# Breath-holding spells - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: Breath-Holding Spells - StatPearls (NCBI Bookshelf NBK539782) - https://www.ncbi.nlm.nih.gov/books/NBK539782/ · Breath-holding spells - disease-level clinical article (breath-holding-spells-full.txt) · Breath-holding spells - disease-level clinical article (breath-holding-spells-clinical.txt) - Verified date: 2026-08 ## Verified against - Breath-Holding Spells - StatPearls (NCBI Bookshelf NBK539782) - https://www.ncbi.nlm.nih.gov/books/NBK539782/ - Breath-holding spells - disease-level clinical article (breath-holding-spells-full.txt) - Breath-holding spells - disease-level clinical article (breath-holding-spells-clinical.txt) ## Treatment metadata - Confirm the story, exclude seizure and long QT (Recognition & Referral) - Iron — oral.liquid ## Complete treatment card ```text BREATH-HOLDING SPELLS Sources: Breath-Holding Spells - StatPearls (NCBI Bookshelf NBK539782) - https://www.ncbi.nlm.nih.gov/books/NBK539782/ · Breath-holding spells - disease-level clinical article (breath-holding-spells-full.txt) · Breath-holding spells - disease-level clinical article (breath-holding-spells-clinical.txt) Review status: REVIEWED against 3 sources listed above (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (2) - The episode is preceded by an identifiable emotional trigger - No aura occurs before the spell and no postictal state follows it SIGNS - what you find (2) - Physical exam findings are otherwise normal - The patient's color during the spell, blue versus pale, helps distinguish the two types [pallor] TESTS (6) - No specific diagnostic test is required; diagnosis rests on the history of the episode - Iron studies are checked, since iron deficiency is common in these children - An EKG is obtained routinely to exclude an underlying cardiac cause - EEG is not routinely recommended unless there are red flags for seizure - An ocular compression test during EEG can help separate a seizure from a breath-holding spell - Neuroimaging is not needed, since these children have normal anatomy IF NOT THIS - what else fits (4) - Considered alternatives include congenital laryngeal stridor and cardiac arrhythmia - Apnea of prematurity and an underlying genetic disorder are also considered - Epilepsy, sepsis, and nonaccidental trauma are among the differentials - A PDA-dependent congenital heart lesion is also on the differential list Source Breath-holding spells - disease-level clinical article (breath-holding-spells-full.txt) Status traced to the source above 1. CONFIRM THE STORY, EXCLUDE SEIZURE AND LONG QT (RECOGNITION & REFERRAL)[1st line] Adult Source Breath-Holding Spells - StatPearls (NCBI Bookshelf NBK539782) - https://www.ncbi.nlm.nih.gov/books/NBK539782/ Why The point here is to stop a dangerous mislabel. A breath-holding spell is diagnosed on a history with a clear trigger and a clean recovery; the two things it is mistaken for - an epileptic seizure and a cardiac arrhythmia such as long QT - are both potentially fatal and neither is excluded by the child looking well in the clinic. The article's own instruction is to rule them out, and an ECG is the cheap half of that. Caution WHAT A TRUE SPELL IS - a frequent and harmless event, seen in as many as 5% of children, and it comes in two forms. In the cyanotic kind, anger or frustration sets it off: the child holds their breath and the face goes blue or purple. In the pallid kind, a sudden fright comes first and the breathing then stops. THE HISTORY IS THE DIAGNOSIS, AND IT HAS TO BE CLEAN - the story must name an unmistakable emotional trigger, and then a spell of one type or the other, cyanotic or pallid. Decisively: there must be NO aura beforehand, and the child must NOT have any postictal features once they come round. No trigger, or a drowsy confused child afterwards, means this is not a breath-holding spell. IT CAN LOOK LIKE A FIT AND STILL BE A SPELL - a spell can knock a child out cold and can tip over into a convulsion. A jerk at the end of a spell does not by itself make it epilepsy. Telling a seizure disorder apart from these spells is genuinely difficult, so an electroencephalogram (EEG) is sometimes done - but absent a red flag, an EEG is generally NOT advised. DO THE ECG - THIS IS THE LINE THAT KILLS IF IT IS SKIPPED - an ECG is a cornerstone of the work-up, there to exclude a cardiac cause that would matter. The article names long QT syndrome among the conditions to rule out, and asks that the other causes of a faint or a fit be excluded too - epilepsy and the arrhythmias. A pallid spell, an episode with no crying, one during exercise or swimming, or a family history of sudden death or deafness makes the ECG urgent. THE CHILD MUST BE NORMAL BETWEEN EPISODES - the children who get these spells have a neurological examination that is normal and are hitting their milestones for their age; the rest of the examination should turn up nothing worrying either. Developmental regression or an abnormal neurological examination is a different diagnosis. ANYTHING THAT DOES NOT FIT GETS REFERRED, NOT WATCHED - where any piece of the assessment sits at odds with that story, it earns a work-up without delay and a referral onward: paediatric cardiology, paediatric neurology or genetics, as the case demands. CHECK THE IRON - send iron studies, because iron deficiency runs high in this group of children. This is the one test that also changes treatment, and iron deficiency is common in Egyptian toddlers. THE DIFFERENTIAL WORTH HOLDING IN MIND - the article lists arrhythmia, epilepsy, sepsis and nonaccidental trauma among the conditions to consider, and adds stridor of the larynx present from birth, and a congenital heart lesion that depends on a patent ductus. An episode described by a carer but never by the parent, or bruising that does not fit, deserves the same suspicion as any other unexplained collapse. WHAT TO TELL THE PARENTS, AND WHAT NOT TO DO - nothing lasting comes of these spells, so tell the parents to make as little of an episode as they can, or the child learns a behaviour out of it. Reassurance, plus that behavioural handling, is the standard treatment. Put NOTHING in the child's mouth, and do NOT shake, slap or splash the child. THE PROGNOSIS THEY CAME FOR - the spells do no damage and they do NOT injure the brain. Where neurological development is normal already, it stays normal. In most children the episodes have stopped by the age of 6. WHY NO ANTI-EPILEPTIC IS PRESCRIBED HERE - the article reports randomised trials in which piracetam at 40 mg/kg/d cut the spells markedly against placebo, and suggests levetiracetam may do better still. It then qualifies the whole class at once: because the condition settles by itself, the good and the harm of any treatment have to be balanced with care. That is a specialist decision and no such row is offered here. 2. IRON [add-on - not a substitute] Adult Peds 3-6 mg/kg/day (The article gives 3 to 6 mg/kg/d to start and stops there - it does not say whether that means elemental iron or a weight of ferrous salt, and it sets no maximum, no duration and no adult dose. Prescribe it as elemental iron, which is the usual reading, and check the elemental content of the Egyptian syrup in hand before converting. There is no adult indication here, so no adult dose is printed.) 3kg -> 9-18 mg/day 4kg -> 12-24 mg/day 5kg -> 15-30 mg/day 6kg -> 18-36 mg/day 7kg -> 21-42 mg/day 8kg -> 24-48 mg/day 9kg -> 27-54 mg/day 10kg -> 30-60 mg/day 11kg -> 33-66 mg/day 12kg -> 36-72 mg/day 13kg -> 39-78 mg/day 14kg -> 42-84 mg/day 15kg -> 45-90 mg/day 16kg -> 48-96 mg/day 17kg -> 51-102 mg/day 18kg -> 54-108 mg/day 19kg -> 57-114 mg/day 20kg -> 60-120 mg/day 21kg -> 63-126 mg/day 22kg -> 66-132 mg/day 23kg -> 69-138 mg/day 24kg -> 72-144 mg/day 25kg -> 75-150 mg/day 26kg -> 78-156 mg/day 27kg -> 81-162 mg/day 28kg -> 84-168 mg/day 29kg -> 87-174 mg/day 30kg -> 90-180 mg/day 31kg -> 93-186 mg/day 32kg -> 96-192 mg/day 33kg -> 99-198 mg/day 34kg -> 102-204 mg/day 35kg -> 105-210 mg/day 36kg -> 108-216 mg/day 37kg -> 111-222 mg/day 38kg -> 114-228 mg/day 39kg -> 117-234 mg/day 40kg -> 120-240 mg/day 41kg -> 123-246 mg/day 42kg -> 126-252 mg/day 43kg -> 129-258 mg/day 44kg -> 132-264 mg/day 45kg -> 135-270 mg/day 46kg -> 138-276 mg/day 47kg -> 141-282 mg/day 48kg -> 144-288 mg/day 49kg -> 147-294 mg/day 50kg -> 150-300 mg/day Source Breath-Holding Spells - StatPearls (NCBI Bookshelf NBK539782) - https://www.ncbi.nlm.nih.gov/books/NBK539782/ Why The only medicine the article supports in primary care. Its claim: iron supplements can make the spells come less often. Its amount: 3 to 6 mg/kg/d to begin with. It is offered second, below the assessment row, because giving iron never substitutes for the ECG. Caution IT IS GIVEN EVEN WHEN THE CHILD IS NOT ANAEMIC - iron may be started whether or not the child turns out to be iron-deficient, since it can bring the spells down in number. Still send the iron studies, because a genuinely iron-deficient toddler in Cairo needs a cause looked for as well as a syrup. IRON IS NOT A SUBSTITUTE FOR THE CARDIAC AND NEUROLOGICAL CHECK - the article's instruction to obtain an ECG and to refer anything that does not fit the history stands whether or not iron is started. A child whose spells continue on iron has not been treated; they have been observed. EXPECT THE USUAL IRON PROBLEMS AND WARN THE FAMILY - dark stools, constipation, nausea and staining of the teeth with liquid preparations. Give it away from milk, and keep the bottle out of reach: iron overdose is one of the commonest serious accidental poisonings in small children. NO RESPONSE IS A REASON TO GO BACK TO THE DIAGNOSIS - the article frames this as a self- limiting condition in which the good and the harm of treating have to be balanced with care, so a course of iron that changes nothing should prompt a second look at whether these are breath-holding spells at all. Egypt FERRITOP 15MG/5ML SYRUP 100 ML HIKMA PHARMA 10.00 EGP ANSCHLARIN SYRUP 120 ML AVERROES PHAR... 10.50 EGP FEROSE 50MG/5ML 100ML SYRUP SPIMACO > EIMC 16.20 EGP GOLDEN FER 10 MG/ML SYRUP 100 ML MEDIZEN PHARM... 34.00 EGP FABUGLYCINA SYRUP 120 ML PRAXO PHARM 45.00 EGP FERRMARRON SYRUP 100 ML KAHIRA > ABBO... 60.00 EGP FERROSWAB 100MG/10ML 20 UNIDOSE ORAL SOLN.* 10 ML UNISWAB 137.00 EGP BALANCERON DROPS ORGANIX > BAL... 160.00 EGP HAEMOPOWER 50MG/5ML ORAL SYRUP 100 ML AMRIYA 16.25 EGP -> ? strength differs, ? different route - not oral liquid HAEMOPOWER 50MG/ML ORAL DROPS 30 ML AMRIYA 20.00 EGP -> ? strength differs, ? different route - not oral liquid Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)