366. Breath-holding spells in children: What’s normal, what’s not, and how to stay calm with pediatrician Dr. Caity Gilman

Dr. Caity (00:00):

It’s terrifying, and I think that is one thing that really I would not diminish, that it’s a very scary thing for parents. I think we can continue to offer reassurance and hopefully remind people that it is not a dangerous thing and it’s not associated with having injuries down the road or problems, but it’s scary.

Dr. Sarah (00:29):

If you’ve ever seen your child suddenly stop breathing while they’re crying, turn blue or even go limp and lose consciousness for a few seconds. The kind of terror that hits you instantly as a parent. And what makes it even harder is that most parents have no idea these breath holding spells are something that can even happen until it does right in front of them. Hi, I’m Dr. Sarah Bren, a clinical psychologist and mom of two who specializes in child development, emotion regulation and attachment science. Today on Securely Attached we’re talking about breath holding spells and to help us understand what’s actually happening, why some kids are more prone to this reflexive reaction, what parents should do during and after an episode, and the red flags to pay attention to. I’m joined by pediatrician, Dr. Caity Gilman. Caity is an academic general pediatrician at the Children’s Hospital at Montefiore, where she cares for children from infancy through young adulthood and teaches future pediatricians. She’s also a mom of two boys, which gives her such a grounded and compassionate perspective in these conversations. So whether your child has had a breath holding spell, maybe you’ve witnessed something that scared you or you simply want to feel more prepared for the unexpected moments that come with raising little ones. This episode will give you clarity, reassurance, and practical guidance.

(01:53):

Hi Katie, welcome back to Securely Attached.

Dr. Caity (01:57):

Thank you so much for having me, Sarah. I’m really happy to be back with you today.

Dr. Sarah (02:01):

I know, me too. So, okay. Last time you were here we had a very insightful conversation about vaccine safety and I really appreciated your detailed perspective on the matter and just the academic research you brought to the conversation. And we do these q and a episodes and people send in listener questions and someone sent in this listener question and normally we would answer them on the Thursday episodes in our beyond the session segment. But when I got this question, I immediately thought of you because as both a pediatrician and a mom, I just think you are the perfect person to help me answer it. First I’m going to read you the question. Does that sound good to you?

Dr. Caity (02:50):

Perfect, I’m ready.

Dr. Sarah (02:51):

Okay. So this listener Rodin. Hi Sarah. Thank you for your podcast. It’s truly amazing. I wonder if you know much about breath holding spells. I have recently found out my 18 month old boy is a breath holder. So in times of high emotion such as pain, frustration or shock, he will hold his breath, his eyes will roll to the back of his head, he goes blue and floppy and loses consciousness. It’s quite disturbing. I have found information on what to do when it happens, but very little on why it happens to certain babies or children. And I wonder if it’s to do with my son’s temperament. He is, as you would say, spicy. Maybe you or someone you could interview has some insight or experience on this topic. So I feel like it has to be one of the scariest things for parents to experience with their kids. And I really wanted a pediatrician.

Dr. Caity (03:45):

It’s a great question because there’s a few different things I think that the question is getting at firstly the description of the event. This is the exact classic what we see in breath holding spells. There’s a few variations on it, but it’s really exactly as your listener described that these young children get either frustrated or mad. It might be in response to you saying no or taking something away from them or pain as well a minor injury that really causes them to get so frightened. Typically there’s crying immediately after whatever the trigger was. And that crying is followed by a breath, a holding of the breath, really just a short period where the child is not voluntarily holding their breath but actually as some type of reflex. And while we don’t know what the exact trigger for the reflex in the body, we know that it is not voluntary and that it is just something that happens and then leads to this very scary appearing chain of events where the child, again, as your listener described, becomes blue floppy and really may even have muscle twitches.

(05:03):

That can be very scary as well. The other type that is slightly less common, instead of turning blue, the children can actually just look really pale and white almost, and this type is more associated with pain rather than a frustration. So that sort of the description of the episodes and why they happen. But I think the other part of the question is having to do with the child themselves, like the temperament of the child and is it something associated with their personality or something along those lines. And as far as I understand, no, I don’t believe that there’s any relationship to the temperament of the child. I’ve got two spicy kids and one did have the breath holding spells and the other did not. And it really can be genetic I think is the biggest thing that has an association. And then another thing that can be associated, although is not any kind of guarantee is children who have iron deficiency anemia or actually more likely to be the ones that are having these breath holding spells.

Dr. Sarah (06:20):

Interesting. It’s interesting your point. I also have two kids, one far more spicy than the other and it was actually my more easy going kid that had similar breath holding spells. I think his was more like you were, I don’t really know. It did seem actually, no, I think it was more the one that you’re describing where they go a little bit white and it’s more pain. Although I guess I am not sure. I remember when he was really little, basically if he started crying, it was almost like if he started crying hard enough or if he was upset enough, almost his cry would turn into a silent cry that was so tight in his vocal chords that he wasn’t taking air in and he didn’t go blue and he didn’t lose consciousness, but he would just sort of freeze in this silent scream and I’d have to kind of bop him on the back a little bit to get him to snap out of it.

Dr. Caity (07:27):

Yeah, that’s exactly what it is. I mean with the actual, I mean it’s called breath holding for a reason and while the breath holding part of it is not voluntary, like I said, they’re not purposely trying to hold the breath. It’s that specific action that triggers the change in their level of consciousness, whether it’s actually being floppy and limp or you’re describing almost out of it in a sense, my son who had it did have the palate type and it was very specific two times where he did have a minor injury, immediately cried and then you could just see the whole thing unfold into limp and almost looking like, I don’t even know. I mean I knew what was happening because of my background, but it’s terrifying. And I think that is one thing that really I would not diminish that it’s a very scary thing for parents. I think we can say we can continue to offer reassurance and hopefully remind people that it is not a dangerous thing and it’s not associated with having injuries down the road or problems, but it’s scary. It really is as a parent for sure.

Dr. Sarah (08:41):

Yeah, that was another question. This listener didn’t specifically ask this but that I had had was like if your kid is holding their breath so much so that they’re losing consciousness or even before that happens, is oxygen not getting to the brain? Is there any risk associated? What do we know about the potential for that to have a damaging effect?

Dr. Caity (09:06):

In a normal otherwise healthy child? So a child who has no other medical issues or anything that might potentially be a little different than what I’m saying, the amount of time that they’re holding the breath is really not enough to deprive any oxygen or cause any type of effect such as that it’s just the actual loss of consciousness rather than anything. And the other indication to parents when this happens, especially for the first time, and it can be really scary if you think that it’s a seizure or you don’t know about it, is that the child pretty quickly returns to normal. Some children have slightly longer post episode almost haziness, but it’s much more typical for children to be completely back to their baseline very quickly, which is another reassuring indicator that there’s no real changes inside the body.

Dr. Sarah (10:11):

Got it. And so you were saying that some of it is this autonomic response to stress, whether it’s anger or pain or shock, some type of shock to the system that they’re almost getting stuck in that physiological arousal and they can’t exit it like a normal cycle. So some of it’s reflex, what is causing that? Do we know what’s causing that to happen or what? What’s happening in the body?

Dr. Caity (10:47):

I think we actually still don’t know. So as far as I understand, like you said, there is part of the autonomic nervous system that is creating this response. But in terms of the other specifics of how it’s what’s happening, I’m not sure that that’s fully understood.

Dr. Sarah (11:06):

Got it. But we know that it has to do with reflexes too. This is almost like the holding of the breath is a reflex.

Dr. Caity (11:13):

Correct. As part of the crying.

Dr. Sarah (11:18):

And so, I have no idea what I was doing. I just bought my kid on the back of his back until he came back until he inhaled. But what can parents do? What’s helpful?

Dr. Caity (11:31):

So trying to stay calm, which I know is easier said than done, but if you can stay calm that will sort of help the episode pass quicker. I think actually maybe I also patted my child on the back until he was completely jolted. I do think a little bit of jolting them can be helpful. You’re almost reminding them to take a breath if they do lose consciousness, which again, it does happen in many of these episodes where they lose consciousness even though as I mentioned, there’s no danger inside the body or the brain or compromise to the nervous system. You do want to protect their airway. So you would just want to make sure that they’re in a position where their breathing is fully sort of accessible. Their nose is not covered by something. So if they were to fall into a, because sometimes children will literally fall to the floor if they were to fall onto a blanket or a pillow, you’d want to make sure to turn them over.

(12:36):

And then again, some children really even do have stiffening or almost shaking that can look like a seizure. And while it’s not a seizure in the same sense as a child who has a seizure disorder, similarly with that, you would want to make sure you’re protecting the airway. And that would just be making sure they have a full breathing space around them, staying calm, being there to reassure them when it’s over and then remembering that this is transient and typically it resolves in children by about age five or six. Some children have episodes more frequently, some have it less frequently. I don’t know that there’s any way to predict that, but being reassured that it is not a permanent thing.

Dr. Sarah (13:27):

Yeah. Any comorbidities? Is this more common in kids who have, maybe I’m thinking maybe autism spectrum disorder or ADHD more neurodiverse brain profiles or is it common across the board, across the bell curve?

Dr. Caity (13:45):

I think it’s across the bell curve. I mean, it is possible that we need to do more research so that there hasn’t been, especially with where we are now with more and more diagnoses and people being recognized that maybe wouldn’t have been a while ago, doing some kind of research with that could certainly be interesting. But I think it’s really, there isn’t a specific such diagnosis that precludes children more. Like I said before, I think it’s the biggest things that we know about are genetics and iron deficiency.

Dr. Sarah (14:20):

That’s really interesting. And so you were saying this is transient, it happens in early childhood, eventually they will eventually grow out of it. When does it start? What does the age range? When might a parent start seeing this come online?

Dr. Caity (14:41):

It can start early six months, even potentially slightly earlier. Six months I would say is probably the safe bet as the sort of generalization. And then I think around 18 months, just as your listener had said, that was how old their child was. That’s more of the common starting age. And while I can’t remember exactly, I want to say that my son was somewhere in that range when his started.

Dr. Sarah (15:09):

It’s interesting because I asked you to come on to talk about this because I respect your opinion as a medical professional, but we happen to just both be two moms whose kids also did this. So I’m imagining it’s pretty prevalent. Do we have any sense of how common often many kids, what percentage of the population shows this?

Dr. Caity (15:31):

I think about 5%, which is not a huge number, but if you take a backyard full of moms and the two that add up to that 5%, yeah, and I’ve spoken to other colleagues who have had their own children do it and then patients that certainly I’ve had a number of patients that it’s happened to as well. So again, not a huge number, but it is out there and it’s scary.

Dr. Sarah (16:03):

Yeah. Okay. So we talked about what’s going on, why it’s happening, what to do during, what about what do we do after our kid kind of comes back to themselves? Do kids tend, they tend to know what happened? Do they tend to be confused? Do they tend to be scared? How do we help ease them back into things and help them kind of feel safe again?

Dr. Caity (16:33):

Yeah, so I think it also probably depends on the age a little bit. Like an 18 month old or six month old is just not really capable. I think in the same sense of understanding what has happened versus what they were feeling like before. An older child, especially ones at the end of the spectrum of when breath holding spells happen would be more aware that something is off. And like we were talking about before, some children have a very short period of being out of it and almost none back to normal within two minutes. I love how resilient kids are that they honestly might just be completely fine after that and go finish playing with whatever they’re playing with. Some children have longer recovery times and I think the biggest thing is just whatever your child needs in general to be comforted. Everybody knows what their own child needs in a different way, and that’s what I would do.

(17:36):

If you have a kid who just wants to sit on your lap and hear a song, then I would do that. If you have a kid who wants to go back and play with whatever their Legos, then that’s okay. We don’t have to treat them different afterwards unless they need comforting or whatever we can do for them. As a parent, you don’t have to take them to the doctor. We’re more than happy to evaluate your child and reassure you and make sure that everything is okay, but it’s not something, especially if you’ve seen it before and you know what to do that you have to go to the doctor for. Your child doesn’t need more tests. They don’t need EEG where we monitor brainwaves. Really there isn’t more that has to be done assuming all of the features of the event are consistent with what is happening. So if it’s the first time you’re seeing it, definitely talking to the pediatrician about specifically what happened. I think something to be aware of is there really has to be a trigger. So if a child were to suddenly lose consciousness and turn purple or pale without something that either caused them injury, minor injury or feelings being frustrated, sad, angry, if those that is not there, then there would be more reason for I would say further workup.

Dr. Sarah (19:11):

Got it. So this is really an emotional response that kicks in some type of higher level physiological nervous system response that then leads to potential loss of consciousness versus your kids playing and all of a sudden they kind of go blue and lose consciousness. If that is happening in and of itself without these precursors, that could be the sign something else might be going on and is definitely worth going to check out with your pediatrician about.

Dr. Caity (19:43):

Absolutely. You nailed it. I would say that’s exactly right, that it is this body response and while we don’t understand everything about the response, we know that it’s a response to strong feelings in whatever sense and that because that is the cause of it, the recovery is expected and easy, but certainly if a child is having these events without a trigger, then that needs more workup. Yes, because that could be something else that’s causing it. Similarly, these events will always happen when a child is awake, so they need to have that stimulus of pain or fear or anger. Whereas if you have a child that is sleepy or sleeping and then all of a sudden they turn a different color, that is not what a breath holding spell is. So that needs more about evaluation too.

Dr. Sarah (20:35):

Got it. Are there any other sort of rule out red flags that we’d want to say like, okay, hold on. If this is happening, and this might not be a breath holding spell, you should get some medical attention.

Dr. Caity (20:47):

So I was mentioning before that children can have some shaking and twitching afterwards and even quite significant that can look like a seizure for people who have seen seizures before, this should be pretty short. And again, the child should be pretty much back to their baseline quickly. If this type of movement or behavior is really lasting more than a minute, then I would recommend that the child be evaluated typically. And then the other thing would be if you have a child who has any known other medical comorbidities such as a known heart condition for example, you would want to make sure that there isn’t any association with that.

Dr. Sarah (21:35):

That makes total sense. And I feel like this is helpful because I would imagine because this is scary, and if this is happening for the first time, it sounds like if it’s the very first time, it’s still worth maybe checking with giving your pediatrician a call. But if you have recognized this is a pattern, I know that this has sometimes happened when my child is having a really strong feeling and he goes into this elevated state of fight or flight, loses a little bit of consciousness potentially, but it comes back quickly, then our ability to stay sort of like calm is a loose term because you’re never going to just be like, oh, hmm, this is happening again. But at the same time, knowing how to make sense of something really reduces stress and anxiety in the response of it, even if it is still stressful and anxiety provoking.

(22:30):

It’s about the intensity of that stress and anxiety and being able to say, oh, I know what’s going on. I know this is that we are safe. I know what I can do. I know what I don’t need to worry about right now and I can just stay focused on what I am in control of. Which it sounds like is making sure that they’re physically in a safe position and that when they come back too, you’re able to help them kind of feel soothed and return back to life as usual back to what they were doing and be able to reengage.

Dr. Caity (23:02):

Yeah, definitely. I think I agree with you. It’s very hard to actually imagine staying totally calm in that scenario, but being able to maybe regulate how you’re emotions or you’re feeling is being displayed to your child and knowing that what the end of it is going to be like is I think really helpful.

Dr. Sarah (23:32):

In my conversation with Dr. Gilman, we’ve been talking about how one of the most important things you can do during your child’s breath holding spell is to stay as calm as possible yourself. But this advice actually goes far beyond holding spells. Our ability to remain grounded in the heat of the moment is one of the most powerful tools we have as parents, but of course that’s much easier said than done. So how do you actually stay calm when you’re flooded, triggered or overwhelmed? That’s exactly what I teach in my 60 minute workshop, Be the Calm in your Child’s Storm: How to Keep Your Cool When Your Child Loses Theirs.

(24:07):

In this workshop, you’ll learn practical science-backed tools to regulate your own nervous system in those hot moments, whether it’s a breath holding, spell a meltdown, a power struggle, or any situation where your child’s big reactions light up your own stress response. You’ll learn how to ground yourself quickly, how to stay connected instead of reactive, and how to bring the steadiness your child’s nervous system needs most, even when the moment feels scary or chaotic. These are the same strategies I use every day with parents in my clinical practice, and they truly can transform how you move through stressful situations with your child. You can get instant access to this workshop by clicking the link in the episode description or by heading to drsarahbren.com/bethe calm. That’s drsarahbren.com/bethecalm. Alright, now let’s get back to my conversation with Dr. Gilman.

Dr. Caity (25:07):

And of course, definitely if your child does it often and you want to talk to your pediatrician every time, I’m sure that they would love to hear about it and make you sort of reassured. But I think again, it is something that doesn’t need to be evaluated every time.

Dr. Sarah (25:30):

And then one last thing I think could be helpful is like, okay, medically I feel like you painted a really good picture about what’s going on. I’m trying to think about for kids who are sensitive to getting this level of overstimulated and over amplified in their emotional reactivity. And for some kids they’re just going to go that far that fast and there’s just not a whole lot we can do to help them. And certainly not in the moment because it sounds like it’s going to happen really quick and that train is going to lead the station very fast and we just have to recognize I’ve got to let this ride itself out. There’s nothing I can really do to reverse course. But one of the things I teach parents a lot is that there’s a before, during and an after, every time there’s a hot moment. And if we think about this breath holding spells, kind of like the during.

(26:29):

After will be the, I’m going to be here soothe you, help you make sense of what happened and help you reenter the world. But there’s a before the next event happens, and that I feel like a time where perhaps some skill building around frustration tolerance, emotion regulation skills, and obviously this is going to be very wildly dependent and variable based on the age of your kid. If you’ve got an 18 month, you’ve got a six month old, there’s just no skill building you’ll be doing. You have to wait. But at 18 months, maybe a little bit at two, three years, certainly more, but what are some things that you’ve seen help be helpful for families to try in the before moments and then not related to the hot or even after the hot moment, but just like how do we teach some frustration tolerance? How do we teach some advocating saying, I want that no assertiveness skills. Those are actually big trigger. The lack of assertiveness skills often leaves kids vulnerable to getting super frustrated because their boundaries get crossed and they don’t have the tools to say, oh, that’s mine. I’m using that stop.

Dr. Caity (27:48):

I think at this age in particular, especially if we’re thinking about the younger kids, maybe if we take this 18 month old age range, they have some language, but really the expectation is that maybe it’s six words if you have an advanced child, they’re starting to get to between 20 and 50, but it’s not all of the tools you need to be able to express yourself. And obviously even older toddlers don’t have those tools. So I do agree that I think if it’s related to being able to express that you do want something or you don’t want something, I think that there is potentially room for intervening ahead of time. I think you probably have more tools than I do, but I usually try to tell parents if they know they have a child who gets upset when they hear no, instead of saying no, they can offer different choices instead.

(28:50):

So if the child is doing something that’s extremely unsafe, instead of screaming, no, don’t tug on the fire extinguisher, would you like to play with your stuffed giraffe or would you like to play with this ball? And that act of giving them a choice and also distracting them I think can be really helpful. So I think those are two things together, both distraction and the choices that I think can work pretty well in this age group. Certainly for the child who is having a breath holding spell in response to an injury, we can always do as much as we can to prevent injury as we would like, but it happens. And so that probably is not going to change. But I do think these life skills and teaching children, regardless of if they have a predisposition to breath holding spells can be really helpful. Again, talking about our own experiences, both of my kids I think have always been pretty spicy. And the older one who never had this, this was never had the breath holding spells, these were very helpful tools for me to use as I was navigating the toddler years.

Dr. Sarah (30:05):

Yeah.

Dr. Caity (30:05):

And maybe still today.

Dr. Sarah (30:07):

Yeah, seriously. Well, thank you so much. This was really interesting and I am really grateful that you took the time to come on and share your wisdom with us.

Dr. Caity (30:18):

I appreciate you having me back. It’s so great to talk to you about this topic and I love to hear that one of your listeners had the question and to be able to help answer it.

Dr. Sarah (30:28):

And if anyone who’s listening has more questions, please send them in. You can always submit questions on our website, drsarahbren.com/question and we will make sure they get to the right people to give those answers. So again, Dr. Gilman, thank you so much and we’ll see you again soon, I’m sure.

Dr. Caity (30:50):

It’s a pleasure

Dr. Sarah (30:51):

Looking forward to it.

(30:52):

If you enjoyed listening to this conversation, I want to hear from you, share your thoughts and your feedback with me by scrolling down to the ratings and review section on your Apple Podcasts app or whatever app you’re listening on. And let me know what you think of this episode or the show in general. Your support means the absolute world to me, and just a simple tap of five stars can make a real impact in how the show gets reached by parents everywhere. So thank you so much for listening and don’t be a stranger.