A breath holding spell is an involuntary pause in breathing, sometimes accompanied by loss of consciousness. It usually occurs in response to an upsetting or surprising situation.

Breath holding is seen in some normal children from as early as age 2 months, but it can start as late as 2 years old. A small number of children have severe spells. Usually the spells stop by the time a child reaches ages 6 - 8.

Breath holding spells appear to be a response to fear, confrontation, a traumatic event (for example: pain), or to being startled. The sudden reaction can cause the nervous system to temporarily slow the heart rate or breathing, causing breath holding and color changes.

Although they often occur with tantrums, breath holding spells are not thought to be a willful act of defiance.

Breath holding spells can run in families. If a child's parents had similar spells in childhood, the child may be more likely to have spells. They also can occur with genetic conditions, such as Riley-Day syndromeor Rett syndrome. Children with iron deficiency anemia may also have increased episodes of breath holding.

• Bluish discoloration of the skin caused by lack of oxygen (cyanosis) or loss of skin color (pallor)
• Crying and then stopping breathing (apnea)
• Momentary unconsciousness or fainting
• Short seizure-like movement (one to two jerks)

After being startled or becoming upset, the child may make a short gasp and then exhale and stop breathing. Then the child quickly becomes blue (cyanotic) and may have many jerky movements that look like a small seizure.

The event ends with a brief period of unconsciousness, at which time normal breathing restarts. The child's color improves with the first breath and the event ends. The child may repeat this behavior several times per day, or do it only on rare occasions.

Breath holding can be a frightening experience for parents, who may think it is a seizure or even cardiac arrest. After a doctor has diagnosed the child with breath holding spells, the parent can simply wait for the event's natural end.

The doctor will take a history and do a thorough physical exam to rule out a physical cause of the breath holding. Because of a known association with iron deficiency, a blood test may be done.

Sometimes patients will have a cardiac test (such as an EKG) to be sure the heart is not involved in the spells. Sometimes an EEG may be done, especially if it is difficult to tell the seizure-like movements of the breath holding spell from an actual seizure.

No treatment is usually necessary. Children who have breath holding spells do not have epilepsy or brain damage.

Avoiding situations that provoke temper tantrums can help reduce the number of spells your child has. Placing a cold cloth on your child's forehead during the spell may shorten the episode.

Breath holding spells that do not cause the child to become unconscious are best ignored, in the same way temper tantrums are ignored. See also: Temper tantrums for more information about how to react to breath holding spells.

If your child has an iron deficiency, you should start iron replacement treatment.

When a spell occurs, be sure that your child is in a safe place where he or she won't be hurt during a fall or a brief seizure. After the spell, try to be calm and avoid giving too much attention to the child, because this can reinforce the behaviors that lead to the breath holding spells.

Affected children outgrow breath holding spells by ages 4 - 8. Even children who have a seizure after losing consciousness do not seem to have an increased risk for seizure disorders.

The biggest risk is injury, especially head injury, due to a fall during a spell.

Call your health care provider if your child exhibits breath holding behaviors, especially if this is a new behavior for the child or if the child does this frequently.

If your child stops breathing or has convulsions for more than a minute, call 911 or your local emergency number for immediate medical help.

No specific preventive measures are available. If you know your child is prone to breath holding spells, you might try to distract him or her before the behavior reaches the point that typically provokes a spell.

Dalton R, Boris NW. Disruptive behavioral disorders. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 28.