When I entered the room to see Gina for her one-year physical, she was sitting in mom’s lap playing with a toy. She took one look at me, spun around, and tried to climb up her mother’s torso holding on for dear life. Mom calmed her down, and Gina was all right for the history portion of the visit where we discuss her appetite, sleep pattern and development, but Gina’s wary eyes followed my every move as she clutched mom’s shirt. Now it was time for the physical exam. Sensing Gina’s fear, I told them to just have Gina stay in her lap as I pulled up a chair next to mom. I warmed up my stethoscope and playfully put it on Gina’s chest. She froze momentarily, and then started to cry at the top of her lungs. Her crying reached a crescendo after which she let out a loud screech which seemed to go on forever. Abruptly the chaos stopped... as if in suspended animation. She had not taken in a breath. Her face took on a pale color, her lips turned pasty and her eyes started to roll back. Then she went limp like a rag doll. This all happened in a matter of seconds, but to mom it seemed like an eternity. I gently laid Gina on her back on the examining table and reassured mom that she would be just fine. Sure enough, within 10 seconds Gina was back to her normal self as if nothing had happened. She had a breath holding spell.
Steven is a willful 18-month-old who mom brought into the office to see if he had an ear infection. He was very curious, and everything in the office caught his interest. As we were going over the history, he grabbed a handful of tongue depressors from the dispenser. Without even a pause in her sentence, mom placed her hand on his, took the tongue depressors and returned them to their proper place. He stopped for a second, looked at her briefly, and then proceeded to pilfer through her purse. Eureka! He found her cell-phone and started to push all the buttons, which created strange electronic noises. Mom calmly excused herself and turned to Steven and scolded him gently saying that the phone was not a toy. By now, the proverbial "line in the sand" had been drawn, and he was not about to relinquish his big find. A tug of war over the phone ensued and as one would expect, mom won. Steven stood up, arched his back, and wailed as if he had been dealt a mortal wound. His cries intensified and he let out a huge wail as the color in his face took on an ashen and dusky hue. There was no breath to follow. In an instant, he went limp and fell to his side. Mom calmly picked him up, stroked his forehead, and told me that he has these "spells" as often as once or twice a week. They occur when he hurts himself or is mad. Undaunted, she proceeded to tell me about the suspected ear infection. Steven too, had a breath holding spell.
Breath holding spells (BHS), although very frightening to the unsuspecting parent, are not dangerous or serious to the child. They occur in around 5% of all children. They are usually triggered by anger, fear, frustration, or the child hurting themselves. BHS are quite classic in their presentation: the child cries, gives a forced cry without taking a breath in, becomes pale or bluish in color, loses consciousness and becomes limp, may even become rigid or stiff, and within seconds is breathing normally and is back to their normal state as if nothing had even happened.
This can be a devastating experience to the un-initiated parent and frequently results in futile attempts at mouth to mouth resuscitation, and unnecessary 911 emergency calls. At first glance, these spells can resemble a seizure (epilepsy). Yet, while seizures should be considered and ruled out in evaluating a child with BHS, they are two very different problems.
Seizures (epilepsy) occur spontaneously and do not follow the typical sequence of events that lead up to a BHS. Some seizures in children occur as a direct result of a high fever (febrile seizures). Seizures typically cause the patient to become rigid and stiff for a brief moment after which they go through a period of jerky rhythmic movements of the extremities. When the seizure is finished (it can last for minutes) the patient goes limp and is slow to come around. They may seem dazed or sleepy for quite some time before returning to their baseline level of activity. It is not uncommon for a child who is having a seizure to become incontinent of urine.
There are two main types of BHS: the cyanotic type, and the pallid type. The cyanotic type is the more common of the two types occurring in over 60% of all cases. In this form of BHS, the child becomes angry or frustrated, cries, breath holds and turns blue in the face before going limp. This was what happened with Steven.
In the pallid type, the child is often surprised (an immunization) or sustains a painful injury (slamming a finger in the door) after which they cry, breath hold, become ashen or pale, go limp, may have jerky movements that resemble a little seizure, and then lose consciousness.
Both the pallid and cyanotic types are brief lasting from a few seconds to 20 seconds, and they are self-limiting, which means that they resolve without any treatment. Within literally seconds the child is perfectly normal.
Very little work-up, if any, is required in the evaluation of a child with BHS. A good history and a thorough physical exam should be sufficient to make a proper diagnosis in most cases. The physician should look to rule out other entities such as: "atypical" seizures, cardiac problems, vaso-vagal syncope (fainting caused by a certain reflex) and familial dysautonomia (a genetic abnormality of the portion of the brain that controls the heart rate and respirations). There has been some data to link BHS with iron deficiency anemia, or with a prolonged QT interval which is a prolongation of a portion of the electrocardiogram of the heart. These situations are not common and need to be dealt with on an individual basis.
Most children have their first BHS between 6-18 months of age, and most have stopped completely by the age of 5 years. The frequency of BHS varies greatly. About a third have 2-5 spells per day, whereas another third have less than one a month.
The take home message for parents of children with BHS is that these are not dangerous or serious, are self-resolving and require no intervention on the part of the parent, and are not a sign of a serious underlying medical problem. In certain exceptions, it may be necessary to do a blood count to check for anemia, or an electrocardiogram to look at the QT interval. When the child has a BHS, the parents should remain calm, insure that the child is in a safe place should they lose consciousness (not standing on something from which they could fall), and be sure that they don’t have something in their mouth that they could choke on. BHS are in no way associated with seizures, and the vast majority of BHS will cease by 6-7 years of age. Above all, if there are ANY questions about these spells, or a particular BHS that "seemed different", be sure to check with your child’s doctor.