Breath-holding spells are a common, involuntary occurrence in young children, often causing alarm for caregivers but generally considered harmless. This phenomenon affects approximately 0.1% to 5% of healthy children, with episodes typically beginning between six months and 18 months of age. Spells are a reflex of the nervous system, not a purposeful action by the child to manipulate behavior. They are temporary, non-epileptic events that children almost always outgrow, usually by the time they reach six years old.
Defining Breath Holding Spells and Their Types
A breath-holding spell is an episode where a child, following an emotional or physical trigger, stops breathing, may lose consciousness briefly, and then quickly recovers. The entire event typically lasts from a few seconds up to one minute, although it often feels much longer to an observer. These spells are broadly categorized into two main types based on the child’s appearance during the event.
The most frequently encountered type is the cyanotic spell, accounting for over half of all cases. This type is usually precipitated by emotional distress, such as anger, frustration, or a temper tantrum. The child typically lets out a short, vigorous cry, exhales forcefully, and then holds their breath. This causes their skin and lips to turn a bluish or purplish color due to a temporary lack of oxygen. They may become limp or stiff and lose consciousness before automatically resuming breathing and recovering.
The second, less common type is the pallid spell, sometimes referred to as reflex anoxic syncope. This spell is often triggered by sudden pain, a minor injury, or an unexpected fright. Physiologically, the pallid spell is a reflex mediated by the vagus nerve, which causes an abrupt slowing of the heart rate, sometimes to the point of a brief stop. The child’s face will become noticeably pale or white, rather than blue, and they may immediately lose consciousness without a preceding strong cry.
Common Triggers and Underlying Factors
Breath-holding spells are a reflexive response of the autonomic nervous system. Cyanotic spells are usually set off by strong emotional reactions, such as being reprimanded, denied a request, or intense frustration. Pallid spells are typically initiated by a sudden physical stimulus, like a minor fall or unexpected pain.
There is a recognized physiological link between the frequency of breath-holding spells and iron status in children. A significant percentage of children who experience these spells have either iron deficiency or iron deficiency anemia. Iron plays a part in the metabolism of catecholamines and the function of neurotransmitters, suggesting that a deficiency may contribute to the nervous system dysregulation that characterizes these events. Treating the underlying iron deficiency, even without full anemia, can often lead to a reduction in the severity and frequency of episodes.
Immediate Actions During a Spell
The most effective action for a caregiver during a spell is to remain calm, recognizing that the event is involuntary and self-limiting. The primary concern is ensuring the child’s physical safety during the brief period of unconsciousness. Immediately lay the child flat on the floor or a soft surface to prevent injury from a fall and to help increase blood flow back to the brain.
Avoid putting anything into the child’s mouth, and there is no need to attempt resuscitation, as normal breathing will restart spontaneously within a minute. After the child recovers, offer comfort and reassurance, but avoid giving excessive attention to the spell itself, which helps prevent unintended reinforcement of the preceding emotional trigger.
When Medical Consultation is Necessary
Most children naturally stop having breath-holding spells by the time they are five or six years old, and the spells do not cause any long-term neurological harm. However, a medical evaluation is warranted in several specific instances to rule out other possible conditions. It is advisable to consult a healthcare provider if a child experiences their first spell, even if the event appears typical.
Urgent consultation is necessary if spells begin before six months of age or persist beyond age six. Assessment is also needed if the spells do not follow the classic pattern, such as lacking a clear trigger, or if the episodes last longer than one minute. The presence of prolonged stiffness, significant jerking movements continuing for more than a few seconds after consciousness loss, or a lengthy recovery period should prompt a professional assessment to distinguish the spell from a seizure disorder.