Positive Relationships: Behaviour - Don't hold your breath

We have a one-year-old in our nursery. He has been with us since he was six months old and just recently whenever he falls down he cries and goes stiff. The last time it happened he actually passed out and stopped breathing for almost a minute. It was terrifying. His mother says it is nothing to worry about - that she used to do this as a child - but some of our team think it might be anxiety attacks. Do children this young have anxiety attacks? How do we know it's not something more serious? What should we do about it?

t sounds as if this little boy is having something called breath-holding spells. These are quite common in toddlers - about one in 20 will have them - but they can be alarming to witness.

Breath-holding episodes can happen after a child has had an upset or is startled or frightened. The child will usually open their mouth, give a short cry, breathe out and stop breathing. Their lips will probably turn blue and they will become limp and possibly fall to the ground unconscious as if they are fainting.

They may start thrashing their arms and legs around as if they are having a convulsion. They may recover very quickly or remain unresponsive for a little longer, usually no more than a minute, and then recover completely.

This type of breath-holding spell, when the child turns blue, is known as a cyanotic spell and can be mistaken for a seizure. A cyanotic spell caused by a change in the child's breathing pattern, which is usually a response to feeling angry or frustrated, is the most common type.

Children can also have pallid breath-holding spells, when the child quickly turns pale and passes out without crying very much. Children who have pallid breath-holding spells may suffer from fainting attacks when they grow older. A pallid spell is caused by a slowing of the child's heart rate and is usually a response to pain.

Some children may have both types of spells, cyanotic and pallid, at one time or another. Both types do not have any serious consequences (unless the child hurts themselves when they fall) but they are frightening to watch, especially if you don't know what's going on.

CAUSES

Breath-holding spells often occur as part of toddler tantrums. The spell is a reflex reaction to an unpleasant stimulus, which the child can't prevent. It is not a deliberate behaviour on the child's part. No one is quite sure of the reasons behind breath holding, but one-third of children who have breath-holding spells will have a family history.

In some children, breath-holding spells may be related to iron deficiency anaemia, a condition in which the body does not produce a normal number of red blood cells. However, most children that go through a stage of breath-holding do not have a serious underlying problem.

Breath holding is not a precursor of epilepsy, even though a breath-holding spell may resemble an epileptic seizure. The main difference is that a child with epilepsy will turn blue during or after a seizure and not before. Wetting and soiling are common during an epileptic seizure but rare with breath-holding spells.

Whereas epileptic seizures may occur during wakefulness or sleep, breath-holding spells only occur when the child is awake and frequently when they are standing. Apnoea (pauses in breathing) only occurs during sleep.

AGES AND FREQUENCY

Breath-holding spells usually begin when a child is between six and 18 months and are usually outgrown before they start school, although for some children these spells may continue until they are around eight years old. Unfortunately, until they are outgrown, they may occur once a year, once a month, or even more frequently.

Breath-holding spells can vary in severity and frequency. They may happen fairly often, sometimes several times a day or once every few weeks. They usually occur more often when the child is overtired, upset and irritable. The more experienced you become in handling a child who holds his breath the better you will be able to predict when the spells are likely to happen.

HOW TO RESPOND

So what do you need to do when a child is having breath-holding spells? You have obviously already talked to the child's mother, who has told you she is not concerned, but you need to know if she has taken the child to the doctor for tests to rule out anaemia or heart problems. A child who has had whooping cough will also have difficulty catching his breath when he coughs and may turn blue.

Doctors will want to investigate further when a child loses consciousness and becomes very pale for no apparent reason.

Although several spells a day are probably not caused by an underlying problem, a doctor would want to rule out possible medical causes, especially breath holding that is followed by thrashing of arms and legs, shaking or stiffening that continues for more than a minute or when the child is excessively sleepy or confused afterwards. Because it is rare - but not unknown - in babies of less than six months, this would need to be investigated further.

Assuming that there are no underlying medical problems, you need to know what you should do when one of these spells occurs:

• Most importantly, keep calm

• Lie the child down on their side, check their mouth for food or any object that could pose a choking hazard

• Once they regain consciousness, remove all objects or furniture within reach, prevent their head, arms and legs from hitting anything sharp

• Don't try to shake them awake or splash cold water on them

• Wait for the episode to stop by itself and afterwards do not punish or reward

• Remember that breath holding in children is rarely dangerous. The child can't hold their breath long enough to cause brain damage, because they will pass out and resume breathing long before that is a concern

• However, if the child shows no sign of regaining consciousness after a minute begin administering CPR (cardiopulmonary resuscitation) and dial 999.

Since breath-holding spells usually follow crying and tantrums, you can to try to avoid them by preventing temper tantrums. This doesn't mean giving in to the child's tantrums, since that will likely just teach the child that tantrums work and they will probably then have even more. Instead, distract the child when you see a tantrum coming and before it really gets started.

It is rarely possible, however, to prevent a breath-holding spell because it is not always easy to stop small children from being frightened, startled, angry or frustrated. It is important not to blame the child for breath holding. It is not done deliberately in order for him to get his own way, but it will sometimes be possible to see a pattern emerging.

The incident may occur each time a tantrum is coming on, but while it may be possible to use techniques to distract the child, is important not to start allowing the child to 'get away' with things just in case they hold their breath.

Regular routines that prevent a child from becoming overtired or hungry, clear boundaries and knowing what the triggers for frustration are likely to be will do much to reduce the frequency of spells.