breath holding

Breathholding is usually a particular form of tantrum behavior seen in children from the ages of about one to three years old. Most cases in my experience cluster around 18-24 months. The spell begins with the child crying, usually out of frustration, but occasionally when upset after an injury. This crying causes hyperventilation. Hyperventilation - breathing too deeply and too often - "blows off" too much carbon dioxide in the bloodstream and causes a brief, harmless period of unconsciousness. The child generally stiffens, turns blue, and then relaxes, breathes normally, and awakens. This brief period of blueness (cyanosis) unconsciousness in no way harms your child's brain.

Breathholding is more than just an irritating and indeed frightening tantrum behavior, though. It seems to be related to an oversensitivity of certain regulatory functions of the respiratory and circulatory systems. That is to say, situations that the average child will cry through in complete consciousness will stimulate an overly sensitive brain to shut down consciousness temporarily.

Breathholding probably is genetically based and therefore hereditary, and you should tell your doctor about any other family members who might have been breathholders as children, or who might have had problems with fainting spells at any age. Breathholding seems to be aggravated by iron deficiency or anemia, and based on a number of recent studies it is probably worthwhile to check for this, and perhaps treat the child with iron drops. Iron treatment has been shown to greatly lessen the spells in many children.

As far as what to do if your child has a breathholding spell, do nothing. You do not need to blow in her face, start CPR, or call 911. Wait for a few seconds. Once the child is unconscious, normal respiration will resume immediately, the CO₂ level will rise to normal, and she will awaken. It is best to act as if nothing happened, because if everyone around the child is in a dither and rewards the crying tantrum, the child will not know about the unconscious period, but will learn how to hyperventilate into getting her way every time. Bad lesson to learn.

Because certain types of seizure disorder could be mistaken for breathholding spells, it is wise to tell your pediatrician about them. There is also a more rare form of severe breathholding spells in which severe slowing or stopping of the heart (bradycardia) may occur (reflex anoxic spells). Your doctor might want to do further examination or testing if she suspects something other than simple breathholding might be at work, and she may want to consider iron therapy.

Simple breathholding spells are always outgrown, usually by 3-5 years old (although the rare reflex anoxic spells may persist much longer).

In response to a request, some references to iron and breathholding:

1. Anemia in children with breath-holding spells [letter; comment] Yilmaz S - J Pediatr - 1996 Mar; 128(3): 440-1 From NIH/NLM MEDLINE

2. Effectiveness of iron therapy on breath-holding spells [see comments] Daoud AS - J Pediatr - 1997 Apr; 130(4): 547-50

3. Breath-holding spells: waiting to inhale, waiting for systole, or waiting for iron therapy? [editorial; comment] Hannon DW - J Pediatr - 1997 Apr; 130(4): 510-2

4. Breath-holding spells in a patient with transient erythroblastopenia of childhood [see comments] Tam DA - J Pediatr - 1997 Apr; 130(4): 651-3

5. Iron therapy in breath-holding spells and cerebral erythropoietin [letter; comment] Mocan MC - J Pediatr - 1998 Oct; 133(4): 583-4

6. Breath holding spells in 91 children and response to treatment with iron. Mocan H - Arch Dis Child - 1999 Sep; 81(3): 261-2

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