Behavioral Issues

Breath-Holding Spells

Breath-holding spells are episodic occurrences that usually result in apnea, loss of consciousness, and changes in postural tone.

View some real examples:   Example 1   Example 2    Example 3


Great Video for a quick explanation of BHS: 

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  1. Occurs in approximately 5% of the population with equal distribution between males and females.
  2. Most common between 6-18 months and usually not present after 5 years of age. They are unusual before 6 months but about 7% occur < 1month of age.
  3. A positive family history can be elicited in 25% of cases.
  4. May be related to a dysfunction of the autonomtic nervous system (ANS), which normally controls passive breathing, among other below-conscious activities (digestion, sweating, controlling heart rate, etc).
  5. Iron deficiency may be a contributing factor to the dysfunctional ANS, therefore contributing to breath holding-spells.

Cyanotic Breath-holding Spells

  1. Usually precipitated by anger or frustration although may occur after painful experience.
  2. Child cries and has forced expiration leading to cyanosis, limpness, and loss of consciousness. The majority of children will regain consciousness and be fine within 1 minute, but some will fall asleep for an hour. Physiologically, there is hypocapnea, hypoxia because the child is not breathing, increased intrathoracic pressure secondary to the Valsalva maneuver, and decreased cardiac output. This leads to a fall of cerebral circulation and LOC.
  3. 4. There is normally NO post-ictal phase, NO incontinence, and the child is fine in between. There is a normal EEG, no relationship to the development of seizures or cerebral injury.
  4. If the breath-holding spell is long, there may be other clinical signs, such as decorticate or decerebrate posturing.
    • There have been a few reports of children having generalized motor seizures (increased muscle tone followed loss of the tone and prolonged unconciousness).
  5. Most children with breath-holding spells can have 1-6 episodes per week. 15-25% of children with breath-holding spells have multiple episodes daily. 

Pallid Breath-Holding Spells

  1. The most common stimulus is a painful event. The child turns pale and looses consciousness with little crying. There is asystole and autonomic deregulation.  The EEG is normal, there is NO post-ictal phase.  The child is usually alert within 1 minute. It is not uncommon for the child to be sleepy afterwards, however, for several minutes.
  • If the spell lasts longer than a few seconds, then it is normally followed by increased tone of the upper torso and the extremeties, and this prolonged spell often is accompied by incontnence.
  1. Evidence that episodes are caused by bradycardia, or a slowing of the child’s heart rate.
  2. There appears to be some relationship with adulthood syncope.


  1. The diagnosis is generally made clinically. There is no diagnostic test that can confirm breath-holding spells. A good history including the sequence of events, lack of incontinence and no post ictal phase, help to make an accurate diagnosis. 
    • ​Be sure to ask about any inciting events (head trauma, crying, painful stimulus), as this can help differentiate breath-holding spells from seizure activity.
    • Color change is also a helpful detail, as this is not typical of seizures.
  2. It is important to still consider cardiac abnormalities as a cause of syncope (loss of conciousness), as that is a must not miss diagnosis.
  3. A full iron deficiency anemia work up should be done, as it is possible that iron deficiency could be a contributor to the breath-holding spells.
  4. Some families are advised to tape the events to aid diagnosis (see examples 1-3 above)


  1. The most important treatment is reassurance because witnessing a breath-holding spell is a frightening experience for most families. Some families believe that these will be harmful and will push hard to get medications and carry oxygen with them at all times. 
  2. Most cases have spontaneous resolution around the age of 4. Almost all children stop having breath-holding spells by the age of 8. There is no evidence of long term neurological disturbances with breath-holding spells.
  3. Iron supplementation can help if the child is anemic or iron deficient. Complete resolution has been reported to be 32-52% with patients.
  4. Try to avoid known precipitating events and circumstances.
  5. Don't call 911 or perform mouth-to-mouth resuscitation or CPR if it appears to be a typical breath-holding spell. Don't place anything in the child's mouth. 
  6. Guard against the child hurting themselves
  7. Afterwards give the child a hug and then walk away. Try to avoid reinforcing the behavior. Don't give in to whatever the child wanted before the spell began - lack of rules or boundaries is not the answer.
  8. If complicated type, may need EEG to rule out seizure disorder.


  1. Evans, Owen,B. Breath-Holding Spells. Pediatric Annals July 1997.
  2. Anderson and Bluestone Breath Holding Spells Contemporary Pediatrics Jan, 2000
  3. DiMario, Francis Prospective Study of Children with Cyanotic and Pallid Breath Holding Spells.  Pediatrics February 2001
  4. Millichap G. Clinical Features and Outcome of Breath-holding Spells AAP Grand Rounds 2001
  5. Hüdaoglu O, Dirik E, Yiş U, Kurul S. Parental attitude of mothers, iron deficiency anemia, and breath-holding spells. Pediatr Neurol 2006; 35:18.
  6. Kuhle S, Tiefenthaler M, Seidl R, Hauser E. Prolonged generalized epileptic seizures triggered by breath-holding spells. Pediatr Neurol 2000; 23:271.
  7. Breningstall GN. Breath-holding spells. Pediatr Neurol 1996; 14:91.