally between 1 and 3 years, with some sources specifically indicating age 2. The frequency of breath-holding spells may vary greatly from child to child. While some children may have spells several times a day, others may experience them very rarely, such as once or twice a month. An important point to remember is that breath-holding spells occur only when the child is awake and are never seen during sleep. The fact that children outgrow these spells within a few years is a great source of relief for parents concerned about long-term effects.

What Are the Causes and Triggers of Breath-Holding Spells?

Breath-holding spells are thought to be a reflex response to strong emotional reactions or physical stimuli. Common triggers for cyanotic spells include anger, frustration (often related to limit-setting), irritability, sadness, or temper tantrums. Pallid spells are often triggered by pain resulting from minor injuries such as falling or hitting the head, sudden fear, a traumatic event, or anxiety. In addition, a relationship is known to exist between iron deficiency anemia and the frequency of breath-holding spells. This suggests that low iron levels may make children more susceptible to such spells. In some cases, genetic predisposition or a family history of breath-holding spells may also play a role. Some studies show a possible connection with a temporary dysfunction of the autonomic nervous system or a developmental delay in certain regions of the brainstem. The most important thing for parents to understand is that these spells are not a manipulation or attention-seeking behavior; they are a completely involuntary reflex. Identifying potential triggers may sometimes help parents avoid situations that may lead to a spell, but it is not always possible to prevent them completely. The connection with iron deficiency also offers a potential path for medical intervention.

How Are Breath-Holding Spells Diagnosed?

The diagnosis of breath-holding spells is based primarily on a detailed medical history. In this history, the detailed descriptions provided by the parents about the spells are very important. A healthcare professional will perform a physical examination to make sure that the child’s general health is good. Blood tests may be requested, especially to check whether there is iron deficiency anemia. In some cases, especially if there is suspicion of any underlying heart problem, an electrocardiogram (ECG) may be performed. Electroencephalogram (EEG) is generally not recommended unless there are other concerns related to seizures or neurological conditions. It is important to exclude other medical conditions that may mimic breath-holding spells, such as congenital laryngeal stridor, arrhythmia, prematurity apnea, genetic disorders, epilepsy, sepsis, non-accidental trauma, or PDA-dependent congenital heart lesion. A prolonged breath-holding spell lasting longer than 60 seconds should require further investigation to consider alternative diagnoses. The diagnostic process is vital for confirming that the spells are truly benign breath-holding spells and not signs of a more serious underlying medical problem.

What Should Be Done and How Should It Be Managed in Case of Breath-Holding Spells?

During a breath-holding spell, it is very important for parents and caregivers to remain calm. This will help them respond effectively and reassure the child after the spell. The priority is to lay the child in a safe place to prevent injury if loss of consciousness occurs. It is recommended to lay the child on the floor or on the bed. Keeping the child upright during the spell is not recommended, as it may potentially reduce blood flow to the brain. Although some parents think that gently placing a cool, damp cloth on the child’s forehead helps, its effectiveness in shortening the spell has not been definitively proven. It is important to avoid shaking the child or splashing water on them, because these actions do not help and may be harmful. Likewise, placing anything into the child’s mouth, including a finger, food, or drink, is absolutely not recommended in order to prevent the risk of choking or vomiting. Mouth-to-mouth breathing or CPR should not be attempted, because the child’s breathing will return spontaneously. Noting the duration of the spell may help parents realize that these events usually last less than one minute. After the spell is over, it is important to give the child a brief hug and reassurance, then return to normal activities. In general, it is recommended to avoid giving excessive attention to the spell itself, because this may unintentionally reinforce the behaviors that led to the spell.

Preventing Future Spells

Although breath-holding spells are involuntary, there are strategies that parents can apply to potentially reduce the frequency of triggering events. It may be helpful to identify situations that often lead to the child’s tantrums or strong emotional reactions and avoid them as much as possible. It is also important to ensure that the child gets enough rest and is not overly tired or hungry, because these factors may reduce their tolerance to frustration. Using consistent and calm discipline methods can contribute to a more stable emotional environment. Offering age-appropriate choices to the child may give them a sense of control and help reduce feelings of frustration. Praising good behavior may also encourage positive interactions and potentially reduce negative outbursts. In general, it is advised to avoid giving in to tantrums or unreasonable behavior immediately after a breath-holding spell, because this may unintentionally reinforce the behavior that led to the spell. In some cases, distraction techniques may be effective in preventing a spell if intervention occurs before the child becomes too upset or cyanotic.

The Role of Iron Deficiency

There is a known relationship between iron deficiency anemia and the increased frequency of breath-holding spells. As part of the diagnostic evaluation, healthcare professionals may request blood tests to check the child’s iron levels. If the child is diagnosed with iron deficiency, iron supplementation in the form of drops or tablets may be recommended as part of the treatment plan. Interestingly, some studies have shown that iron supplementation may be beneficial in reducing the frequency of breath-holding spells even in children who are not diagnosed with iron deficiency. The typical starting dose for iron supplementation is generally in the range of 3 to 6 mg/kg per day.

When Should Medical Help Be Sought?

Although breath-holding spells are generally benign, it is important for parents to know when they should seek medical help. If you suspect that your child is having a breath-holding spell, especially if it is happening for the first time, it is recommended that you consult your child’s healthcare provider. Medical help should also be sought if the breath-holding spells become more frequent or seem to be worsening. In some cases, urgent medical intervention is required. You should call 112 if the child stops breathing or has difficulty breathing. Medical help should also be obtained immediately if the child has spells lasting longer than 1 minute. Similarly, if the child faints and cannot be awakened, emergency medical services should be contacted. New-onset or different stiffening, trembling, or jerking movements that differ from typical breath-holding spells, especially if breath-holding spells have not previously been diagnosed by a doctor, may indicate a more serious underlying condition requiring immediate evaluation. Sudden paleness, bluish discoloration, or graying of the lips, tongue, face, or skin also requires immediate medical intervention. If a breath-holding spell lasts longer than 1 minute or the child does not regain consciousness quickly, emergency help should be sought. In addition, if tantrums worsen after age 4 and include breath-holding spells to the point of fainting, consulting a healthcare professional is recommended.

Frequently Asked Questions

At what ages are breath-holding spells generally seen in children?

Breath-holding spells are most commonly seen in children between 6 months and 6 years of age and mostly disappear spontaneously as age advances.

What are the differences between breath-holding spells and epileptic seizures?

Breath-holding spells usually begin after crying or anger and are short-lived; epileptic seizures, on the other hand, begin suddenly without cause, last longer, and drowsiness may occur afterward.

What are the triggers of breath-holding spells in children?

The most common triggers are intense emotional reactions such as sudden fear, pain, frustration, or anger; rarely, hunger or fatigue may also be triggering factors.

What findings are observed in a child during breath-holding spells?

Breath-holding, cyanosis or paleness, convulsions, and short-term loss of consciousness may be observed in the child; the spell usually ends within one minute.

How should first aid be performed in children having a breath-holding spell?

Move the child to a safe environment, turn the head to the side, loosen tight clothes, and wait for the spell to pass on its own; if it lasts long, medical help should be sought.

Do breath-holding spells negatively affect children’s intelligence or development?

Breath-holding spells mostly do not negatively affect children’s brain development, intelligence, or learning and do not cause permanent damage.

What are the psychological effects of breath-holding spells?

Frequently recurring spells may create anxiety and insecurity in the child, and intense worry and overprotective behaviors in the family; psychological support is recommended if necessary.

In which situations is specialist evaluation required for breath-holding spells?

If the spells recur very frequently, last long, the child does not recover for a long time after cyanosis, or there is a family history of epilepsy, a pediatric neurologist should evaluate the child.

Is medication use necessary in the treatment of breath-holding spells?

Most children do not need drug treatment; rarely, if the spells are very severe and frequent or are confused with other diseases, medication may be considered.

How can breath-holding spells be prevented and what should families pay attention to?

Being sensitive to the child’s emotional needs, avoiding triggering situations, and providing stress management may be beneficial in reducing the frequency of spells.

Which Department or Doctor Should Be Consulted for Breath-Holding Spells in Children?

Breath-holding spells usually occur in the form of short-term fainting and breath cessation, especially after crying, and are generally benign. However, in order not to confuse similar conditions with more serious neurological diseases such as epilepsy, it is recommended to consult the Pediatric Neurology department.