Seeing alarms flash and numbers dip can make time slow down—especially in an Indian NICU, where the monitor beeps can feel louder than your own thoughts. Apnea of prematurity—breathing pauses in a preterm baby—often sits at the centre of that fear: “Is my baby forgetting to breathe? Will this leave any lasting effect? When will we go home?” Most of the time, the explanation is straightforward: the breathing control system is still maturing. Still, teams watch closely, because pauses can come with oxygen dips and a slowing heart rate.
You will hear about pause duration, SpO₂ targets, heart rate trends, caffeine citrate, and supports like CPAP. You may also hear a look-alike term that causes confusion—periodic breathing. Let’s put the pieces together, calmly.
Apnea of prematurity: what it means
Apnea of prematurity refers to pauses in breathing that happen mainly because a preterm baby’s respiratory control is immature. In many neonatal units, an episode is described as:
- a breathing pause lasting more than 20 seconds, or
- a shorter pause associated with bradycardia (slower heart rate) and/or desaturation (a drop in oxygen saturation on the pulse oximeter, SpO₂).
What feels frightening is not only the pause, but the domino effect: SpO₂ drops, then the heart rate may slow. In most babies, this pattern reflects immaturity rather than permanent injury, and it improves as weeks pass.
How NICU teams judge severity (not by one alarm)
Doctors and nurses don’t label Apnea of prematurity based on a single beep. They look at the overall pattern—what happens across hours and days.
They usually consider:
- Duration of pauses (especially >20 seconds)
- Frequency (events per hour/day)
- Depth of bradycardia (often discussed when the heart rate falls below ~100/min)
- Degree of desaturation and how quickly SpO₂ recovers
- Need for intervention (self-resolving vs needing gentle stimulation, oxygen adjustment, CPAP, or bag-and-mask ventilation)
A short event that settles on its own is not treated the same as repeated, prolonged events with deep drops.
Periodic breathing vs Apnea of prematurity
Many preterm babies show periodic breathing: a few regular breaths, then a short pause, then breathing resumes—often 5 to 20 seconds—without meaningful bradycardia or significant desaturation.
Apnea of prematurity is different because the pause is longer, or because a shorter pause is paired with bradycardia and/or desaturation. That difference matters. Periodic breathing is usually benign, Apnea of prematurity calls for monitoring and sometimes treatment.
What an episode can look like in the NICU
A typical Apnea of prematurity event may start as a breathing pause and then trigger alarms for SpO₂ and/or heart rate. You might notice:
- no visible chest movement
- colour change (pale skin, or bluish lips/face)
- a drop in SpO₂ on the monitor
- a slowed heart rate
Many episodes are brief and settle spontaneously or with a simple, gentle action.
Why bradycardia often follows apnea
In many preterm infants, bradycardia is a response to low oxygen. As oxygen levels fall, the heart rate slows—often through a stronger vagal reflex than you would see in a term baby. This is why teams pay attention to repeated intermittent hypoxemia and not just to the pause itself.
When apnea tends to appear
Timing helps the team decide if the pattern fits typical Apnea of prematurity or if another cause should be considered:
- common onset: around day 2–3 of life
- very early events (from day 1) may prompt discussion of other causes, depending on the situation
- later onset (for example, after two weeks in a previously stable baby) often triggers a search for an intercurrent factor—commonly infection
Types of apnea: central, obstructive, and mixed
A preterm baby may stop breathing because the brain’s signal pauses, because airflow is blocked, or because both occur together.
Central apnea
In central apnea, there is little or no breathing effort (no chest movement). It is linked to immaturity of the breathing centre in the brainstem and a still-developing response to rising carbon dioxide (CO₂) or falling oxygen. These episodes often happen during sleep and can be followed by desaturation and bradycardia.
Obstructive apnea
In obstructive apnea, the baby tries to breathe, but airflow is limited. Contributing factors can include:
- more collapsible upper airway structures
- lower pharyngeal tone
- nasal congestion or secretions
- head/neck position that narrows the airway
In very small preterm babies, even tiny changes in airway size can make a big difference.
Mixed apnea
Mixed apnea combines central and obstructive parts in the same event (central then obstructive, or the reverse). This is common in neonatal care. It can shape treatment choices: respiratory stimulants for the central component and airway-support strategies (such as CPAP) if obstruction contributes.
Why apnea of prematurity happens: physiology and risk factors
Gestational age is the biggest driver
The earlier a baby is born, the more likely Apnea of prematurity becomes:
- before 28 weeks, most infants will have events at some point
- around 34 weeks, a meaningful proportion can still have episodes
This is not something you “caused”. It is a predictable effect of immature respiratory control.
Ventilatory control: CO₂ and oxygen sensing
Breathing is regulated by sensors and brain centres that adjust ventilation based on CO₂ and oxygen. In preterm babies, this feedback loop is less stable:
- the response to rising CO₂ can be slower
- the response to low oxygen can be incomplete
Result? Irregular breathing—especially in sleep—where pauses can trigger desaturation and then bradycardia.
Airway stability and feed coordination
Even if the brain sends the signal to breathe, the upper airway can narrow more easily. Also, coordination between sucking, swallowing, and breathing is still developing. Around feeds, this can contribute to obstructive or mixed events.
Factors that can increase episodes (especially a sudden change)
A sudden increase in Apnea of prematurity episodes always prompts re-checking the baby’s overall status. Common contributors include:
- neonatal infection (including sepsis)
- hypoglycaemia
- electrolyte disturbances (sodium, potassium, calcium, magnesium) or acid–base imbalance
- hypothermia or temperature instability
- anaemia
- respiratory conditions such as respiratory distress syndrome or bronchopulmonary dysplasia
Diagnosis and monitoring: what clinicians use
Diagnosis is clinical: the team observes events in the context of prematurity and overall stability. Continuous cardiorespiratory monitoring tracks:
- respiratory rate and breathing effort
- heart rate
- oxygen saturation (SpO₂)
Teams also quantify the pattern over 24 hours: frequency, duration, association with bradycardia/desaturation, need for stimulation, and how recovery happens.
When the team looks for another cause
If Apnea of prematurity becomes more frequent, more prolonged, or different from baseline, clinicians check whether immaturity still explains it—or if another condition is adding fuel.
Possible evaluations may include:
- infection/sepsis assessment (exam, blood count, inflammatory markers, blood cultures, sometimes chest imaging)
- blood glucose check and correction if low
- metabolic testing (electrolytes including calcium/magnesium, acid–base balance)
- thermal environment review, because cold stress can worsen breathing instability
- neurologic evaluation when indicated (cranial ultrasound depending on gestation and signs, EEG if seizures are suspected)
- cardiac evaluation when needed (murmur, persistent hypoxemia, poor tolerance, echocardiography may be considered)
- neuromuscular considerations if there is marked hypotonia or unusual respiratory weakness
Reflux: why the link is often overestimated
Gastro-oesophageal reflux is frequently blamed for apnoea, but it does not explain most episodes on its own. Digestive symptoms can be managed separately when they are significant.
What happens during an episode: immediate, gentle care
Often, a simple step is enough: gentle tactile stimulation (touching, rubbing) and a small position change. If recovery does not occur promptly, staff may provide mask ventilation and adjust respiratory support.
Treatment: step-by-step support while maturation catches up
The aim is clear: reduce events and prevent deep desaturations and bradycardias—without overdoing interventions while the baby matures.
Non-pharmacologic measures
These can reduce events, especially when obstruction contributes:
- careful head and neck positioning to keep the airway open (in monitored settings)
- keeping nasal passages clear of secretions when needed
- grouping care when appropriate to reduce stress and protect sleep
Caffeine citrate
Caffeine citrate is the reference medication for Apnea of prematurity. It stimulates the respiratory centre, improves breathing regularity, and reduces event frequency.
Monitoring focuses on:
- effectiveness (fewer apnoeas, fewer desaturations)
- tolerance (possible faster heart rate, restlessness, sleep disruption)
Oxygen: stabilise without excess
When Apnea of prematurity is associated with repeated desaturation, oxygen therapy can help. Oxygen is treated like a medicine: the aim is to avoid both deep dips and unnecessary high oxygen exposure. NICUs use target SpO₂ ranges tailored to the baby’s condition.
CPAP: supporting airway and lung stability
Nasal CPAP (continuous positive airway pressure) helps keep the upper airway and lungs more stable. It can be especially helpful when obstruction contributes or when respiratory stability is fragile. Teams also protect the nose and skin and monitor comfort.
Mechanical ventilation
If Apnea of prematurity is severe and repetitive despite caffeine and CPAP—or if there is significant lung disease—mechanical ventilation may be needed. Often it is temporary: a bridge while the baby grows and any intercurrent illness is treated.
Other options (selected situations)
Depending on local protocols and the clinical picture, some units may consider:
- theophylline/aminophylline (same family as caffeine, with closer monitoring)
- doxapram (use varies, usually reserved for selected situations)
How it improves over time
Apnea of prematurity usually decreases over weeks and often resolves between 36 and 40 weeks postmenstrual age (gestational age + time since birth). It may resolve later in extremely preterm babies or those with associated respiratory conditions.
Weaning support and discharge planning
Weaning respiratory support
Support is reduced when events become rare and mild. The pace follows the baby’s tolerance—more trend-based than calendar-based.
Stopping caffeine
Caffeine is typically stopped when there are no longer clinically significant apnoeas needing stimulation and stability holds for several days. After stopping, the team observes closely to ensure events do not return.
If apnea persists beyond term-equivalent age
Apnoea beyond 36–40 weeks postmenstrual age, or a return after a calm period, usually prompts reassessment (infection, metabolic disturbance, anaemia, neurologic issues, obstructive contribution) and sometimes consideration of another diagnosis.
Possible complications and outcomes
Why monitoring is careful
Repeated intermittent hypoxemia and bradycardia are why NICU teams track patterns closely and aim to reduce significant episodes.
Oxygen exposure and eye health
In preterm infants, retinopathy of prematurity is influenced by oxygen exposure and fluctuations in SpO₂. Teams balance preventing deep desaturations with avoiding unnecessary high oxygen levels.
Neurodevelopment: the broader picture
In very preterm infants, repeated hypoxemia may add to other factors (severe infection, brain haemorrhage, bronchopulmonary dysplasia) that can increase risk of neurodevelopmental challenges. Apnea of prematurity alone does not explain everything, the whole medical context matters. Follow-up after discharge usually tracks tone, motor development, attention, and language, and supports early intervention if needed.
After discharge: when to seek urgent medical advice
After going home, follow-up focuses on growth, feeding, and sleep. Seek medical advice promptly if you observe:
- breathing pauses with blue colour change, marked pallor, or visible distress
- loss of tone or a collapse-like episode
- unusual sleepiness or difficulty waking your baby
- breathing difficulty (persistent fast breathing, retractions, grunting)
To remember
- Apnea of prematurity involves breathing pauses sometimes accompanied by bradycardia and/or desaturation, severity depends on frequency, duration, and physiologic impact.
- It is different from periodic breathing, which is common and usually harmless.
- Events may be central, obstructive, or mixed.
- The main driver is immaturity, with improvement most often between 36 and 40 weeks postmenstrual age.
- If Apnea of prematurity increases or changes, teams look for contributors such as infection, hypoglycaemia, metabolic imbalance, temperature instability, anaemia, and respiratory disease.
- Care is stepwise: gentle stimulation and positioning strategies, caffeine citrate, oxygen and/or CPAP, and sometimes ventilation.
- There are professionals to explain trends and next steps. You can also download the Heloa app for personalised advice and free child health questionnaires.
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