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

breath-holding 1
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

breath-holding 2
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?

breath-holding 4
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.



Why Your Toddler Won’t Nap… And How to Fix It

Q: My toddler won’t nap! What can I do?

She is 2 years and four months old. Until about two weeks ago she took a nap every afternoon after lunch for two hours. Now at nap time she complains that she wants to do something else. Anything else but nap. By 6 o’clock she’s so cranky that she throws tantrums and she never throws tantrums! Help!

True story… This is a very common situation. I get a lot of questions like this. In order to answer them, I need a lot more information!

A: So, your toddler won’t nap!

First, I need a lot of background. I ask about the child’s sleep history and her developmental history. Was she full-term or premature? Did she feed and grow normally during the first two years (I ask specific questions about milestones). Then I ask a sleep history. What is her current daily routine like? I’m particularly interested in nighttime sleep: how many hours does she get? Does she sleep continuously or does she wake up? If so, how many times? I also ask about diet and exercise (Really! These things matter!)

With this toddler, it turns out she was getting enough sleep – but the way her sleep was distributed was a little screwy.

Her parents had a terrific bedtime routine: everything from dinner time to bedtime was completely regular and predictable. The girl went down without a fuss at 7PM sharp (in her toddler bed!). She would wake up at 7AM, have a bottle in her bed, and a short time later would fall asleep again until 9AM, when she’d be up for the day. For several months, she’d take a brief nap in the afternoon. Now she wasn’t napping at all, and the tantrums were beginning.

The Routine

toddler won't nap

Her parents didn’t count the 7 AM bottle as an awakening and a nap, they counted it as part of her nighttime sleep. This little girl was getting 14 hours of sleep per day, which is on the high end for a toddler of her age. But she was getting all this sleep basically in one shot.

When most children drop down from two naps to one, it’s the morning nap that goes. They tend to keep the afternoon nap. This child kept her morning nap but lost the afternoon nap. As a result, by bedtime she would have stayed up 9 straight hours, which was a lot for her. She would become overstimulated and cranky. This actually made it more difficult for her to go to sleep at night!

Her fix

toddler won't nap
I LOVE daycare!

I explained to these parents that their daughter was getting great sleep at night: 12 hours! By the afternoon, she was not getting sleepy, because she had already taken a two-hour nap in the morning!  I thought that when she woke up in the morning, she should be up! But instead, she was conditioned to have her bottle and fall back to sleep. I pointed out that what she was doing was holding on to her morning nap beyond the point where she really needed it. She probably still needed the nap, only later in the day.

The fix was remarkably simple. Frankly, I was surprised how easy it was. I recommended that at 7AM, mom should start a new morning routine. She’d invite the girl to get up, have her bottle in the kitchen, eat a healthy breakfast and start her day. This activity alone was enough to stimulate the girl enough to convince herself she was awake and ready to play. By 1 o’clock in the afternoon, she began to get sleepy and went down for a nap. She’d get up at 3, and then would go down for the night at 7PM.  No crankiness, no tantrums.



There are many other reasons why a toddler’s nap schedule can get screwed up. Some toddlers have the kind of temperament that makes them sensitive to stimulation. In order to nap, they need low light and quiet. If there is too much sound, light, or activity, they will want to pay attention and stay awake.

Many toddlers nap badly at daycare. Even though most daycares do a terrific job of lowering the lights, playing soft music, and limiting noise and activity, sometimes it doesn’t work. The sensitive toddler won’t nap because she’ll be stimulated by whatever sound and activity is going on at nap time.

On the other hand, some parents tell me that daycare sleep is great but the toddler won’t nap at home! With further questioning, I usually find that the toddler is being overstimulated at home more so than at daycare!

toddler won't nap
Yeah.. no

In both these situations, if your toddler won’t nap and the reason is overstimulation, the fix is to try to reduce the amount of activity, sound, and light as much as humanly possible.

The Cheetos Sweetos Nap

Diet matters. Sorry, folks, it just does.

Here’s another true story: I did a consult for a family that had three children. One in first grade, a pre-schooler (age 3), and a baby just turned one. The reason for the consult was that the 3-year old wasn’t napping.

The mom had all three children with her when we sat down to talk. I spotted the sleep problem immediately before we even started getting to know one another. There was an open bag of Cheetos Sweetos being passed around and all of them were eating them… even the baby! Everyone had a sippy cup of juice.

Sure, they’re tasty. But Cheetos Sweetos is not food. It is the enemy of sleep. These poor kids were so amped up on sugar that it’s a wonder any of them slept at all. They got plenty of activity – this was obvious from watching them, but their diet was awful.

The Three Legs

I never get tired of reminding people that all of health and wellness stands on three legs: diet, exercise and sleep. All three of these are closely related to one another. Good habits in one domain reinforce the other domains. For example, kids who eat well tend to get better exercise, and they sleep better. Kids who sleep well tend to have more energy for exercise… and so on.

But you can also see how poor habits in any one domain can throw off the others. In the case of the Cheetos Sweetos family, poor diet was probably the most important key to understanding why the toddler won’t nap. So the take home messages are identical to the three legs of health:

  • Eat Real Food: If it doesn’t look like it did when it came out of the ground or from the animal, it’s not real.
  • Get Plenty of Vigorous Exercise: Humans are meant to move. Make sure the kids get at least an hour of real physical activity every day.
  • Get Plenty of Sleep: Keep consistent, predictable schedules, as much as possible. Avoid overstimulation. Listen to sleep cues, but provide structure!