You Know It When You See It…

Tantrum – Definition: BRIEF periods of extreme unpleasant behavior in response to frustration or anger in your child, with normalization of mood/behavior between episodes

  • About once per day
  • Average duration 30 seconds to 1 minute (median duration of 3 minutes)
  • Gradual improvement in severity and frequency with age

Common Tantrum Triggers



History & Physical Exam:

  • “Tell me all about the tantrums”
    • Time of day, circumstances triggering, behaviors, duration of tantrum, what the caregiver’s emotional reaction is, how mood is between episodes, any changes to home or school structure, any new conflicts, any scary or upsetting events, other behaviors concerning child’s functioning (sleep issues, incontinence, regression)
  • Developmental history, Family history, Social determinants, Trauma screening
  • Look for signs of anemia


  • Screening: vision, hearing, learning disability, lead level
  • Consider CBC to rule out IDA and ECG to rule out long QT
  • Consider referral in presence of concurrent sleep disorder, enuresis, or negative mood behaviors between tantrum episodes

Breath-Holding Spells

Breath-holding spells may occur in up to 5% of healthy children, but usually disappear by 5yo (rarely last until 8yo)

Spells occur especially when upset and crying, may hold their breath until they syncopize (not usually on purpose), and may have convulsive movements, which are usually harmless

Two types: 

  • Pallid (cardiac)
    • Less common
    • MOA: Vagally-mediated cardiac inhibition → transient arrhythmia (brady or asystole) → sudden LOC and pallor
    • ECG needed
  • Cyanotic (respiratory)
    • More common, >50% of cases
    • Triggered by emotional stress/crying, prolonged expiratory apnea → LOC (syncope) and cyanosis
    • Associated with IDA and may be responsive to treatment with iron replacement


  • Prognosis for typical toddler tantrums is excellent!
  • Children should outgrow tantrums by school age (~4-5yo)
  • Consider tantrums as an essential developmental milestone
  • Tantrums are benign (as long as they are in a safe environment)
  • Prevention is the best way to manage
  • Avoid common triggers by implementing nap time, snack time, safe play space

Some tantrums are inevitable… so what do we do then?

  • Great opportunity to build emotional resilience for all!

Tantrum Scripts

Toddlers are learning CAUSE and EFFECT. Push-back is healthy—learning independence, reasoning, and the urge for CONTROL. 

  1. Tell your child that you hear them and understand them. Help them by teaching them what emotions they are feeling. Show acceptance. Give yourself, as a parent, time to calm down and identify your own feelings as well. 
  2. Remove the stimulus. Do not give in because they will learn that boundaries are flexible. Pushing and crying will get them what they want in the end and this is a lesson that you do not want to reinforce. It’s hard in the moment, but will decrease the number of tantrums in the future. 
  3. Giving a child two options gives them back some sense of control while overall allowing the parent to maintain overall structure.

Situational Strategies




What’s the difference between discipline and punishment?

Discipline is a way of teaching and a way of enhancing a good parent-child relationship. Provide your child with PRAISE along with INSTRUCTION in a firm tone, with the intent on improving behavior.

Punishment is a negative. Until age 3yo and sometimes later, children simply don’t understand the concept.

  • Corporal punishment (e.g. spanking, slapping) is proven to be ineffective in the long-term as effects have been shown to be transient, and may be associated with subsequent aggressive behavior (i.e. toddlers who were spanked have higher incidence of externalizing behavior, lower vocabulary scores, and increased aggression)

Common things to AVOID

  • Big reactions (i.e. yelling)
    • Preverbal kids may interpret big reactions as something positive
  • Dismissive / Authoritarian
    • “It’s okay, there’s no reason to cry. Stop crying.” (dismissive)
    • “By the time I count to 3, you need to stop.” (authoritarian)
  • Negotiating
    • Challenges your boundary, reinforcing behavior that negotiating works
  • Excessive Time Out
    • Tip: 1 minute of time out for age in years (2yo = 2 minutes) 

Take-Home Points!

  • Educate parents that keeping their child safe should be the top priority.
    • Kitchen and bathroom are dangerous places
    • Childproofing, take away dangerous objects
  • Tell parents to STAY CALM, STAY CONSISTENT, and that it’s okay for kids to have tantrums.
  • Positive reinforcement is the best way to teach discipline.
  • Screen for learning disability (including hearing/vision), sleep disorders, and ADHD

“Ignore bad behavior and go out of your way to praise even a little bit of good behavior. Kids are performers and actors. If there is no audience, there is no reason to do it.”

-Burton Shen, MP Core Faculty & Father of Teddy the Toddler


Resources for Parents!

Blog post based on Med-Peds Forum talk by Vivian Shi, PGY3

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