Breath-Holding Spells: Symptoms, Types, Causes and Treatment

Breath-holding spells are a common and often alarming phenomenon in young children. While these episodes can be distressing for families, they are generally benign and self-limited. This article provides a comprehensive overview of the symptoms, types, causes, and treatment options for breath-holding spells, synthesizing the latest research and clinical evidence to empower parents and caregivers with accurate, actionable information.

Symptoms of Breath-Holding Spells

Breath-holding spells can be dramatic, often causing significant fear and anxiety for observers. However, understanding their typical features helps differentiate them from other more serious medical conditions.

Symptom	Description	Typical Age	Source(s)
Crying/Trigger	Often triggered by emotion or pain	6–18 months	1 3 4
Color Change	Cyanosis (blue) or pallor (pale)	6 months–6 yrs	1 3 4 6
Loss of Consciousness	Brief fainting or "passing out"	6 months–7 yrs	1 3 4
Seizure-like Movements	Rare, short convulsions	Any	3 5 6

Table 1: Key Symptoms

Typical Presentation

Breath-holding spells usually occur in young children, with most cases starting between 6 and 18 months of age. Episodes are commonly triggered by strong emotions such as anger, frustration, pain, or fear. A classic spell often follows a sequence:

• The child experiences a triggering event (e.g., minor injury, being upset).
• They may let out a loud cry or become silent.
• The child stops breathing, typically during expiration.
• Skin color changes—either turning blue (cyanotic) or pale (pallid).
• The child may become limp or rigid.
• Brief loss of consciousness can occur, sometimes with mild twitching or convulsive movements.
• The episode resolves within 10 to 60 seconds, with the child quickly returning to normal 1 3 4 6.

Frequency and Duration

• Most children have infrequent episodes, but some may experience spells weekly or even daily at their peak.
• The duration of a spell is usually less than a minute.
• Spells commonly resolve by age 5 to 7 and do not cause long-term harm 3 4.

Associated Features

• Hypoxic convulsions (brief seizure-like activity) can occur in up to 15% of children experiencing breath-holding spells, but these are typically self-limited and not dangerous 3 5.
• Episodes do not cause brain damage or permanent injury 1 4.

Types of Breath-Holding Spells

Breath-holding spells are generally classified into two main types based on the color change observed during the episode. Both types are benign but differ in their triggers and underlying mechanisms.

Type	Color Change	Common Trigger	Source(s)
Cyanotic	Blue (Cyanosis)	Anger, frustration	1 4 6
Pallid	Pale (Pallor)	Pain, fear	1 4 8
Mixed	Combination	Multiple triggers	9

Table 2: Types of Breath-Holding Spells

Cyanotic Breath-Holding Spells

• Most common type (up to 80% of cases) 9.
• Typically precipitated by anger, frustration, or being startled.
• The episode usually starts with crying, followed by forced expiration and breath-holding.
• The child turns blue (cyanosis) around the lips and face.
• Loss of consciousness may follow, occasionally accompanied by limpness or mild convulsions.
• The episode resolves spontaneously, and the child recovers quickly 1 4 6.

Pallid Breath-Holding Spells

• Less common than cyanotic spells.
• Often triggered by pain or sudden fright rather than emotional upset.
• Minimal or no crying precedes the event.
• The child becomes suddenly pale, limp, and may briefly lose consciousness.
• Episodes are caused by abrupt slowing of the heart rate due to excessive vagal stimulation (vagally-mediated cardiac inhibition) 1 4 8.
• The spell is shorter than the cyanotic type and resolves quickly 1 4.

Mixed and Atypical Types

• Some children may exhibit features of both types, or have spells that do not fit neatly into one category 9.
• Mixed spells can be triggered by a variety of stimuli, with both color changes possibly observed.

Age and Resolution

• Both types are most frequent between 6 months and 4 years old.
• The majority of spells resolve spontaneously by age 5–7, with no long-term effects 3 4.

Causes of Breath-Holding Spells

Although breath-holding spells are well-recognized, their underlying causes are multifactorial and not fully understood. Recent research has shed light on several contributing factors.

Cause	Mechanism/Contribution	Key Evidence	Source(s)
Autonomic Dysregulation	Imbalance in autonomic nervous system	Key pathophysiology	1 6 7 8
Vagal Overactivity	Sudden cardiac inhibition (pallid)	Pallid spells	1 5 8
Iron Deficiency/Anemia	Contributes to frequency/severity	Responds to iron	1 7 9 10 11
Family History/Genetics	Familial clustering, inherited tendency	Positive family hx	3 4 8 9
Delayed Brainstem Maturation	Delayed neural development	Proposed factor	1

Table 3: Key Causes and Mechanisms

Autonomic Nervous System Dysfunction

• A central feature in breath-holding spells is an imbalance in the autonomic nervous system, which controls involuntary bodily functions such as heart rate and breathing.
• Both cyanotic and pallid spells reflect different manifestations of this autonomic dysregulation, with frequent respiratory sinus arrhythmia observed in affected children 1 6 7 8.
• In pallid spells, excessive vagal tone can cause abrupt slowing of the heart (bradycardia) or even brief cardiac pause, leading to fainting and pallor 1 5 8.

Iron Deficiency and Anemia

• Iron deficiency, with or without anemia, is found in a significant proportion of children with breath-holding spells.
• Low serum ferritin and hemoglobin levels are common among these children.
• Iron deficiency is believed to worsen the frequency and severity of spells; treating it often leads to marked improvement 1 7 9 10 11.

Genetic and Familial Factors

• Breath-holding spells often run in families, indicating a genetic predisposition.
• Both maternal and paternal family histories are equally represented, and a positive family history is seen in 30–51% of cases 3 4 8 9.

Brainstem Maturation

• Delayed myelination (development) of the brainstem has been proposed as a contributing factor, possibly affecting autonomic control 1.

Psychological and Environmental Triggers

• Emotional distress, frustration, pain, and fear commonly precipitate spells.
• While these triggers are not the underlying cause, they play a key role in initiating episodes 1 2 4.

Treatment of Breath-Holding Spells

The good news for families is that breath-holding spells are benign, self-limiting, and rarely require aggressive intervention. However, certain treatments and management strategies can be highly effective, especially in frequent or severe cases.

Treatment	Purpose/Outcome	Special Notes	Source(s)
Reassurance	Reduce parental & child anxiety	Mainstay of therapy	1 5 6
Iron Therapy	Reduces spell frequency/severity	Check ferritin/hemoglobin	1 10 11
Piracetam	May reduce frequency in some cases	Safe, effective in trials	12 14
Pacemaker	Rare, for severe bradycardia	For refractory pallid type	13

Table 4: Treatment Approaches

Reassurance and Education

• Explaining the benign nature of breath-holding spells is the cornerstone of management.
• Parents should be assured that the spells are not harmful, do not cause brain damage, and typically resolve with age 1 5 6.
• Avoiding reinforcement of negative behaviors and not overreacting to spells can help reduce their frequency.

Iron Supplementation

• If iron deficiency or anemia is identified, iron therapy is highly effective.
• Studies demonstrate 84–88% of children experience reduced frequency or cessation of spells after iron supplementation 10 11.
• Even in children without overt anemia, iron supplementation may be beneficial 1 10.
• Checking hemoglobin and ferritin levels is recommended in all children with breath-holding spells 9.

Pharmacological Interventions

• Piracetam: This nootropic medication has been shown in controlled trials to reduce spell frequency, with no significant side effects observed. It may be considered for children with frequent, severe spells not responding to reassurance and iron 12 14.
• Other medications are rarely needed and not routinely recommended.

Intervention for Severe/Refractory Cases

• In extremely rare cases where pallid spells are accompanied by significant bradycardia or asystole (prolonged cardiac pause), pacemaker implantation may be considered.
• This is reserved for children with life-threatening episodes not responsive to other therapies 13.

Monitoring and Additional Evaluation

• Most children do not need extensive testing.
• If the diagnosis is uncertain or if there are atypical features (e.g., spells not triggered by emotion or pain, spells occurring during sleep, persistent neurological deficits), an electrocardiogram and neurological evaluation may be warranted to rule out other conditions (such as epilepsy or cardiac arrhythmias) 5.

Conclusion

Breath-holding spells are dramatic but generally harmless events that affect young children. They can be deeply distressing for families but, with the right information and support, can be managed effectively and safely.

Key Points:

• Breath-holding spells most often occur in children aged 6 months to 4 years and almost always resolve by age 7.
• The main symptoms are triggered episodes of crying or pain, followed by color change (cyanosis or pallor), brief loss of consciousness, and rapid recovery.
• Two main types exist: cyanotic (blue, anger/frustration) and pallid (pale, pain/fear).
• Autonomic nervous system dysfunction and iron deficiency are central to the underlying cause.
• Positive family history is common, suggesting a genetic component.
• Treatment focuses on reassurance and education; iron supplementation is effective if deficiency is present.
• Piracetam may help in severe cases, and pacemakers are reserved for rare, life-threatening forms.
• Most children outgrow breath-holding spells without complications.

By understanding the nature of breath-holding spells, caregivers can respond with confidence and compassion, ensuring the best outcomes for affected children and their families.