Breath-Holding Spells
A breath-holding spell is an episode in which the child stops breathing and loses consciousness for a short period immediately after a frightening or emotionally upsetting event.
Breath-holding spells occur in 5% of otherwise healthy children. They usually begin in the second year of life. They disappear by age 4 in 50% of children and by age 8 in about 83% of children. The 17% of children who continue to have spells as adults lose consciousness as a reaction to emotional stress. Breath-holding spells can take one of two forms.
The cyanotic form of breath-holding, which is most common, is initiated subconsciously by young children often as a component of a temper tantrum or in response to a scolding or other upsetting event. Episodes peak at about 2 years and are rare after 5 years. During the episode, a child holds his breath (without necessarily being aware he is doing so) until he loses consciousness. Typically, the child cries out, breathes out, then stops breathing. Shortly afterward, the child's skin begins to turn blue and he becomes unconscious. A seizure may occur. After the loss of consciousness (which generally lasts for seconds only), breathing resumes and normal skin color and consciousness return. It may be possible to interrupt the episode by placing a cold rag on the child's face when the spell begins. Despite the frightening nature of the episode, the parents must try to avoid reinforcing the initiating behavior in the cyanotic form. As the child recovers, parents should put the child safely in bed. Parents should enforce household rules; the child cannot have "free rein" of the house just because these spells follow temper tantrums. Distracting the child and avoiding situations that will likely lead to tantrums are good strategies.
The pallid form typically follows a painful experience, such as falling and banging the head or being suddenly startled. The brain sends out a signal (via the vagus nerve) that severely slows the heart rate, producing loss of consciousness. Thus, in this form, the loss of consciousness and stoppage of breathing (which are both temporary) result from a nerve response to being startled that leads to slowing of the heart.
The child stops breathing, rapidly loses consciousness, and becomes pale and limp. A seizure may occur. The heart typically beats very slowly during an attack. After the attack, the heart speeds up again, breathing restarts, and consciousness returns without any treatment. Because this type is rare, if the attacks occur often, further diagnostic evaluation and treatment may be needed.
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