Is my toddler having a breath-holding spell?
Have you experienced this? One minute your kid is crying or is upset about something, then suddenly stops breathing until you either give them what they want or become blue and pass out. Welcome to the terrible twos my friend. This is a real medical condition called Breath Holding spells or BHS which happens in infants and young children.
What is a Breath Holding Spell?
Breath Holding Spells or BHS is a reflex that is commonly seen in children aged between six months to six years. About 90% of children will have their first spell before the age of 18 months. It usually occurs when a child experiences a sudden shock, pain, anger, or frustration that causes them to hold their breath involuntarily.
What are the Types of Breath Holding Spells?
There are two types of BHS.
- Cyanotic spells: In this type of BHS, the child stops breathing, and their body turns blue or pale. It is usually caused by a lack of oxygen in the body.
- Pallid spells: Here, the child loses consciousness, and their body becomes limp. Pallid BHS is usually caused by a sudden drop in blood pressure and heart rate. This type is rare but can be dangerous and often misdiagnosed as seizures.
The child will start with pain or fall, then become limp, followed by the trunk becoming stiff and finally will have jerking movements that look like a seizure. They will typically be confused afterwards.
What are the Features of a Breath-Holding Spell?
The symptoms of BHS can vary from child to child, but they usually include:
- Stopping breathing for a brief period
- Turning blue or pale
- Limpness or loss of consciousness
- Twitching or stiffening of the body
- Convulsions or seizures (rarely had status epilepticus i.e., back to
back seizures or prolonged seizures that need hospitalization).
What Causes Breath Holding Spells?
It is not clear what the exact cause of BHS is. There is a role played by the autonomic nervous system which controls breathing and blood flow, some contribution by unexpectedly low iron in blood (iron deficiency anemia) and a third of cases have a family history so there appears to be a genetic component as well.
On the other hand, some of the triggers that precipitate BHS in children are:
- Pain or discomfort
- Frustration or anger
- Emotional stress
- A sudden scare or shock
- Overstimulation
- Physical exhaustion
How to Diagnose and Test for Breath-Holding Spells?
The diagnosis depends mostly on the features of the event and the triggers. So as a parent, it would be very useful to record a video of the event, because it may very well be the clue to the diagnosis.
It is important to evaluate for the possibility of seizures by doing an EEG to evaluate the brain waves, and do blood work to check for anemia by doing a CBC and then check for iron and ferritin levels. Lead levels should be obtained as well. In cases of a family history of cardiac disease or sudden death, cardiac work up with EKG (i.e., testing the electrical conductions of the heart) and evaluation of the heart is important.
The worst we can do is to misdiagnose BHS as epilepsy. I have seen it in many occasions and not only does this create an unnecessary stress on the family, but it also requires treatment with anti-seizure medications which can have harmful side effects. This is why it is important to see a pediatric neurologist.
What is the Treatment for Breath-Holding Spells?
The good news is that almost all children will outgrow this condition by the age of four, and rarely continue to have BHS until 8 years of age. There will be no effect of BHS on neurological development.
As treatment, your doctor will probably recommend a few of the following:
- First, behavioral modifications like avoiding situations that might be triggering the events. I do understand that sometimes it is hard to do. Take it from a parent of an active toddler. But setting a few rules and teaching children deep breathing exercises may go a long way in preventing these scary events.
- Iron supplementation – especially in children with iron deficiency anemia can yield excellent results.
- Some studies found that Theophylline may reduce the frequency of BHS but is left as a second choice after iron and for resistant cases. But this will have to be prescribed by a neurologist.
- We know that anti-seizure medications do not help BHS and they can’t even prevent seizures that accompany BHS, but we want to avoid missing the dangerous seizure types seen in little children that if left untreated can cause permanent brain damage.
Again, all children will outgrow breath holding spells and it will be a childhood memory you share with your little one when they grow up.