Breath-holding spells in children

'Breath-holding spells' refers to two distinct conditions that can occur when a child is frightened, upset or angry, or experiences a sudden shock or pain.

The child seems to stop breathing on the outward breath (exhalation), turns a deathly pale grey or blue colour, and temporarily loses consciousness.

The episodes are involuntary, which means the child can't control them. They usually last for less than a minute and, although upsetting to witness, don't harm the child.

Breath-holding spells are common, with one type or the other occurring in around 1 in 20 children. They usually start between 6 and 18 months of age, and affect both boys and girls equally.

In many cases they'll stop by the time the child is 4 or 5 years old, although some children will continue to experience them into adulthood.

Types of breath-holding spells

There are two distinct disorders that are called breath-holding spells.

Blue breath-holding spells

Blue breath-holding spells are the most common type of breath-holding disorder, and often occur during vigorous crying or sobbing that's triggered by pain, frustration, anger or fear.

The child usually cries vigorously for less than 15 seconds and then becomes silent, their breath held on the outward breath, unable to take an inward breath (inhale).

They turn blue – particularly around the lips – and lose consciousness. Milder attacks without loss of consciousness will be familiar to most parents.

The child will become either floppy or stiff and remain unconscious for less than a minute before regaining consciousness and breathing normally again. They may appear tired for a while afterwards.

Blue breath-holding spells are caused by an involuntary reflex that's part of the crying mechanism.

In some children, particularly in toddlers, it's so intense that they get stuck in an outward breath for so long that they faint.

In the pre-school years, some children may have several fainting episodes a week. However, most children will grow out of them by the time they start school.

The episodes are involuntary, aren't dangerous and don't cause brain damage. They're not a sign of a difficult child or poor parenting. They're not epileptic seizures.

The episodes will improve with age, but may get more frequent before they become less frequent and disappear altogether.

If the child is iron deficient, treatment with iron supplements can help. A simple blood test can be used to determine whether the child is anaemic or iron deficient.

Reflex anoxic seizures

Reflex anoxic seizures are often triggered by a sudden unexpected fright or pain, such as a fall with a minor head injury. The seizure isn't caused by the injury itself, but by the sudden fright or pain.

The child will often open their mouth as if they're going to cry, but make no sound before turning a deathly pale grey colour and losing consciousness.

They'll become either limp or more often stiff, with their eyes rolling upwards and their fingers clawed. Their body may also jerk a few times.

The seizure will usually last less than a minute. Afterwards the child will regain consciousness, but may appear sleepy and confused for a few hours.

Reflex anoxic seizures are caused by an involuntary slowing of the heart rate, to the extent that the heart actually stops beating for 5 to 30 seconds. This is why the child looks so deathly pale.

However, the heart is normal and the slowing is caused by an excessively strong reflex signal from the brain via the vagus nerve.

The vagus nerve is one of 12 nerves in the head. It runs down the inside of the head, passes through the neck, and into the chest and abdomen.

After 5 seconds of the heart beat stopping, the child will start to lose consciousness, and after 10 seconds they'll be deeply unconscious. Usually, by 30 seconds the vagus nerve starts to lose its signal strength and the heart starts beating again on its own.

The heart will always automatically start to beat on its own as the strength of the vagus nerve signal fades.

In the pre-school years, some children may have several reflex anoxic seizures a month, but most will grow out of them by the time they start school. Some children will continue to occasionally have them into adult life.

Reflex anoxic seizures are involuntary, aren't dangerous and don't cause brain damage or death. They're not a sign of a difficult child or poor parenting. They're not epileptic seizures.

The seizures will improve with age, but may get more frequent before becoming less frequent or disappearing altogether.

If the child is iron deficient, treatment with iron supplements can help. A simple blood test can be used to determine whether the child is anaemic or iron deficient.

Telling the difference between the two types

It isn't always possible to tell the difference between a blue breath-holding spell and a reflex anoxic seizure.

However, in most cases the advice will be the same: reassurance and treatment for iron deficiency.

If episodes are very frequent or severe, it's worth trying to distinguish between them.

The main features of a blue breath-holding spell are:

they usually occur when the child is very upset and cries vigorously
the child turns blue and stops breathing after a series of sobs where they breath out (exhale)
breathing will resume after gasping or taking an inward breath
the child may go stiff or floppy while unconscious

The main features of reflex anoxic seizures are:

they usually occur when the child has a sudden, unexpected fright or pain – the trigger may not always be obvious
the child may or may not cry or sob first
they typically go a deathly pale grey colour and collapse, losing consciousness
they often go stiff rather than floppy, and then gasp as they come round when their colour returns

What to do if your child has a breath-holding spell

If your child has a blue breath-holding spell or reflex anoxic seizure, you should:

stay calm – it should pass in less than a minute
lie them on their side – don't pick them up
keep an eye on them until the spell ends
make sure they can't hit their head, arms or legs on anything – if they start to jerk, gently cushion their head, arms or legs to prevent injury
avoid shaking or hitting them
avoid putting anything in their mouth – including your fingers
avoid splashing them with water
avoid mouth-to-mouth resuscitation

You don't need to try to help your child breathe or help their heart beat.

They'll start breathing on their own, and their heart will return to a normal rhythm on its own after the episode or seizure has finished – this is usually in less than a minute.

Afterwards, they may cry or scream.

Reassure your child and make sure they get plenty of rest after having a blue breath-holding spell or reflex anoxic seizure.

Act as if nothing has happened and avoid making a fuss – don't punish or reward them.

When to see your GP

See your GP the first time your child has a blue breath-holding spell or reflex anoxic seizure. Your child will need to be thoroughly examined to check whether they have a more serious underlying problem.

Ask your GP to carry out a routine ECG if they don't suggest one themselves.

Your GP may ask you to describe what happens during an episode to see whether there's a trigger.

Blue breath-holding spells almost always occur during crying. Reflex anoxic seizures will sometimes have a trigger, such as a sudden unexpected pain or fright.

Epileptic seizures can look similar, but don't usually occur in these circumstances.

You should also take your child to see your GP if they have episodes and:

they're younger than 6 months
they have frequent episodes (more than 1 a week) – it may be being caused by anaemia
they're confused after a breath-holding episode
any stiffness or shaking lasts much longer than a minute and they take a while to recover
the episodes are so frequent and severe that they're affecting normal family life

Although blue breath-holding spells and reflex anoxic seizures can be scary to witness, they don't harm the child and don't cause neurological problems, such as brain damage or epilepsy.

Iron deficiency anaemia

In some cases, blue breath-holding spells and reflex anoxic seizures may be linked to iron deficiency anaemia.

This is where a lack of iron in the body leads to a reduction in the number of red blood cells, causing symptoms such as tiredness, shortness of breath, heart palpitations and a pale complexion.

Treating breath-holding spells

There's no specific treatment for blue breath-holding spells, but your child should have a thorough examination to check for any underlying problems, and an ECG to check for an irregular heartbeat.

Reflex anoxic seizures can respond to some specific medicines, but these are usually only offered in cases where the seizures occur very frequently and have a significant impact on family life.

These medicines – which include glycopyrronium, atropine, and hyoscine – can cause a dry mouth, large pupils and other side effects.

Ask your GP to refer your child to a specialist in childhood conditions (paediatrician) if you're concerned.

Your child's blood iron levels, such as ferritin, may also need to be checked and iron drops or tablets prescribed if levels are low.

Being a parent of a child with these seizures can be stressful, so see your GP if you're finding it difficult to cope.

They may be able to give you some advice about things you can do to reduce stress, such as breathing exercises for stress.

You could also seek help from a specialist counsellor who can teach you parenting techniques to help you deal with your child's breath-holding episodes.

Preventing breath-holding spells

Some parents are able to tell when their child is about to have a blue breath-holding spell or reflex anoxic seizure because they display certain behaviours.

Try to distract your child if you think they're about to have an episode as this can sometimes prevent it happening.