A battle of wills. You know how this ends. You know she doesn’t (cue Cartman voice from South Park) respect your authorit-ay. Yet, you’re determined this time to stand your ground. It’s time to come in for dinner. She thinks it’s not: her swing set, her decision when she’s done with the slide. There’s a glint of defiance in her eye. The camera pans from her face, to yours, and back again. That familiar cowboy whistle rings out, tumbleweeds blow through the backdrop of this scene. Sweat drips from your face.
Then, it happens.
Your 18-month-old daughter hasn’t been staring you down so much as she’s been not breathing mid temper tantrum. Her lips turn blue. Her legs buckle, and there you go, swooping in to save her from certain head injury as she starts to pass out. She wins. She always does.
What you’ve just witnessed is a good, old fashioned breath holding spell. Although you’ve witnessed it before, it always takes your breath and quickens your pulse.
There is a silver lining: while scary to parents as they witness this fainting episode, these are very benign disorders. In fact, this scenario is so classic, that if you bring your kid to see me in the emergency department with this exact story, I’m probably going to offer you some reassurance and teaching on the subject, then discharge you and your princess home.
There are a number of things that precipitate this toddler equivalent of a fainting goat show. Usually either little Johnny is upset because you didn’t give him what he wanted, or your little girl got hurt so bad it made her cry and then be unable to take that next breath. In the great state of Indiana, parents are sometimes known to blow in the face of the blue infant. We call that Hoosier CPR. Yes, we’re keeping it classy.
We used to think that this was a volitional act of defiance. What’s actually thought to be the cause is something caused autonomic dysfunction. The autonomic nervous system is the part of us that we don’t have to think about. It controls our heart rate, respiratory rate, and blood pressure. It’s also responsible for the fight or flight response to perceived bad things. So, as you can see, dysfunction in this arena can make kids hold their breath to the point of not being able to take another breath and then passing out, or even slowing the heart rate so severe that also leads to fainting. Most kids will outgrow these, a small number will go on to be adults who pass out at the site of blood or with some other tragic stimulus.
Let’s break down for a second what happens when a child has one of these episodes. With this “autonomic dysfunction,” there is either a halt in breathing, or just a very slow heart beat. This results in a decrease in blood and oxygen going to the brain, which the brain does not like so much. As a result, the child passes out, which, if you think about it, causes breathing to start up again, and it increases the blood flow to the brain (easier to push blood to a brain on a flat body than pushing it uphill when one is upright). And, voila! The universe is once again right and in order. Occasionally these episodes are so severe that there is a brief seizure or seizure-like activity at the end.
If your child does have one of these episodes, by all means feel free to go see your doctor, or at least place a phone call. There are many nuances to the practice of medicine and, as such, it’s always a good idea to run your specific case by a provider. Just don’t be surprised if your doctor doesn’t launch into an exhaustive series of tests.
There is an association between iron-deficiency anemia and breath-holding spells. So, screening for this with a complete blood count is reasonable for your doctor to do. If this diagnosis is made, iron replacement can be helpful.
Most patients outgrow these episodes by age 5. It’s important to remember that, unlike the perception in the story at the beginning, this is not an attempt by your child to undermine your parenting prowess. It also doesn’t mean that your descendant should enjoy a life without boundaries. What it does mean is that it’s an opportunity to love this child through a brief tantrum or fit, and keep her safe while she passes out. When she wakes up, you tell her she’s still not going down the slide again. Dinner is almost ready. She probably won’t have the nerve to pass out on your twice in a row.
What scary experiences have you had with a child who tortured you with these?