Breath-Holding Spells in Children

Breath-holding spells (BHS) are prevalent in otherwise healthy newborns and young children, have a dramatic appearance, and can be frightening for parents. Although the participle "holding" in BHS implies a choice activity, BHS is involuntary and reflexive. BHS occurs when the kid is awake and actively breathing, usually lasts 2-20 seconds (but can extend up to a minute or longer), and is classified as simple or severe according to the event's severity. Simple seizures go from discomfort (usually indicated by sobbing) to quiet breathing to a change in skin color. In contrast, severe seizures develop further to loss of consciousness and simple seizures.

The corresponding differences in skin color also differentiate BHS. Cyanotic BHS, the most frequent kind, is distinguished by fast-growing bluish or purple skin staining, whereas pallid BHS is distinguished by paleness or skin color deficit. Crying occurs in both forms but is more prevalent in cyanotic BHS than pallid BHS. A typical BHS episode begins with a distressing environmental incident for the infant, is followed by sobbing that fades to silence, is accompanied by a change in color (cyanotic or pallid), and ends with the kid being confused but conscious (simple) or unconscious (severe).

Incidence and Frequency

Estimates of severe BHS incidence range from 4.6 percent for young children to 27 percent for simple BHS. Children with the cyanotic type have 54-62 percent of instances, the pallid type has 19-22 percent, both kinds have 12 percent, and the remaining 12 percent have an indeterminate type. The average beginning age is between 3 and 18 months, while up to 10% of cases begin before three months, and a comparable amount begins beyond 18 months. The frequency ranges from many times per day to once a year, with most youngsters experiencing multiple episodes each week. Peak frequency occurs in the second year and gradually but steadily decreases.

Causes of Breath-Holding Spells

Most BHS research focuses on physiological (over-) responses to environmental stimuli. According to the findings, autonomic nervous system disruption is a fundamental underlying condition for BHS. However, precipitating circumstances differ in pallid and cyanotic BHS. Pallid BHS events occur suddenly and frequently due to pain or fear (e.g., falling, hitting the head). These (excess) occurrences excite the vagal nerve, resulting in bradycardia (slowed heart rate) or asystole (brief halt of cardiac contractions) and syncope (fainting).

Pallid episodes can also be created in the laboratory by applying ocular pressure (for example, pressure to a child's closed eyelids with fingers). Cyanotic BHS occurs more gradually and is frequently the culmination of an emotional (usually furious) reaction to upsetting circumstances (e.g., discipline, toy loss). The youngster screams, has apnea, changes color (purple or blue), and occasionally loses consciousness. The underlying physiology is unknown.

However, elements known to cause cyanosis and syncope, such as increased cerebral and thoracic pressure (due to a grunt-like reaction) and transitory pulmonary malfunctions (e.g., ventilation-perfusion mismatches), are considered to be implicated. Although both forms of BHS are involuntary, environmental conditioning mechanisms can alter their incidence and associated behavioral patterns (e.g., more sobbing owing to sympathetic parental reaction).

Assessment of BHS

Parent interviews are done to gather information about BHS and to make a diagnosis. Typically, the interviews contain questions about changes in skin color, body tone, the frequency and length of loss of consciousness or seizures, and the social activities before and after BHS. BHS video documentation can be utilized to support parental spoken reports. Physical tests involving assessments for anatomical or functional airway anomalies are frequently utilized, particularly in children with cyanotic BHS.

With frequent BHS and lack of consciousness, lab testing is used. The electrocardiogram (EKG) is used to check for cardiac abnormalities in both varieties of BHS. The electroencephalogram (EEG) is used to evaluate the characteristic sequence of changes displayed during the pallid type and rule out the likelihood of epilepsy. Finally, blood testing can rule out faintness caused by anemia.

Although stories of significant health repercussions from BHS are uncommon, BHS is virtually always terrifying. However, the scientific literature generally presents a highly favorable outlook. Cyanotic BHS has not been shown to cause long-term harmful consequences. Pallid BHS has been linked to a greater risk of fainting episodes (e.g., at the sight of blood) in adolescence and adulthood.


In most cases, treatment involves demystifying the phenomena and assuring patients of its nonpathological origin and nonharmful consequence. A layperson's description of how disrupted breathing patterns might lead to loss of consciousness should be included in the demystification. With two exceptions, parents are also reminded that a diagnosis should not result in drastic changes in how their kid is handled or attended to.

First, this should be addressed if parents were unduly solicitous towards the child before or after BHS. Second, if parents have relinquished any of their power to the kid in an attempt to reduce distress, this should also be remedied. Furthermore, if the kid is known to be anemic, doctor-assisted therapy with iron supplements can reduce the incidence of BHS.

Although serious health consequences from BHS are rare, they are almost always scary. On the other hand, scientific literature often gives a very positive picture. Cyanotic BHS has not been demonstrated to have long-term adverse effects. Pallid BHS has been associated with an increased risk of fainting episodes in adolescence and adulthood (e.g., at the sight of blood).


Breath-holding spells (BHS) are involuntary and reflexive seizures that occur when an infant is awake and breathing. Breath-Holding Spells (BHS) is an involuntary condition caused by autonomic nervous system disruption. Causes of BHS vary, with pallid BHS occurring suddenly and cyanotic BHS occurring more gradually.

Treatment consists of demystifying the phenomenon and assuring patients of its nonpathological origin and nonharmful consequence. The scientific literature generally presents a favorable outlook, with Cyanotic BHS not showing long-term adverse effects and Pallid BHS linked to an increased risk of fainting episodes in adolescence and adulthood.

Updated on: 09-May-2023


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