Breath-holding spells in babies and children

A child bumps himself or gets angry about something, draws in air to cry, and then suddenly falls silent. The mouth is open, no sound comes out, the lips turn blue, the body goes limp and sometimes a twitch runs through it. A few seconds later breathing returns, the child comes round, and within a couple of minutes is playing again. This is a breath-holding spell. The everyday name is misleading: the child is not holding anything on purpose and cannot stop the episode by choice. It happens to roughly one child in twenty, most often between six months and two years, and it almost always goes away on its own by the age of five or six. For parents the first episode looks like life stopping, so it is worth understanding in advance what is happening and what to do with your hands.

What the episode looks like second by second

There is nearly always a trigger: pain from a fall, a fright, frustration, anger, a sudden noise. After that a short sequence unfolds.

• the child starts to cry, or simply opens the mouth as if about to cry, but no sound comes;
• breathing stops on the out-breath and the chest goes still;
• the lips and then the face turn blue or, on the contrary, go sharply pale to a greyish tone, which on darker skin shows better on the palms, the soles and the inside of the lips;
• the body goes floppy and the child sinks in your arms or drops, or instead arches and stiffens;
• a few jerks of the arms and legs may pass through, which are not epilepsy but the brain's response to a brief shortage of oxygen;
• breathing restarts by itself, the skin colour evens out and consciousness returns.

The episode itself takes a matter of seconds and rarely reaches a minute. Afterwards the child is usually subdued, sleepy or bewildered for a few minutes and sometimes falls asleep. Spells like these leave no consequences for the brain or for development.

Why it happens: two different mechanisms

Behind a scene that looks identical lie two different routes, and it matters to the doctor which one your child had.

The blue type. This is the more common one. It begins with hard crying out of anger or upset. On a long out-breath the breathing falters and stops, oxygen in the blood falls, the skin turns blue and the child loses consciousness. The body does exactly what is needed: losing consciousness releases the emotional tension and breathing starts again.

The pale type. It is set off by sudden pain or fright: a bang on the head, an unexpected fall, alarm at an injection. There may be almost no crying. Here the vagus nerve takes over: the heart abruptly slows or pauses for a few seconds, the brain is left without blood flow, and the child goes white instantly and drops. From outside it looks like an adult fainting at the sight of blood, and the mechanism really is the same.

In both cases the child is not in charge of what happens. This is not naughtiness, not manipulation and not the result of parenting mistakes.

What to do in those seconds

The main job is to do no harm and wait for the episode to end. Help comes down to a few simple actions.

• lay the child on his side on the floor or another flat surface, which is safer and sensible in case of vomiting;
• clear anything hard from under the head and around it, and support the head so it is not knocked;
• stay beside him and look at the clock: the real duration almost always turns out to be two or three times shorter than it felt;
• loosen tight clothing at the neck;
• when it is over, hold and comfort him calmly, let him rest, and behave as usual.

What not to do

• do not shake the child, slap the cheeks, splash water or blow into the face: none of it speeds anything up;
• do not lift him upright or carry him during the episode, because upright less blood reaches the brain, and in the pale type this directly prolongs the faint;
• do not put a spoon, a dummy or your fingers into the mouth: the tongue cannot be swallowed, and what suffers is the child's teeth and your fingers;
• do not scold or punish afterwards, because he did not choose to do it;
• do not start giving in to every demand just to prevent crying. The spells do not stop because of that, and the boundaries simply blur.

Resuscitation needs one qualification. In a typical spell it is not required, since breathing restarts on its own. But if the child has not taken a breath for about a minute, stays pale or blue and does not respond, this is no longer an ordinary episode: call the emergency services and begin resuscitation as taught on first aid courses.

When emergency help is needed

Call for an ambulance without hesitating if:

• this is the first episode ever and no diagnosis has been made before;
• the child has not come round within one or two minutes, or breathing has not resumed;
• the jerking lasts more than a minute, repeats one after another, or the child stays confused for a long time;
• the episode followed a head injury, or the child hit himself hard in the fall;
• the blue or grey colour persists after breathing has returned;
• the episode happened while running, swimming, in a state of excitement, or with no trigger at all.

The last point is the most important of them all. An ordinary breath-holding spell always has a trigger: pain, fright, anger. Loss of consciousness with no cause, on exertion, in water or in response to a loud noise may turn out to be a disturbance of heart rhythm rather than a harmless reaction.

What the doctor checks and why an ECG is not optional

The diagnosis rests on the account of whoever saw it: the circumstances, the order of events, the duration, the skin colour, the behaviour afterwards. A video helps enormously if anyone managed to film it, since thirty recorded seconds are worth half an hour of explaining. Two tests are usually arranged, each for its own reason.

• A blood test for haemoglobin and iron stores. Iron deficiency turns up noticeably more often in children with frequent spells. When the stores are replenished, in some children the episodes become rarer or stop. Iron preparations are prescribed by a doctor on the basis of the result: giving them blindly is pointless and not harmless.
• An electrocardiogram. It is not ordered as a formality but to rule out rare inherited rhythm disorders, above all long QT syndrome. They are uncommon, but they show themselves in a similar way: sudden loss of consciousness in a child, sometimes with jerking. Tell the doctor separately whether the family has had sudden deaths at a young age, an unexplained drowning of someone who swam well, or fainting in relatives, because that is a reason to look more closely.

If the picture is atypical, an electroencephalogram is added to separate the spell from an epileptic seizure. With a classic description it is usually not needed.

Living with it and when it ends

There is no specific treatment and, as a rule, none is needed: medicines are hardly ever used for breath-holding spells. Other things work instead.

• Reduce the background against which spells are triggered more easily: lack of sleep, hunger, overexcitement towards the evening, a day that runs too long without a break.
• Catch the build-up before the child gets as far as crying: attention is easier to divert in the first second of a grievance than in the fifth.
• Keep the usual rules. Children quickly notice that after an episode they get what they wanted and, although they do not bring the spell on deliberately, the number of flashpoints grows.
• Tell everyone who is left with the child: grandparents, the childminder, nursery staff. The worst of it falls on whoever sees this for the first time and has no idea what to do.
• Write down how often it happens and in what circumstances. From memory these details come out badly, and they are exactly what the doctor needs.

With age the spells become rarer and disappear: in most children by four or five, in some a little later. It is worth going back to the doctor if the episodes have become more frequent, longer or heavier, if they start happening with no clear trigger, or if they are shaping family life.

Online consultation

In an online consultation the doctor will go through what the episode looked like, what came before and after, will watch the video if there is one, and will help separate a typical breath-holding spell from something that needs investigation. It is also the place to work out which tests are worth doing, whether an ECG is needed soon and what to make of results already obtained, and to sort out the household rules: how to behave during a spell and how not to build the whole family's life around it. A first-ever episode is assessed in person and without delay, and that is the case where a remote consultation is not the right tool.

This material is for information only and does not replace medical advice.