Breath Holding

Barry Zuckerman

I. Description of the problem. Breath-holding spells (BHS) involve the involuntary cessation of breathing in response to a painful, noxious, or frustrating stimulus. If prolonged, they can lead to loss of consciousness and/or seizures. There are no reported long-term adverse outcomes associated with breath holding.

A. Epidemiology.
- Simple breath holding without loss of consciousness may be seen in up to 25% of children.
- True BHS with loss of consciousness has been reported in approximately 4%.
- The peak frequency is between 1-3 years of age, although they may begin in the newborn period.
- BHS after 6 years of age are unusual and warrant further investigation.
- They occur equally in males and females.
- There is a positive family history in approximately 25% of cases.
- 50% resolve by the age of 4 years; 90% by the age of 6 years.
B. Etiology. The etiology of BHS is speculative.
- Pallid spells may be facilitated by an overactive vagus nerve; cyanotic spells may be related to a more central nervous system inhibition of breathing in response to stress.
- Hematologic differences (iron deficiency, transient erythroblastopenia) have been reported.

C. Types.

1. Cyanotic spells. The most common type of BHS is a cyanotic spell, which is precipitated by anger or frustration. A short burst of crying, usually less than 30 seconds, leads to an involuntary holding of the breath in expiration, resulting in cyanosis that can lead to a loss of consciousness and occasionally a seizure (Table 32-1).

2. Pallid spells. The second type is precipitated by fright or minor trauma (e.g., occipital trauma due to a fall). Following the precipitating event, there is an absence of crying or a single cry, followed by pallor and limpness. This sequence of events is thought to be due to a hyperresponsive vagal response that results in bradycardia (and even asystole), causing pallor and loss of consciousness. Some of these children (about 15%) go on to faint when they are injured or frightened as adults.

Table 32-1. Progression of breath-holding spells

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