Breath-holding spells in children

Original post on 10 April 2007

What is a Breath holding spell?
Breath holding spell is a scary event for a parent to witness. The child suddenly goes motionless, as if lifeless, with no breathing at all. Frightened parents may fear the worst and initiate mouth-to-mouth breaths and even chest compressions.

Traditionally breath holding spells have been divided into 2 kinds. One which is associated with bluish discoloration (cyanosis) of the lips, tongue, face or even the whole body. These are called cyanotic breath holding spells. The other type is called the Pallid breath holding spell. In this type the child becomes pale and floppy during the episode.
In both types there is an inciting factor that triggers the event. This may be a sudden painful experience (fall, injury….), or a sudden startling or an upsetting event (like scolding).

How does the breath holding spell occur?
There is usually a trigger event that initiates the attack/ episode. In very small infants this trigger may not always be noticeable. In most cases this provoking or triggering event causes the child to cry. Very strong, sustained crying leads to progressive expulsion of air in the lungs (breathing out) ending in apnea (cessation of breathing). In Dhivehi language this can best be described with the phrase “romun romun gos hidhun”. Sometimes forceful crying may not be noticed. For instance it is common for the crying to be very brief. There may be instances where there isn’t much or any crying.
In some of the cases of breath holding spells the period of cessation of respiration lasts long enough to cause seizure-like activity with stiffening of the body, jerky movements of limbs and opisthotonus (arching of the back – idhifushah dhemun).

What is the common age when these attacks occur?
Breath holding spells are rare before the age of 6 months. The attacks peak at around 2 years of age and usually disappear by about 5 years of age. It is common for the attacks to occur repeatedly and can sometimes occur several times within a few hours.

Is it something that the child does consciously?
Many experts on these events believe that in older kids the breath holding spell is brought on by the child in an attempt to change their environment and the response from the care-givers in much the same way as temper-tantrums (whether consciously or sub-consciously). With this view many experts believe that in these cases the best approach is behaviour modification by changes in parenting. Interventions such as placing the child safely in bed and refusing to cuddle or carry until recovery is complete has been used successfully.
This approach is not always accepted by parents who are concerned about the events and considers them to be life threatening events. Many parents initiate mouth to mouth breathing and other measures. This is not required in cases where the events are stereotypical and are clearly brought on by the will of the child.
There is some debate regarding the occurrence of the same events in infants less than 6 months. Although it has been documented to occur in this age group, it is much rare and the mechanisms are believed to be different. It is believed to be unlikely that the events are brought on by a conscious effort by the child. The most common observation in this age group is that the child cries very strongly followed by breath holding (which is associated with cyanosis and stiffening or jerky movements of the body). The child would spontaneously recover without any assistance.

Does the event cause damage to the brain?
Brain waves have been monitored in kids who have experienced these events. EEG is invariably normal. Statistically these has been no evidence that there is any increased incidence of epilepsy. There is however an association with behavioral changes in older kids, in whom it is believed that the breath holding spells are the result of behaviour changes and not vice versa.

When should a parent be concerned about apnea?
During a breath holding spell the main concern of the parent is that the cessation of respiration could caused the brain to be damaged because of lack of oxygen. The breath holding episode are usually of a short duration, a few seconds to less than about 1 minute. This may seem a lot longer to a parent or an on-looker witnessing the event. It may be difficult for that person to remain calm and do nothing. However, it has been shown that there is no need to do any thing during this short spell. The best thing that one can do is to place the child safely away from harms way and observe.
Many parents want to know, how long they should wait before doing something to help. If the episode lasts longer than described above, assistance in breathing is usually initiated. There is no convincing evidence whether this is needed or not.

What can be done to help?
Although easier said than done, staying calm is perhaps the best thing one can do. This will enable the person to be more objective. I must emphasize here that there is usually no need to do anything! There will be complete recovery with no long term effects. It helps greatly if one is trained in first aid and basic life support skills.

If there is concern about choking, placing the child over the lap face down and giving a couple of gentle but firm blows to the back between the shoulder blades can help to expel the object causing choking. This maneuver is only helpful if there is choking.

If an object is clearly seen within the mouth it may be removed. However, it is no longer recommended to do a blind finger sweep of the mouth. It could cause more damage.
Gentle physical stimulation may initiate breathing in the child. This can be achieved by flicking the sole of the feet or rubbing the back.

Rescue breaths may be required if the apnea lasts longer. This can be done by placing the helpers mouth over the child’s mouth and nose (if mouth only- then the nose would need to be pinched to close it). It is best if the helper takes a fresh breath just before placing his mouth over the child’s. The helper then blows gently to inflate the Childs’ lungs. this has to be done gently to prevent damage. A couple of breaths may be all that is needed.

When resuscitation is required, the diagnosis of breath holding spells should be questioned. Other causes should be looked for.

More detailed resuscitation should only be attempted if one is trained in life support skills.

What should not be done?
The child should not be shaken! Shaking can cause damage to the brain and the spinal cord. Some people have given chest compressions believing that it helps in re-establishing breathing. Chest compressions (as seen on TV) is used only when the heart beat is slowed or absent. It does not help in breathing. Chest compressions should only be attempted by someone skilled in life support.Water (whether cold or not) should not be splashed on the child.

Consulting the health care provider.
Especially in those cases where the breath holding spell is the first episode, the child is younger than 6 months or when there are other associated problems or events it is important to have the child seen by a health care provider.

What should we expect to see at the end of the event?
With a breath holding spell the child would return to his or her normal self a few minutes after the event passes. There would be no lasting effects on the child. If there is any concern about any physical signs after the event has passed, the child should be taken to the health care provider.