Breath-holding Spells at Bedtime

One of my most memorable clients is a 15-month old girl who threw tantrums at bedtime. Recently she had begun crying so hard she began breath-holding. One night in particular, she held her breath so long she collapsed. Her mother became so scared she called 911.

The little girl was fine. She woke up moments after collapsing, but it was too late for the 911 call. EMS was already on the way. When they heard the story, the paramedics and the doctors immediately understood what had happened. They had received many cases of breath-holding spells where someone panicked and dialed 911. But there was one funny twist to this story: mom witnessed the entire episode and she swears the baby’s lips did not turn blue before she passed out. She was quite sure the baby stayed her usual (somewhat pale) color throughout.

Breath-holding Spells

Of all the “normal things” that can happen to our children, breath-holding spells have got to be the scariest.  They are triggered most often by temper tantrums, but they can also occur when the child becomes suddenly frightened, frustrated or any other form of emotional upset.

They cry so hard they actually stop breathing. And anyone who stops breathing long enough will eventually faint from loss of oxygen to the brain. The good news is that as soon as the child faints and falls down, she starts breathing again, and “wakes up” often a moment later. Sometimes the child’s body will jerk briefly, causing witnesses to believe the child is having a seizure. These are myoclonic jerks, not seizures. These fainting spells are not harmful to the child and there are no lasting effects whatsoever.

Here’s the important point: the child is not doing it on purpose! It’s actually very difficult to make oneself pass out purposefully. Certainly no toddler can do it.

Tears Before Bedtime

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She’s holding her breath

I hear a lot of stories from parents of toddlers who perform a consistent bedtime routine, at the same time every evening. But it always seems to end with the toddler dissolving into tears the moment she’s put in the crib, or when a parent leaves the room. In cases like these, the crying has become part of the routine! The toddler (and the parents) know the sequence: dinner, bath, PJs, book, bed, cry… then pick the child up, put her down, more crying, etc. Clearly, this isn’t the bedtime routine anyone wants.

This is the time to sit down and re-think the bedtime routine. Is the toddler really tired enough to go to sleep? It makes sense to keep a log of the number of hours she sleeps. At 15 months, she should be getting a total of 12-14 hours, 11-12 of which happen at night. If the toddler has had an afternoon nap, perhaps late in the afternoon, it could be that she’s not ready to sleep at the prescribed bed-time. In that case I recommend pushing the bedtime routine later in small increments, say 15 minutes at a time.

What if there has been too much time between the last nap and bedtime? Perhaps the child is overstimulated (some say “over-tired” – I say it’s the same phenomenon: tired brain). Or the child is overstimulated because her day is just too full of sensory overload? In these cases, it may be time to change things up.

Mid-course Correction

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No more sweets, please!

Very often, in the course of a consult, the parents and I can identify some factor that we can adjust, and test to see if it has effect on bedtime tears.  Reducing stimulation is easier said than done, but it is often helpful. Paying attention to the child’s diet can be important as well.

Do you give her juice? You don’t have to. In fact, you shouldn’t! Juice is not fruit, it’s sugar-water. Better to have her drink water. The same goes for sweet cereals and snacks.

Some children are sensitive to the things that are added to processed foods, such as dyes, flavorings, and other additives. Very few children I know of react badly to real food. By “real” I mean food that resembles the thing that came out of the earth or the livestock pen.

Limits setting

It’s also possible that the toddler may tantrum at bedtime (even to the point of breath-holding), because she knows this will delay bedtime. In cases like these, I recommend that parents become actors. They need to pretend that they are not fazed at all when the child passes out. This isn’t easy to do, and should be considered a last resort. But just as you want to avoid bad sleep associations, you want to avoid convincing the child that breath-holding is an effective way to get you to stay with her. Like any behavior you want to modify, limits setting and enforcement are key to raising a happy, secure child.

Back to the Twist

What about the 15-month old who didn’t turn blue when she fainted from breath-holding?

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Diet matters, folks

Because the EMTs took her to the emergency department, she had blood drawn. One test showed that the girl was severely anemic. Anemia is known to be associated with breath-holding spells. She was so anemic that she didn’t have enough red blood cells to turn blue when she passed out!

The anemia in this girl’s case was due to her diet. This girl drank about 40 ounces of whole milk per day. She ate very little or no food. Why should she? She was full of milk! In about 40% of infants, drinking cow’s milk causes them to lose small amounts of blood through their gut. Since this girl drank only cow’s milk, she became profoundly anemic as a result.

This girl’s anemia, and her breath-holding spells, were cured by taking her off milk and giving her an iron supplement.

So this breath-holding story had a happy ending. Virtually all of such stories do. The behavior goes away in a few months. If you have any questions or concerns about breath-holding, or if you are having a difficult time managing these episodes, consult your pediatrician.