Breath-holding games: what every parent should know

"Who can stay under longest?" is one of the oldest pool games there is. Children play it with friends, with siblings, and against themselves. It feels harmless, and most of the time nothing goes wrong. When it does, it can go wrong silently, in seconds, with adults close by.

This guide explains why, in plain words, and what to do instead. It is not meant to frighten. A few clear rules make the risk very small.

Why children play them

• It is a natural challenge. Holding your breath is easy to measure and easy to compete at.
• Friends and siblings. Nobody wants to be first up.
• Films and social media. Children's Hospital of Orange County (CHOC) in California notes that preteens and teenagers try underwater breath-holding challenges they see online.
• Copying training drills. CHOC notes that these challenges seem to come from drills used in diving and competitive swimming. There, trained supervisors and rescue help are close by.
• Mermaid play. Children in tails, or pretending, want to stay "under the sea" for as long as they can.

None of this is naughty. It simply needs a better outlet.

What happens in the body

The breathing alarm

Most people think we feel the need to breathe because oxygen runs low. Mostly, we do not. Divers Alert Network (DAN) explains that the urge to breathe is driven mainly by carbon dioxide building up in the blood.

In a normal breath-hold, that works well. The carbon dioxide alarm goes off while there is still plenty of oxygen, and your child comes up.

What "big breaths" do

Children often take lots of fast, deep breaths before going under. It feels like filling up. In fact it does something else.

• It blows off carbon dioxide, so the alarm goes off much later.
• It adds almost no oxygen. DAN describes the gain as trivial.
• Oxygen keeps falling at the usual rate.

So the child feels fine for longer, but the oxygen is running out on the same schedule. Dr Joanna Chan of Singapore General Hospital, writing for ActiveSG, explains that oxygen can then drop too low for the brain without any warning.

Hypoxic blackout

When oxygen to the brain falls too far, the swimmer loses consciousness. This is called hypoxic blackout, or shallow-water blackout.

• There is no struggle. The child simply goes still.
• It can look like the game. Dr Chan notes that it can look like someone holding their breath on purpose, so help may come late.
• It can happen in an ordinary pool. Dr Chan notes that many cases happen in water less than 5 m deep.
• The end is riskiest. DAN explains that blackouts are most likely near the end of a breath-hold and just after surfacing. It advises watching for at least 30 seconds after someone comes up.

Once unconscious, the body eventually breathes by reflex, and water can enter the lungs. That is how a quiet game becomes a drowning.

What the research shows

In 2015, the CDC's journal MMWR published a study by New York City's health department. It looked at 16 people in New York State who drowned or nearly drowned after dangerous breath-holding in water, between 1988 and 2011.

• The youngest was 7. Ages ran from 7 to 47.
• The most common behaviour was static breath-holding, staying still underwater for as long as possible. The authors include breath-holding games with a partner in this group. One teenager was taking part in breath-holding contests.
• Fifteen of the incidents were at regulated pools, and nearly all of those had a lifeguard on duty.
• More than half happened with other swimmers present.
• Four people died. All four were experienced swimmers aged 17 to 22 who had over-breathed first.

Since 2014, New York City has required pools to display warning signs about these behaviours, including a picture sign aimed at younger swimmers.

The point for parents is simple. Being a good swimmer, being in a pool, and having a lifeguard nearby did not prevent these incidents.

Who is at risk

• Children who swim well. Confident swimmers can hold their breath longest, which is exactly the problem.
• Children in swim squads. Some squads use breath-control drills. MMWR counted this kind of training among the behaviours studied.
• Teenagers. Peer pressure, challenges and online videos raise the stakes. See Teenagers and mermaiding.
• Children in tails. A tail makes it harder to get to the surface or the side quickly.

Pool rules for children

These match the rules in our shallow-water blackout guide, in children's language.

1. No contests. Not with friends, not with a stopwatch, not against yourself.
2. Normal breaths only. No big, fast breaths before going under.
3. One length, one breath. Come up and breathe between underwater lengths.
4. Listen to your body. When you want to breathe, come up. Dr Chan and CHOC both stress never ignoring the urge.
5. Only when someone is watching you, and keeps watching for at least 30 seconds after you come up. An adult who is looking, close by, the whole time. See Never alone.
6. Get out when tired or cold.

How to talk to your child

Children respond better to understanding than to bans.

• Explain the alarm. "Your body has a clever alarm that tells you to breathe. Big breaths switch it off, and that is dangerous."
• Make it about smart, not scared. Trained mermaids never hold their breath underwater without someone watching every hold.
• Practise saying no. CHOC suggests preparing children for peer pressure. Give them words: "Nah, I'll judge."
• Talk about videos. Ask what challenges they have seen online. Listen first.
• Tell other adults. Grandparents, helpers and friends' parents may not know these rules.
• Revisit it every summer, and before holidays. See Mermaiding on holiday.

What to play instead

The fun is in being underwater gracefully, not for long. Swap the stopwatch for a judge's scorecard.

• Best mermaid surfacing. Score the smoothest, calmest way up, then a breath.
• Glide competitions. Who glides furthest from a push-off, along the surface?
• Statues. Freeze in a pose at the surface, one breath each.
• Shallow treasure hunt. One dive, one object, one breath, in water they can stand in.
• Synchronised shapes. Two children copy each other at the surface.

Each still needs an adult watching. None rewards time spent underwater.

Signs a watcher can see

DAN lists signs that a breath-holder is running low on oxygen:

• Movements becoming jerky or falling apart.
• Tense shoulders and neck, trembling fingers.
• A change in facial expression, or blue lips.
• A sudden burst of big bubbles from the mouth.
• Going still and not responding.

Any of these means the game is over now.

If a child blacks out

1. Get them to the surface and out of the water at once. Do not wait to see if they are joking.
2. Shout for help and get someone to call 995 in Singapore.
3. Start CPR if they are not breathing normally. If you are trained, begin with two rescue breaths. If not, the 995 call taker will talk you through it, and chest compressions alone are far better than nothing.
4. Get a medical check, even if they recover. StatPearls, a medical reference, advises hospital assessment for anyone who loses consciousness in the water.
5. No more swimming that day. A DAN article by Capps advises at least 24 hours out of the water after a blackout. Ask your doctor before your child swims again.

Myths

"It only happens in deep water." Many cases happen in less than 5 m of water, including ordinary pools.

"My child would struggle or shout." A blackout is silent.

"The lifeguard will spot it." In the New York study, nearly all the pools had a lifeguard on duty.

"Big breaths give you more air." They switch off the warning instead.

In our lessons

Breath-holding at our school starts from calm, normal breathing, and holds stay well within comfort. Lessons are mostly one-to-one and never more than four, and every breath-hold is watched from start to finish, one student at a time, in the shallow end. The goal is never a record. It is a calm, beautiful hold, finished with air to spare.