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Some young children terrify their parents when they stop breathing in response to pain or anger. They start to cry, turn blue, stop breathing, and go limp.

It’s understandable that a breath-holding spell is terrifying to a parent who watches their child become limp and lifeless, but it is of no consequence to the child.

A breath-holding spell occurs because of involuntary cessation of breathing which can actually lead to unconsciousness and even seizures because of lack of oxygen in the brain. Despite these troubling symptoms, there are no long term effects of breath-holding spells.

Why would a child stop breathing? Why such a drastic, seemingly dangerous event?

Breath-holding occurs in response to a painful or frustrating stimulus. They are rare before 6 months of age, peak at about age two, and are usually a thing of the past by age 5. They occur with equal frequency in males and females and there is a family history of breath-holding spells in about 25% of cases.

There are actually two types of breath-holding spells. The much more common cyanotic spell starts when a young child, either angry or frustrated, bursts out crying. The cry leads to the involuntary holding of breath during expiration (breathing-out phase). This leads to cyanosis — the child turns blue — and may become limp and unresponsive.

Doctors confronted with a frightened parent with this story have two tasks: 1)Make the correct diagnosis, 2) Help the parents manage the spells until the child grows out of this unusual response to the strong emotions that all of us have every day. I am convinced that not a day goes by without each of us experiencing both anger and frustration.

Breath-holding spells must be distinguished from seizures because the latter need treatment while the former do not. In a breath-holding spell there is always a PRECIPITATING FACTOR. The crying and cyanosis always PRECEDE THE UNCONSCIOUSNESS or limpness.

In a severe breath-holding spell the child may have twitching, arching of the back, or even seizure-like movements. In a seizure, cyanosis occurs not at the beginning but after prolonged seizing.

Management is divided into two parts: information for parents and management strategies. Parents are scared out of their wits. It takes good doctoring to explain the sequence of events and the physiology that lead to the spells and to convince the parents BREATH-HOLDING SPELLS ARE BENIGN — although very frightening. Parents are thinking death, epilepsy, and brain damage but the doctor must teach them to think “benign.”

Parents need to know four things about management of breath-holding spells.

Quickly apply a cold cloth to the face. If such an intense stimulus is applied to the face in the first 15 seconds of the breath-holding this may terminate the spell. Usually by the time the parent realizes the child is having a spell, rushes to get the cloth, and gets back to the child’s face, the critical window of time has passed. But at least applying the cloth gives the parent something to do. It won’t do any harm and it’s very hard to stand by and watch when your child isn’t breathing.

Put the child on the floor or in the crib to prevent injury from falling during unconsciousness.

DON’T FUSS OVER THE CHILD when the spell is over. The most dangerous possible consequence of breath-holding is behavioral. The child realizes that screaming leads to a spell. The spell causes the parents to give the child lots of attention plus whatever the child wanted in the first place. The child now has a way to get his or her way.

PREVENT the spells. Parents cannot prevent frustration or anger from happening but they can minimize these precipitating emotions in two ways. Allow the toddler maximum autonomy to make choices whenever possible and whenever consequences of these choices are inconsequential. Avoid those frustration-enhancing factors like fatigue and hunger which always make things worse. And set limits that are firm and consistent so the child can practice coping with frustration the same way an older child practices scales on the piano. After a while you get it right.

Think of breath-holding as an extreme kind of tantrumming. Parental attention leads to secondary gain which in turn leads to more episodes in response to frustration. This is one of those times when the best thing a parent can do is nothing.

The second type of breath-holding? The pallid type is much less common. It follows a painful injury, especially a fall on the head, or a severe fright. There is no cry, just pallor (paleness) and limpness. The mechanism is an exaggerated reflex which causes the heart to slow — and even stop briefly — which in turn causes the paleness and limpness. One of my grandchildren had such a spell — the most striking thing was the absence of a cry after the injury. Children grow out of pallid spells as well as cyanotic ones, although some will faint when they are frightened or have a minor injury later in life.