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PubMed This is a summary of 19 peer-reviewed journal articles Updated
Neonatology

Standard of Care Treatment: Caffeine and Respiratory Support

At a Glance

The standard treatment for apnea of prematurity combines caffeine citrate to stimulate the brain's breathing center with respiratory support like CPAP to keep airways open. These safe therapies help stabilize your baby's breathing while their lungs and brain naturally mature in the NICU.

While your baby’s brain matures, the NICU team uses a combination of medicine and technology to help stabilize their breathing. These treatments aren’t just about stopping the alarms; they are designed to protect your baby’s developing lungs and brain [1][2].

‘NICU Coffee’: Caffeine Citrate

One of the most common medications in the NICU is caffeine citrate. You may hear staff refer to it as your baby’s “morning coffee” [1].

  • How it works: Caffeine works by blocking adenosine receptors in the brain. Adenosine is a chemical that naturally slows down nerve activity and can cause sleepiness or breathing pauses [3]. By blocking it, caffeine keeps the brain’s “respiratory center” more active and responsive [4][5].
  • The Benefits: Caffeine is more than just a stimulant. It has been shown to reduce the need for mechanical ventilation and lower the risk of Bronchopulmonary Dysplasia (BPD), a type of chronic lung disease common in preemies [1][6].
  • Long-Term Safety: Parents are often worried about giving a stimulant to a tiny baby. However, long-term studies have shown that caffeine is safe and may even improve motor skills and neurodevelopmental outcomes as children grow [7][8].
  • Side Effects: Some babies may become more jittery, have a faster heart rate (tachycardia), or experience mild “reflux-like” symptoms [9]. The medical team monitors these closely and adjusts the dose as the baby grows.

Respiratory Support Systems

Sometimes, medicine alone isn’t enough to keep the airways open. The NICU uses several non-invasive tools to assist:

  • CPAP (Continuous Positive Airway Pressure): This is the most common support. It uses a small mask or nasal prongs to provide a steady stream of air that keeps the tiny air sacs in the lungs open [10][11]. This makes it easier for the baby to take their next breath.
  • High-Flow Nasal Cannula (HFNC): This is a gentler version of CPAP. It provides warm, humidified oxygen through small tubes in the nose [11][12]. While it provides less pressure than CPAP, it is often more comfortable for the baby [13].
  • NAVA (Neurally Adjusted Ventilatory Assist): This is an advanced technology that uses a tiny sensor to “read” the electrical signals from the baby’s diaphragm (the main breathing muscle) [14]. The machine then provides a breath at the exact moment the baby wants one, making the support much more natural [15].

Positioning and Touch

In addition to machines and medicine, the “low-tech” care provided by nurses and parents is vital:

  • Prone Positioning: You may see your baby placed on their tummy (prone). For premature babies in the NICU, this position can improve oxygen levels and help the lungs expand more efficiently [16]. Note: This is only done under constant medical supervision; at home, babies must always sleep on their backs.
  • Tactile Stimulation: When a monitor alarms, a nurse may gently rub your baby’s back or flick their foot [17]. This “wakes up” the brainstem and reminds the baby to take a breath [18]. It is highly recommended to follow your nursing team’s lead on when to step in. Over-stimulating a baby too early can disrupt their ability to learn how to self-recover.

The Road to ‘Weaning’

As your baby grows, the team will slowly “wean” or reduce these supports [19]. This usually happens as the baby approaches their original due date and their nervous system becomes strong enough to eventually start The Discharge Countdown.

Common questions in this guide

Why do premature babies get caffeine in the NICU?
Caffeine citrate acts as a mild stimulant that blocks certain receptors in your baby's brain. This keeps their respiratory center active and responsive, reducing breathing pauses and the need for breathing machines.
Is it safe to give caffeine to my premature baby?
Yes, long-term studies show that caffeine citrate is safe for premature babies. It helps prevent chronic lung disease and may even improve your baby's long-term motor skills and brain development.
What are the side effects of caffeine for babies with apnea of prematurity?
Some babies may experience a faster heart rate, mild jitteriness, or reflux-like symptoms. The NICU team closely monitors your baby and will adjust the caffeine dose as they grow to minimize these effects.
What is the difference between CPAP and high-flow nasal cannula?
CPAP uses a mask or nasal prongs to deliver a steady stream of air pressure to keep tiny airways open. A high-flow nasal cannula is a gentler option that provides warm, humidified oxygen with less pressure, which is often more comfortable for the baby.
How does prone positioning help my baby breathe?
Placing a premature baby on their tummy (prone) in the NICU can help their lungs expand more easily and improve oxygen levels. This is only done under constant medical monitoring; at home, babies must always sleep on their backs.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.What dose of caffeine is my baby currently receiving, and is it adjusted as they gain weight?
  2. 2.How does NAVA (Neurally Adjusted Ventilatory Assist) differ from the other respiratory supports my baby has used?
  3. 3.What are the specific signs that my baby is ready to start 'weaning' off caffeine or respiratory support?
  4. 4.Are the side effects I’m seeing (like jitteriness or a fast heart rate) normal for this dose of caffeine?
  5. 5.How does prone positioning specifically help my baby's breathing compared to lying on their back?

Questions For You

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References

References (19)
  1. 1

    Methylxanthines: The Major Impact of Caffeine in Clinical Practice in Patients Diagnosed with Apnea of Prematurity.

    Neamțu AV, Zlatian OM, Manda CV, et al.

    Journal of clinical medicine 2025; (14(23)) doi:10.3390/jcm14238417.

    PMID: 41375719
  2. 2

    Is Early Preventive Caffeine Safe and Effective in Premature Neonates? A Clinical Trial.

    Sajjadian N, Taheri PA, Jabbari M

    International journal of pediatrics 2022; (2022()):8701598 doi:10.1155/2022/8701598.

    PMID: 35692738
  3. 3

    Association between PER and CRY gene polymorphisms and the response to caffeine citrate treatment in infants with apnea of prematurity.

    Xie JB, Zhuang W, Zhu Y, et al.

    Frontiers in pediatrics 2024; (12()):1414185 doi:10.3389/fped.2024.1414185.

    PMID: 39108697
  4. 4

    Electrical activity of the diaphragm following a loading dose of caffeine citrate in ventilated preterm infants.

    Williams EE, Hunt KA, Jeyakara J, et al.

    Pediatric research 2020; (87(4)):740-744 doi:10.1038/s41390-019-0619-x.

    PMID: 31622975
  5. 5

    The effect of caffeine citrate on neural breathing pattern in preterm infants.

    Parikka V, Beck J, Zhai Q, et al.

    Early human development 2015; (91(10)):565-8.

    PMID: 26217936
  6. 6

    Influence of prevention of caffeine citrate on cytokine profile and bronchopulmonary dysplasia in preterm infants with apnea.

    Kou C, Han D, Li Z, et al.

    Minerva pediatrica 2020; (72(2)):95-100 doi:10.23736/S0026-4946.19.05428-8.

    PMID: 30961342
  7. 7

    Academic Performance, Motor Function, and Behavior 11 Years After Neonatal Caffeine Citrate Therapy for Apnea of Prematurity: An 11-Year Follow-up of the CAP Randomized Clinical Trial.

    Schmidt B, Roberts RS, Anderson PJ, et al.

    JAMA pediatrics 2017; (171(6)):564-572 doi:10.1001/jamapediatrics.2017.0238.

    PMID: 28437520
  8. 8

    Neurobehavioral Outcomes 11 Years After Neonatal Caffeine Therapy for Apnea of Prematurity.

    Mürner-Lavanchy IM, Doyle LW, Schmidt B, et al.

    Pediatrics 2018; (141(5)) doi:10.1542/peds.2017-4047.

    PMID: 29643070
  9. 9

    Clinical efficacy of different maintenance doses of caffeine citrate in the treatment of apnea of prematurity.

    Ji P, Wan Y, Yin J, et al.

    Pakistan journal of medical sciences 2025; (41(2)):478-483 doi:10.12669/pjms.41.2.9692.

    PMID: 39926649
  10. 10

    A Systematic Review of the Influence of Continuous Positive Airway Pressure on Fetal and Newborn Animal Models: Suggestions to Improve Neonatal Respiratory Care.

    Gie AG, Hubble TR, Regin Y, et al.

    Neonatology 2021; (118(1)):5-14 doi:10.1159/000511086.

    PMID: 33091899
  11. 11

    A case of subcutaneous emphysema/mediastinal emphysema during the use of humidified high-flow nasal cannula.

    Sonobe S, Inoue S, Nishiwada T, et al.

    JA clinical reports 2019; (5(1)):85 doi:10.1186/s40981-019-0305-3.

    PMID: 32026981
  12. 12

    Preliminary evaluation of the use of high-flow nasal cannula oxygen therapy during recovery from general anesthesia in dogs with obstructive upper airway breathing.

    Jagodich TA, Bersenas AME, Bateman SW, Kerr CL

    Journal of veterinary emergency and critical care (San Antonio, Tex. : 2001) 2020; (30(4)):487-492 doi:10.1111/vec.12971.

    PMID: 32542930
  13. 13

    CPAP vs HFNC in treatment of patients with COVID-19 ARDS: A retrospective propensity-matched study.

    Šitum I, Hrvoić L, Erceg A, et al.

    Canadian journal of respiratory therapy : CJRT = Revue canadienne de la therapie respiratoire : RCTR 2024; (60()):164-172 doi:10.29390/001c.125145.

    PMID: 39493584
  14. 14

    Comparison of NIV-NAVA and NCPAP in facilitating extubation for very preterm infants.

    Lee BK, Shin SH, Jung YH, et al.

    BMC pediatrics 2019; (19(1)):298 doi:10.1186/s12887-019-1683-4.

    PMID: 31462232
  15. 15

    Physiology of non-invasive respiratory support.

    Alexiou S, Panitch HB

    Seminars in fetal & neonatal medicine 2016; (21(3)):174-80.

    PMID: 26923501
  16. 16

    Noninvasive Ventilation.

    Ramanathan R, Biniwale M

    Critical care nursing clinics of North America 2024; (36(1)):51-67 doi:10.1016/j.cnc.2023.11.001.

    PMID: 38296376
  17. 17

    The effect of sensory stimulation on apnea of prematurity.

    Abdel Mageed ASA, Olama KA, Abdel Rahman SA, El-Gazzar HE

    Journal of Taibah University Medical Sciences 2022; (17(2)):311-319 doi:10.1016/j.jtumed.2021.10.016.

    PMID: 35592810
  18. 18

    Stabilizing breathing pattern using local mechanical vibrations: comparison of deterministic and stochastic stimulations in rodent models of apnea of prematurity.

    Zeldich D, Bou Jawde S, Herrmann J, et al.

    Biomedical engineering letters 2021; (11(4)):383-392 doi:10.1007/s13534-021-00203-x.

    PMID: 34490067
  19. 19

    Strategies for cessation of caffeine administration in preterm infants.

    Urru SA, Geist M, Carlinger R, et al.

    The Cochrane database of systematic reviews 2024; (7()):CD015802 doi:10.1002/14651858.CD015802.pub2.

    PMID: 39045901

This page explains common NICU treatments for apnea of prematurity for educational purposes. Always follow your neonatologist and nursing team's guidance for your baby's specific care plan.

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