Breath Holding Spells in Children: Scary but Not Seizures

Every week, we see parents in our clinic convinced their child has epilepsy. The story is usually the same: the child was crying, suddenly stopped breathing, turned blue or pale, went limp, and maybe even had some jerking movements. It looked exactly like a seizure.

But in most of these cases, what they witnessed was a breath holding spell — a common, involuntary reflex that affects up to 5% of children between 6 months and 6 years of age.

What are breath holding spells?

Breath holding spells (BHS) are episodes where a child involuntarily holds their breath during crying or after a sudden fright or pain. The breath-holding triggers a reflex that temporarily reduces blood flow and oxygen to the brain, causing the child to pass out briefly.

Key point: The child is NOT deliberately holding their breath. They cannot control it. It's a reflex, like sneezing or hiccupping — just more dramatic.

Types of breath holding spells

There are two main types of breath holding spells, and knowing which type your child has can help you understand what's happening:

1. Cyanotic (Blue) Breath Holding Spells — Most Common (85%)

• Trigger: Frustration, anger, or being told "no"
• What happens: Child cries vigorously → stops breathing at the end of a cry → turns blue (especially lips and face) → loses consciousness → may have brief stiffening or jerking
• Recovery: Child wakes up within seconds to a minute, often crying again

2. Pallid (Pale) Breath Holding Spells — Less Common (15%)

• Trigger: Sudden pain, fear, or startle (like a minor head bump)
• What happens: Brief cry or gasp → turns very pale → loses consciousness → goes limp → may have brief jerking
• Recovery: Child may be sleepy or irritable afterward

Some children have both types. The pallid type is more likely to be confused with epileptic seizures because there's less crying beforehand.

Breath holding spells vs epileptic seizures: how to tell the difference

This is the question that brings most families to our clinic. Here's how we differentiate:

Feature	Breath Holding Spell	Epileptic Seizure
Trigger	Always provoked (crying, pain, frustration)	Usually unprovoked, can occur during sleep
Warning	Crying or upset precedes the episode	May have no warning or brief "aura"
Color change	Blue or pale BEFORE losing consciousness	Color change (if any) AFTER convulsion starts
Duration	Less than 1 minute	Can last several minutes
Recovery	Quick, may resume crying	Often confused, sleepy for extended period
Age	6 months to 6 years	Any age
EEG	Normal	Often abnormal

What causes breath holding spells?

The exact cause isn't fully understood, but we know several factors play a role:

• Autonomic nervous system immaturity: The part of the nervous system that controls automatic functions (breathing, heart rate) is still developing
• Genetic factors: Family history is common — if a parent had BHS, the child is more likely to have them
• Iron deficiency: Studies show a strong link between low iron levels and breath holding spells. Iron supplementation often reduces episodes
• Temperament: Children with strong emotional reactions may be more prone

The iron connection

This is important: iron deficiency anemia is found in up to 50% of children with breath holding spells. Multiple studies show that iron supplementation can reduce the frequency and severity of episodes, even in children without obvious anemia.

At our clinic, we routinely check iron studies (serum ferritin, hemoglobin) in children with frequent breath holding spells. If levels are low or borderline, iron supplementation often helps significantly.

What to do during a breath holding spell

After the episode

• Comfort your child normally — don't over-react or give excessive attention
• Resume normal activities once they've recovered
• Don't punish or reward the behavior — remember, they can't control it
• If this was the first episode, see your pediatrician to confirm the diagnosis

Can breath holding spells be prevented?

You can't completely prevent them, but you may reduce their frequency:

• Treat iron deficiency — this is the most effective intervention
• Avoid triggers when possible — prevent over-tiredness, hunger, sudden frights
• Stay calm during episodes — children pick up on parental anxiety
• Don't give in to tantrums — this can accidentally reinforce the behavior
• Distraction techniques — sometimes catching a tantrum early can prevent escalation

What NOT to do: Don't become overprotective or avoid all situations that might upset your child. This can create behavioral problems and anxiety. Children need normal boundaries and experiences.

Long-term outlook

The prognosis for breath holding spells is excellent:

• 90% of children outgrow them by age 5-6
• They do NOT cause brain damage or developmental problems
• They do NOT lead to epilepsy
• Children grow up completely normal

A very small percentage of children with pallid breath holding spells may develop vasovagal syncope (fainting) as teenagers or adults, but this is also benign.

Do breath holding spells need treatment?

In most cases, no specific treatment is needed beyond reassurance and possibly iron supplementation. The condition is self-limiting.

In rare cases where spells are very frequent (multiple times daily) or causing significant family distress, some doctors may consider:

• Iron supplementation — first-line treatment if levels are low
• Piracetam — sometimes used in severe cases (not commonly needed)
• Atropine — rarely used for severe pallid spells

Anti-epileptic drugs are NOT appropriate for breath holding spells since they are not seizures.

Frequently Asked Questions