Breath holding spells

Breath holding spells

A breath holding spell may happen after a child has an upset or sudden startle, such as a minor bump or a fright.

Key points to remember 

  • children may hold their breath after a fright or becoming upset
  • children may appear drowsy and sleep for a while after a breath holding spell
  • children with breath holding don't usually have a serious underlying illness

What is a breath holding spell?

Toddlers, and occasionally babies, can sometimes have breath holding spells (or attacks). They happen in about 1 in 20 children.  A breath holding spell may happen after a child has an upset or sudden startle, such as a minor bump or a fright. The child opens their mouth as if to cry but nothing comes out. They then can look deathly pale or go blue around the lips.  They may become limp and fall to the ground and then have convulsive movements of their limbs. Your child may recover quickly or be unresponsive for a short period.

Breath holding spells often happen as part of toddler tantrums. The spell is a reflex reaction to an unpleasant stimulus, which your child can't prevent. It is not a deliberate behaviour on the child's part.

Are there different types of breath holding spells?

Yes, there are 2 types of breath holding spells: blue (cyanotic) breath holding spells and pale (pallid) spells. Blue spells refer to the child's lips and mouth turning a dusky blue colour during a spell and are more common than pale spells. Previously these 2 types of spells were thought to be distinct conditions but both may occur in the same child at different times in their lives.

Both types do not have any serious consequences (unless your child hurts themselves if they fall) but they are frightening to see.

What causes breath holding spells?

Breath holding spells are caused by either a change in the usual breathing pattern, a slowing of the heart rate or a combination of the 2. Pain or strong emotions, such as fear or frustration can bring on these reactions.

The underlying reason why breath holding spells occur is not known.  1 in 3 children with breath holding spells will have a family history of similar episodes. In some children, breath holding spells may be related to iron deficiency anaemia, a condition where the body does not produce a normal number of red blood cells. Most children that go through a stage of breath holding do not have a serious underlying problem.

Children with breath holding spells do not have epilepsy. As breath holding spells may resemble an epileptic seizure, the 2 are often confused. In epileptic seizures, the child may turn blue, but it will be during or after the seizure and not before. Wetting and soiling are common in epileptic seizures, but are rare with breath holding spells.

Breath holding spells only occur when the child is awake and usually when the child is standing. Epileptic seizures may occur during wakefulness or sleep. Pauses in breathing (apnoeas) only occur during sleep and usually in infants aged less than 6 months.

There is no increased risk of children with breath holding spells later developing a seizure disorder.

When do they start and will they stop?

Breath holding spells happen at similar rates in boys and girls. The spells usually start before 18 months of age and usually stop by 6 years. They rarely happen before 6 months of age. It is a condition that causes no short or long term consequences. Some children with pale spells may be prone to fainting as they grow into their adult years.

How often do they happen?

Breath holding spells vary in how severe they are, and how often they happen. They may happen fairly often, sometimes several times a day or once every few weeks. They usually happen more often when your child is overtired, upset and irritable (grizzly). Often parents who have witnessed breath holding spells can predict when another is likely to happen.

What should I do during a spell?

Don't panic. Lie your child on their side and watch them. Don't shake your child, put anything into their mouth, or splash water onto them. Keep their head, arms and legs from hitting anything hard or sharp. Allow the episode to stop by itself. Treat your child normally after the event. Do not punish or reward the behaviour.

What can doctors do for my child?

Discuss the problem with your family doctor.  Your child will need a thorough examination to check that they do not have any other problems, such as an irregular heart beat.  Breath holders are usually healthy.

What should concern my doctor and me?

  • loss of consciousness and becoming very pale without any provoking factors
  • very frequent spells (such as several a day) should be assessed
  • children with breath holding spells followed by prolonged stiffening or shaking which goes on more than a minute and is associated with slow recovery, needing several hours of sleep, or remaining confused for a long period of time need to be further assessed
  • children less than 6 months of age need to be investigated for other underlying causes of their symptoms. Breath holding spells may still happen in this age group, though this is less common

What can I do in the meantime?

No special treatment is required.  Anti-epileptic treatment is not effective and doctors rarely recommend it. Oral iron supplementation may have a role in reducing the frequency and severity of breath holding spells, particularly if iron deficiency anaemia is present (common in toddlers) but its widespread use is still being evaluated.

Treating the anaemia, if present, will often decrease the frequency of spells which lead to passing out. Observation and protection from injury are generally all that is required during an episode.

Parents' most important job is to not reinforce the breath holding behaviour. Make sure your child gets plenty of rest, help your child feel secure and help minimise and manage their frustration.

It is important that your child is not treated in a special way or different from their siblings or other children. Behavioural problems can outlast the period of time that the spell can occur and become more of a burden to the family than the spells themselves.

A behaviour modification programme may help.  Ask your doctor for help with this.

Starship Foundation and the Paediatric Society of New Zealand acknowledge the cooperation of The Children's Hospital at Westmead, Sydney Children's Hospital at Randwick, and Kaleidoscope - Hunter Children's Health Network in making this content available to patients and families.

This page last reviewed 22 January 2018.
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