Breath-holding spells (BHS) are involuntary episodes where a child stops breathing and may briefly lose consciousness, often causing significant alarm for parents. These episodes are considered a common, generally harmless neurological reflex that typically appears in children between six months and six years of age. Although a breath-holding spell can be frightening to witness, the child usually recovers quickly without any lasting effects. Understanding the underlying mechanisms and triggers can help caregivers recognize that these spells are not a conscious manipulative behavior but an automatic bodily response.
The Physiological Mechanism Behind the Spells
BHS involve an involuntary reflex arc triggered by a strong emotional stimulus, such as intense anger, pain, or fright. This stimulus causes dysregulation within the Autonomic Nervous System (ANS), the part of the body that controls involuntary functions like heart rate and breathing.
In the most common pathway, a forceful cry is suddenly followed by an involuntary pause in breathing, usually after exhaling. This extended breath-holding causes a rapid decrease in the oxygen supply to the brain, a state known as cerebral hypoxia. The resulting lack of oxygen causes the child to lose consciousness, which is the body’s natural defense mechanism to restore normal breathing.
In a different physiological pathway, a sudden stimulus, like an unexpected minor injury, can cause overstimulation of the vagus nerve, a major component of the ANS. Overactivation of this nerve causes a profound and sudden slowing of the heart rate. This temporary reduction of blood flow to the brain is enough to cause a brief fainting episode.
The Two Primary Types of Breath Holding Spells
BHS are clinically categorized into two main types. The most common is the cyanotic spell, accounting for about 85% of all occurrences, typically triggered by emotional upset, anger, or frustration.
The cyanotic spell begins with the child crying or screaming, then suddenly stopping their breath and turning blue or purplish, especially around the lips and face. This discoloration results from the temporary lack of oxygen in the bloodstream. The child may become limp or rigid and lose consciousness for under a minute before automatically resuming breathing and waking up.
The second type is the pallid spell, which is less common and often triggered by a sudden painful event or fright. This type is primarily a vasovagal response, where the vagus nerve severely slows the heart rate. The pallid spell is characterized by the child turning noticeably pale or gray, becoming limp, and losing consciousness very rapidly, sometimes with little preceding cry. Due to the sudden reduction in blood flow to the brain, the pallid spell can sometimes be mistaken for a seizure.
Underlying Factors That Increase Susceptibility
While intense emotion or pain serves as the immediate trigger, certain underlying factors can increase a child’s predisposition to experiencing breath-holding spells. A significant factor is the presence of iron deficiency anemia, a condition where the body does not have enough iron to produce an adequate number of oxygen-carrying red blood cells. Studies suggest that iron deficiency, even without full-blown anemia, is frequently associated with an increased frequency of spells.
Iron is thought to play a role in the neurological system, and its deficiency may increase the susceptibility of the brain’s control centers to the physiological changes that trigger a spell. Treating the iron deficiency with supplementation has been shown to significantly reduce the frequency of spells. Beyond nutritional status, there is a strong hereditary component, with approximately 16% to 25% of children with BHS having a family history of the spells, suggesting a genetic predisposition.
Distinguishing Breath Holding Spells From Other Conditions
The dramatic nature of a breath-holding spell often leads parents to worry about more serious underlying conditions, such as epilepsy or cardiac issues. A defining characteristic of BHS is the presence of an emotional or painful trigger immediately preceding the event. Unlike a seizure, a breath-holding spell is typically brief, lasting less than a minute, and the child returns to their normal state without a period of post-event confusion or drowsiness.
Certain “red flags” in a child’s presentation would suggest a cause other than a benign breath-holding spell, warranting further medical investigation:
- Episodes that occur without any clear trigger.
- Spells that begin before six months of age.
- Spells that continue past age six.
- An episode involving prolonged unconsciousness or other neurological symptoms.
An episode involving prolonged unconsciousness or one accompanied by other neurological symptoms also suggests the need to rule out conditions like cardiac arrhythmias. An electrocardiogram (ECG) is often used to ensure the spells are not the manifestation of a rare, underlying heart rhythm disorder.