Breath-Holding Spells

Your baby is crying. Between sobs, he or she appears to be holding his or her breath for what seems like an eternity. You’re not sure what might be causing this, or what exactly you should do. You only know that it scares you, and you’re concerned about your child.

Your child may be suffering from Breath-Holding Spells (BHS), also known as Expiratory Apnea. BHS can affect healthy, otherwise normal infants and young children, and often occurs when they cry. We want you, as a parent, to know what this phenomenon is, how frequently it occurs, and its causes, assessment, treatment, and prognosis.

Description
Breath-Holding Spells have a dramatic presentation, and they are often terrifying for parents to observe. Although the label “BHS” suggests a voluntary action, such spells are actually involuntarily and reflexive. BHS occur while the child is awake and engaging in active breathing. The duration of the spells is typically from 2 to 20 seconds, but can last as long as a minute or more.

There are two categories of BHS: simple and severe. Simple BHS are ones that develop from pain, suffering, or misery; they typically are indicated by crying, the appearance of breath-holding, and a change in skin color. Severe spells progress further and can result in a child losing consciousness and/or having a seizure.

A change in skin color during a spell is described as either cyanotic BHS or pallid BHS. Cyanotic BHS, the most common type, is characterized by rapidly occurring bluish or purplish discoloration of the skin. Pallid BHS is characterized by paleness or deficiency in skin color. Although crying occurs in both types, it is more common in cyanotic BHS than pallid BHS.

A typical BHS episode involves an event in the environment that distresses the child. This is followed by the child crying, which diminishes to quietness accompanied by a change in skin color (cyanotic or pallid), and ends with the child disoriented and either conscious (simple) or unconscious (severe).

What We Know About BHS
Here are some research findings about age of onset, frequency, and numbers of children affected (approximations):

  • Age of onset is generally between 3 and 18 months of age, although as many as 10% of cases begin before 3 months and a similar percentage begin after 18 months.
  • Frequency ranges from several times a day to as low as once a year, with the majority of children exhibiting several episodes per week.
  • Peak frequency is in a child’s second year; spells gradually but continuously diminish after that.
  • The average age at which BHS end is 3 years; BHS are rare after age 8.
  • 4.6% of young children suffer from severe BHS (loss of consciousness and/or seizures).
  • 27% of young children suffer from simple BHS (distress and silent respiration, to a change in skin color).
  • 54% to 62% of afflicted children exhibit cyanotic BHS (bluish or purplish discoloration of skin).
  • 19% to 22% of afflicted children exhibit pallid BHS (paleness or deficiency in skin color).
  • 12% of afflicted children exhibit both cyanotic and pallid types.
  • 12% of afflicted children exhibit an indeterminate type.

Correlation
Approximately 20% to 30% of breath-holders have a family member who exhibited BHS during childhood. There are no well-documented differences between genders, and studies that have tried to detect significant behavioral or psychological differences between breath-holders and control groups have been unsuccessful.

Causes
The majority of research on the causes of BHS focuses on a child’s physiological response to environmental events. Events that trigger pallid versus cyanotic BHS differ, however. Pallid BHS events start abruptly, usually from events involving pain or fear (e.g., falling, banging head).  Such events lead to slowed heart rate, temporary ceasing of heart contractions, and/or faintness. Cyanotic BHS occur less abruptly and are typically the result of an emotional (usually angry) reaction to upsetting events (e.g., discipline, loss of a toy). The child cries, exhibits expiratory apnea, changes color (purple or blue), and sometimes loses consciousness.

Although both types of BHS are involuntary, their occurrence and the behavioral patterns associated with them can be influenced by environmental conditioning processes (e.g., increased crying due to sympathetic parental response).

Assessment
Interviews with parents are used to obtain a detailed history of BHS and to make a diagnosis. The interviews usually include questions about changes in skin color, alteration in body tone, frequency and duration of loss of consciousness or seizures, and the social events that precede and follow BHS. Videotaped documentation of BHS can be used to supplement verbal reports from parents. Physical examinations that include checks for anatomical or functional airway abnormalities also are used, especially with children who have frequent cyanotic BHS. Lab testing is used in cases of frequent BHS accompanied by loss of consciousness. BHS lab tests include the electrocardiogram (EKG) to check for heart-related problems in both types of BHS and the electroencephalogram (EEG) to examine the characteristic sequence of changes exhibited during the pallid type, and to rule out the possibility of epilepsy. Finally, blood tests can be done to rule out that anemia is causing faintness.

Treatment
In most cases, treatment primarily involves providing accurate information and reassuring parents about the nonharmful outcome of BHS. This treatment should include a layperson’s account of how interrupted breathing patterns can lead to loss of consciousness. Parents also are told that a BHS diagnosis should not lead to dramatic changes in the way they treat or attend to their child, with two exceptions. First, if parents have been overly anxious or concerned about the child, either prior to or following BHS, this should be remedied. Second, if parents have surrendered some of their authority to the child in an attempt to minimize his or her upset, this too should be corrected. Additionally, if the child is known to be anemic, physician-guided treatment with iron supplements can decrease the frequency of BHS.

When BHS occur, caregivers should lay the child on his or her back and guard against head injury and aspiration until recovery occurs. If necessary, the oral airway should be cleared. These preventive maneuvers should be done, and the overall approach to the child should be marked by, neutral emotions. Although medication is rarely beneficial for children with cyanotic BHS, children with severe and frequent pallid BHS may benefit from medication that slows parasympathetic activity.

Prognosis
Although reports of serious health consequences following BHS are rare, BHS are almost always frightening for parents. Generally, however, the scientific literature provides a very optimistic prognosis. Long-term negative effects for cyanotic BHS have not been reported. Long-term effects for pallid BHS are isolated to an increased risk for faintness episodes (e.g., at the sight of blood) in adolescence and adulthood.

Conclusion
Whether it is simple or severe, cyanotic or pallid, parents must realize that Breath-Holding Spells are a common phenomena in babies and children that rarely cause serious health problems. Research your family history and mention BHS to your family doctor and to people that may care for your child in your absence. If you ever feel it is necessary, contact your local emergency hospital immediately. Generally, being aware and informed about BHS should make the occurrences less terrifying for you.

Recommended readings

  1. Blum, N.J. (2002).  Breath-Holding spells.  In F.D. Burg, J.R. Ingelfinger, R.A. Polin, and A.A. Gershon (Eds.), Current pediatric therapy (17th Ed) (pp. 380-381).  Philadelphia:  Saunders.
  2. Breningstall, G.N. (1996). Breath-holding spells.  Pediatric Neurology, 14, 91-97.
  3. DiMario, F.J. (1992). Breath-holding spells in children.  American Journal of Diseases of Children, 146, 125-131.