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What is breath-holding?
A breath-holding spell is a transient episode in which a toddler turns blue or pale, and appears to be holding their breath.
Although these spells often occur during toddler tantrums, they are a reflex reaction and not a deliberate action on the child's part. Breath-holding spells typically follow a minor accident, pain, fright, or a state of anger and frustration.
Breath-holding typically starts before a toddler is 18 months old, with their peak frequency occurring during the second year of life. Most children grow out of these spells by the time they are six years old and they are rare in children over the age of eight years.
- Are very common in toddlers, but can also occur in babies;
- Occur in about 5% of children aged between six months and six years; 
- Affect girls and boys equally, and;
- Generally do not cause any short-term or long-term harm.
Although breath-holding can be incredibly distressing for a parent to witness, they are not the same thing as epileptic seizures. Some of the main differences between breath-holding spells and epileptic seizures include:
- Breath-holding spells do not cause loss of bladder or bowel control, while epileptic seizures often do;
- Breath-holding spells never occur during sleep, whereas epileptic seizures may do;
- Breath-holding spells generally have a trigger, while epileptic seizures do not;
- Before the breath-holding spell a child may turn blue, whereas in epilepsy, the child may turn blue during or after the seizure, and;
- Children with breath-holding spells have a normal electroencephalography (EEG) test result, while children with epileptic seizures have abnormal EEG results.
Breath-holding spells can vary in their frequency, with some children experiencing multiple spells each day, while others will experience spells only weekly or even less frequently. Every child is affected differently.
The spells are associated with a slowing down of the child's heart and breathing patterns. The cause of the spells is not known; however, most children with breath-holding spells have lower levels of iron in their blood. The significance of this correlation is not known.
- It is estimated that around one third of children with breath-holding spells have a family history of similar episodes;
- Breath-holding is more common in children with iron-deficiency anaemia, and;
- Breath-holding is more common in children with genetic conditions such as Riley-Day syndrome or Rett syndrome.
There are two types of breath-holding spells: blue and pale. Most children who experience breath-holding spells will experience just one type of spell, with only a small number of children experiencing a mixture of the two.
Blue spells are also known as cyanotic breath-holding and are the most common type of spell. During a blue spell, a child may start to cry after becoming angry, scared or frustrated. The child will then hold their breath and may turn red in the face and then blue, particularly around their mouth. The child may then become limp, pass out, or drop to the ground. In some rare circumstances, the child might also have a seizure.
Pale spells are also known as pallid breath-holding and are the less common type of spell. After an upset, startle or fall, a child opens their mouth and look as though they are about to start crying, but they do not make any sound. The child then faints and becomes frighteningly pale. During a spell, they may fall to the ground, go limp, arch their back or become stiff. Only in rare circumstances will they have a seizure.
Signs and symptoms
During a breath-holding spell, a child may:
- Turn blue or become pale;
- Lose consciousness;
- Stop breathing;
- Have a strained face as if they are crying, although they will make no sound;
- Become limp;
- Have muscle twitching or body stiffness;
- Have jerky movements, and;
Methods for diagnosis
The child may need a thorough medical and physical examination to ensure they do not have any underlying medical problems such as a heart condition. The doctor will also ask the child's parents questions to obtain a detailed history of their child's spells. The doctor may ask questions about the skin colour associated with the spells, changes in body tone, the frequency of the episodes, how long the child is unconscious for and the events that precede and follow the spells. The physical examination may involve assessment of their airways and heart function. For more frequent episodes, laboratory tests may include electrocardiography, to assess heart function, or electroencephalogram, to examine their brain activity. Blood tests may be ordered to rule out iron-deficiency anaemia.
Types of treatment
During a spell:
- Lie the child on their side and monitor them;
- Check their mouths to ensure they are not choking on an object or food;
- Do not shake them;
- Do not put anything in their mouth or splash water on them, and;
- Keep their arms, legs and head clear of anything hard or sharp.
Children who are having a breath-holding attack will almost always recommence normal breathing within 60 seconds. Parents are advised not to punish, but instead treat your child as you would normally. Similarly, it is important not to give in to your child's behaviour as this will reinforce the behaviour of throwing tantrums. If iron deficiency is identified, treating the anaemia can ease the frequency of the spells.
If there are features of the episode that do not fit with a breath-holding attack, such as multiple episodes in a day, no trigger before falling unconscious or your child is difficult to wake, call an ambulance. If your child has not started breathing normally again within the first 60-90 seconds, begin cardiopulmonary resuscitation (CPR).
Although it is uncommon, some other conditions may present alongside, or instead of, breath-holding spells. Some of the following symptoms may indicate another underlying cause and prompt medical attention:
- Fever following a spell;
- Spells in a baby younger than 4-6 months and in a child older than 3-4 years who has never had a spell before;
- Loss of bladder or bowel control during a spell;
- Spells that continue past the age of six years, and;
- Spells where a child loses consciousness for longer than a minute.
- Most children outgrow their spells by the age of six years;
- The long-term effects of cyanotic breath-holding spells have not been reported, and;
- The long-term effects of pallid breath-holding spells are isolated to an increased risk of faintness episodes in adolescence and adulthood.
Although they cannot be prevented, you may see a pattern of when the spells occur and you may be able to distract your child before they hold their breath, but this is not always possible. You may also be able to work with your doctor to come up with better coping strategies for you and your child and find a way to discipline them without provoking another spell.