Seeing alarms flash and numbers dip can make time slow down. Apnea of prematurity—breathing pauses in a preterm baby—often sits at the center of that fear: “Is my baby forgetting to breathe? Is this dangerous? Will it stop?” The reality is usually less dramatic than it feels, yet it deserves careful monitoring and, sometimes, treatment. You will hear about pause length, oxygen saturation, heart rate, caffeine, and supports like CPAP. You may also hear a confusing look‑alike term: periodic breathing.
Apnea of prematurity: what it means (and what it does not)
Apnea of prematurity describes pauses in breathing that occur mainly because a preterm infant’s respiratory control is still immature. Many neonatal units define an event as:
- A breathing pause lasting more than 20 seconds, or
- A shorter pause associated with bradycardia (slower heart rate) and/or oxygen desaturation (a drop in SpO₂ measured by the pulse oximeter).
A key point, easy to miss when you’re watching the monitor: Apnea of prematurity is most often a “developmental timing” issue, not a sign of permanent damage. The brainstem circuits that drive breathing and react to carbon dioxide (CO₂) and oxygen are still maturing.
How NICU teams judge severity (beyond a single alarm)
Clinicians rarely label Apnea of prematurity based on one episode. They look at the pattern.
They typically consider:
- Duration of pauses
- Frequency (per hour, per shift, or over 24 hours)
- Depth of bradycardia (often discussed when heart rate drops below ~100/min)
- Degree of desaturation and how quickly SpO₂ rebounds
- Need for intervention: self‑resolving vs needing stimulation, oxygen adjustment, CPAP, or assisted ventilation
A single brief pause that ends on its own is not interpreted like repeated events that require intervention.
Periodic breathing: the common look‑alike
Many newborns—especially preterm babies—show periodic breathing: regular breaths interrupted by short pauses, often 5 to 20 seconds, without significant bradycardia or meaningful oxygen drop.
- Periodic breathing: short pauses, minimal physiologic impact, often benign.
- Apnea of prematurity: longer pauses, or shorter pauses paired with bradycardia and/or desaturation.
What an episode can look like at the bedside
During Apnea of prematurity, you may notice:
- No visible chest movement
- Color change (pale, gray, or bluish lips/face)
- SpO₂ dropping
- Heart rate slowing (bradycardia)
Many episodes end quickly. Some respond to simple measures.
Why bradycardia often accompanies apnea
In preterm infants, bradycardia commonly follows low oxygen—partly through a vagal reflex. As oxygen saturation falls, heart rate may slow. Teams therefore track the intermittent hypoxemia pattern, not just the pause.
Timing that helps clinicians interpret events
- Typical onset is often around day 2–3 of life.
- New or later worsening (for example after two weeks in a stable baby) often triggers a search for an intercurrent factor, frequently infection.
Types of apnea: central, obstructive, and mixed
Central apnea
In central apnea, there is little or no breathing effort. In preterm babies, the response to rising CO₂ and falling oxygen can be unstable, especially during sleep.
Obstructive apnea
In obstructive apnea, effort is present, yet airflow is limited. Contributing factors can include:
- More collapsible upper airway structures
- Lower pharyngeal muscle tone
- Nasal congestion or secretions
- Head/neck positioning that narrows the airway
Mixed apnea
Mixed apnea combines central and obstructive components in one event. It is common, and it can influence support choices (respiratory stimulation plus airway support).
Why Apnea of prematurity happens: physiology and risk factors
Gestational age: the strongest driver
The earlier a baby is born, the more likely Apnea of prematurity becomes:
- Before 28 weeks, most infants experience apnea at some point.
- Around 34 weeks, a meaningful proportion still have episodes.
Breathing control and sleep state
Breathing is regulated by chemoreceptors and brain centers that adjust ventilation based on CO₂ and oxygen. In preterm infants, this feedback loop is less stable:
- The ventilatory response to rising CO₂ may be slower.
- The response to low oxygen can be incomplete.
The result is more irregular breathing during sleep, with pauses that can lead to desaturation and then bradycardia.
Airway stability and feeding coordination
Even with a normal breathing signal, the airway can narrow more easily. Coordination of suck–swallow–breathe is also still developing, so obstructive or mixed events may cluster around feeds.
Factors that can increase episodes
A sudden change prompts reassessment. Potential contributors include:
- Neonatal infection (including sepsis)
- Hypoglycemia
- Electrolyte disturbances (sodium, potassium, calcium, magnesium) or acid–base imbalance
- Hypothermia or temperature instability
- Anemia
- Respiratory conditions such as respiratory distress syndrome or bronchopulmonary dysplasia
Diagnosis and monitoring: what clinicians measure
Diagnosis of Apnea of prematurity is primarily clinical, interpreted in context. Continuous cardiorespiratory monitoring tracks:
- Respiratory rate and breathing pattern
- Heart rate
- Oxygen saturation (SpO₂)
Teams also quantify events over time: how often they occur, how long they last, whether bradycardia/desaturation occur, and whether stimulation is required.
When teams look for another cause
If apnea becomes more frequent, more prolonged, harder to recover from, or simply “different,” clinicians may evaluate:
- Infection/sepsis (exam, blood tests, cultures, sometimes chest imaging)
- Blood glucose
- Metabolic balance (electrolytes, calcium/magnesium, acid–base status)
- Thermal environment (cold stress can worsen breathing instability)
- Neurologic assessment when indicated (cranial ultrasound, EEG if seizures are suspected)
- Cardiac assessment when needed (murmur, persistent hypoxemia, echocardiography may be considered)
Reflux: a frequent suspect, an inconsistent cause
Gastroesophageal reflux is often blamed for apnea, but it does not explain most events on its own. Digestive symptoms can still be managed when they are significant.
What staff do during an episode
Often, the first response is gentle tactile stimulation and a small position adjustment. If recovery does not occur promptly, the team may increase oxygen, adjust support, or provide mask ventilation.
Treatment of Apnea of prematurity
The goal is to reduce pauses and prevent deep desaturation and bradycardia while maturation catches up.
Non‑pharmacologic measures
- Head and neck positioning that supports airway patency (in monitored settings)
- Clearing nasal secretions when they impair airflow
- Clustering care when appropriate to protect sleep
Caffeine citrate
Caffeine citrate stimulates the respiratory center and reduces the frequency of Apnea of prematurity. Teams monitor effectiveness and tolerance (faster heart rate, jitteriness, sleep changes).
Oxygen, CPAP, and sometimes ventilation
- Oxygen therapy can stabilize SpO₂ when desaturations repeat, clinicians use target saturation ranges.
- Nasal CPAP supports airway stability and lung volume, often helpful when obstruction contributes.
- Mechanical ventilation may be needed if events remain severe despite caffeine and CPAP, or if lung disease is significant.
How it improves over time
Apnea of prematurity generally decreases over weeks and often resolves between 36 and 40 weeks postmenstrual age (gestational age plus time since birth). Babies born extremely early, or those with ongoing respiratory disease, may need more time.
Weaning support and discharge planning
Support is reduced when events become rare and mild, guided by trends. Caffeine is often stopped after several stable days without clinically significant apneas, teams then observe closely for recurrence. Persistent or returning events beyond term‑equivalent age usually prompt reassessment for infection, metabolic disturbance, anemia, neurologic issues, or an obstructive contribution.
After discharge: when to seek urgent medical advice
Seek medical advice promptly if you notice:
- Breathing pauses with blue color change, marked pallor, or visible distress
- Loss of tone or a collapse‑like episode
- Unusual sleepiness or difficulty waking your baby
- Persistent breathing difficulty, grunting, or chest retractions
Key takeaways
- Apnea of prematurity involves breathing pauses sometimes accompanied by bradycardia and/or desaturation, severity depends on frequency, duration, and physiologic impact.
- It differs from periodic breathing, which is common and usually harmless.
- Episodes 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, hypoglycemia, metabolic imbalance, temperature instability, anemia, and respiratory disease.
- Care is stepwise: stimulation and positioning strategies, caffeine citrate, oxygen, CPAP, and sometimes ventilation.
- Professionals can clarify alarms, trends, and next steps. You can also download the Heloa app for personalized advice and free child health questionnaires.
Questions Parents Ask
Can apnea of prematurity come back after it seems better?
Yes, it can happen. Many babies have “good days and bad days” as their breathing control matures. A temporary return of alarms may also show up with common stressors like a mild infection, temperature instability, reflux symptoms, constipation/abdominal distension, or after a change in respiratory support. If episodes become clearly more frequent, need more stimulation than before, or look different, it’s perfectly reasonable to ask the NICU team what they’re checking (infection, anemia, electrolytes, feeding coordination, airway position).
Does apnea of prematurity increase the risk of SIDS?
This worry is very common—and understandable. In general, apnea of prematurity is a NICU condition linked to immature breathing control in preterm babies, while SIDS is a separate diagnosis with different risk factors. Having had apnea in the NICU does not automatically mean your baby is at high SIDS risk. After discharge, the most helpful approach is focusing on safe sleep habits and following your care team’s plan, especially if home monitoring or oxygen has been recommended for specific reasons.
Will my baby go home on caffeine or a monitor?
Sometimes, but not always. Many babies stop caffeine before discharge and are observed for a stable, event-free period. In selected situations—ongoing mild events, significant prematurity, or other medical needs—some teams may discharge a baby on caffeine and/or a monitor with clear instructions. If this is offered, you can ask for a simple action plan: what counts as an emergency, who to call, and how long treatment is usually continued.
Further reading :
