Breath-holding attacks

Also called Breath-holding spells, Reflex anoxic seizures

A toddler who stops breathing, goes blue or white, and sometimes stiffens or jerks. Terrifying, involuntary, and harmless.

What it is

Episodes in babies and toddlers where breathing stops briefly, the child changes colour, and sometimes becomes limp or stiff, occasionally with jerking.

There are two types. **Blue spells** follow pain, frustration or anger: the child cries, then stops breathing at the end of a breath out, and turns blue. **Pale spells**, also called reflex anoxic seizures, follow a sudden fright, a minor bump or pain: the heart briefly slows or pauses, and the child goes very pale and floppy.

They affect around 5 per cent of children, usually between six months and six years, and almost always stop by school age.

**They are entirely involuntary.** The child is not doing it deliberately, cannot control it, and should not be disciplined for it. That is the single most important message, because the natural reaction is to think a toddler is holding their breath on purpose.

They are harmless and cause no brain damage.

The clinical task is to make sure it is what it appears to be. Epilepsy, heart rhythm problems including long QT syndrome, and iron deficiency anaemia all need considering. **Iron deficiency is common in this group, and treating it substantially reduces the frequency of attacks**, so a full blood count and ferritin is worth doing in every child with recurrent spells.

Signs you might notice

Blue spells: crying triggered by pain, anger or frustration; breathing stopping on an out-breath; blue around the lips and face; going limp; sometimes stiffening or a few jerks; then a quick recovery.

Pale spells: a sudden fright or minor knock; the child going very pale and floppy, often without crying first; sometimes stiffening; then recovery.

Episodes lasting seconds, usually under a minute.

Brief drowsiness afterwards.

**999 if:** an episode lasts more than a minute; the child does not come round quickly; breathing does not resume; or it is the first time and you are unsure.

Get assessed: after any first episode; if episodes happen without a clear trigger; if they occur during sleep; if there is jerking lasting more than a few seconds; or if there is a family history of sudden death or fainting.

Ask for a full blood count and ferritin, and an ECG.

How it can affect day-to-day life

Watching a child go blue or white and limp is genuinely terrifying, and parents describe it as thinking their child had died. Acknowledging that, rather than moving straight to reassurance, is what makes the reassurance land.

The practical response during an episode: lie the child flat on their side, stay with them, do not shake them, do not put anything in their mouth, do not splash water on them, and do not attempt to prise them upright. Lying flat helps blood return to the brain, particularly in pale spells.

Grandparents, nursery staff and childminders all need to know, and a written explanation helps enormously because the episodes look so alarming.

Parents often become anxious and permissive, avoiding anything that might trigger frustration, and the child then has fewer boundaries. Continuing ordinary parenting is part of the advice, difficult as it is.

Treating iron deficiency is the one active intervention and is frequently missed.

The condition resolves; almost all children have stopped by six.

Supporting someone well

Understand that it is involuntary. Do not punish or discipline for it.

During an episode: lie the child flat on their side, stay with them, time it, and let it pass.

Do not shake, splash water, or put anything in the mouth.

Call 999 for a first episode, one lasting over a minute, or if breathing does not resume.

Ask for a full blood count and ferritin; treating iron deficiency reduces attacks.

Ask for an ECG, and mention any family history of fainting or sudden death.

Tell nursery, grandparents and childminders, in writing.

Keep normal boundaries; avoiding all frustration is not a treatment.

Expect it to stop by school age.

Where to get help

A GP practice for assessment, blood tests and an ECG.

999 for a first, prolonged or atypical episode.

Epilepsy Action on 0808 800 5050, who explain the difference from epilepsy.

Arrhythmia Alliance for the heart causes of blackouts in children.