Breath-holding episodes

Breath-holding spells are episodes in which a child, immediately after a frightening or upsetting event or after a painful incident, involuntarily stops breathing and loses consciousness for a short period of time.

Breath-holding spells occur in 5% of otherwise healthy children. They usually begin by the age of 2 years. They disappear in 50% of children by the age of 4 years, and in about 83% by the age of 8 years. In the remaining children, the spells may persist into adulthood. Breath-holding spells may be either cyanotic or pale. The cyanotic form, which is the most common, often occurs as part of a temper tantrum or in response to scolding or other upsetting events. The pale form usually follows a painful event, such as falling and hitting the head, but may also follow a frightening event. Both forms are involuntary and can be easily differentiated from the infrequent, brief periods of voluntary breath-holding seen in stubborn children, who invariably return to normal breathing after getting what they want or when they become uncomfortable if they do not get what they want.

During a cyanotic episode, the child holds his or her breath (without necessarily being aware that he or she is doing so) until unconsciousness is lost. Typically, the child cries out, exhales, and stops breathing. Soon after, the child gradually becomes cyanotic and eventually loses consciousness. A brief episode of convulsions may occur. Within a few seconds, breathing resumes, and normal color and consciousness return. It may be possible to interrupt the episode by placing a cold cloth on the child's face early in the episode. Although episodes can be frightening, parents should avoid reinforcing the behavior that triggered the episode. Once the child has recovered, parents should continue to insist on following house rules; the child's wishes should not dominate the home simply because he or she has had a temper tantrum. Distraction and avoidance of situations that lead to temper tantrums are good tactics.

During a pale breath-holding episode, vagal stimulation significantly slows the heart rate. The child stops breathing, rapidly loses consciousness, and becomes pale, limp, and lifeless. If the episode lasts more than a few seconds, muscle tone increases, and seizures and incontinence may occur. After the episode, the heart rate returns, breathing begins again, and consciousness returns without any treatment. Because this form is rare, further diagnostic testing and treatment may be needed if the episodes are frequent.

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