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

Ruling Out Other Causes: Is It Just Prematurity?

At a Glance

When a premature baby pauses their breathing, NICU doctors run tests to rule out serious issues like sepsis, brain bleeding, or anemia. If tests are clear, the spells are diagnosed as apnea of prematurity, meaning the nervous system simply needs time to mature.

While the most common reason for a premature baby to stop breathing is simply that their brain is still maturing, doctors do not take that for granted. When a baby has a “spell,” the medical team often works through a checklist to ensure there isn’t an underlying medical issue that needs immediate treatment. This process is called a differential diagnosis—the method of distinguishing one condition from others that have similar symptoms [1][2].

Investigating Infection (Sepsis)

One of the first things doctors look for when a baby starts having more frequent or more severe apnea events is sepsis (a serious infection in the blood) [3]. Infections cause inflammation that can interfere with the brainstem’s ability to control breathing [4].

To rule out infection, the team may look for:

  • Cardiorespiratory Signatures: Doctors look for specific patterns in the heart and breathing rate that are often “signatures” of an early infection [3][5].
  • Laboratory Tests: Common tests include a Complete Blood Count (CBC) to check white blood cell levels and a Blood Culture to see if bacteria are growing in the blood [6][7].
  • Biomarkers: Levels of C-reactive protein (CRP) or Serum Amyloid A (SAA) may be measured. These are simply proteins in the blood that act as “alarm bells” for the immune system when the body is fighting an infection [6][8].

Checking the Brain

Because the brain controls the “drive” to breathe, any stress on the central nervous system can cause apnea.

  • Intracranial Hemorrhage (IVH): This is a term for bleeding in or around the brain’s ventricles, which is categorized from Grade 1 (very mild) to Grade 4 (severe) [9]. Hearing about “bleeding in the brain” is terrifying, but head ultrasounds are a completely routine, proactive check for all highly premature babies in the NICU, not necessarily an emergency finding [10][11]. If a baby has a new or worsening bleed, it can trigger frequent apnea events.
  • Seizures: In some cases, what looks like a breathing pause may actually be a subclinical seizure (a seizure that doesn’t cause obvious shaking) [12]. If the team suspects this, they may recommend an EEG to monitor the brain’s electrical activity.

The Role of Anemia

Anemia of Prematurity occurs when a baby doesn’t have enough red blood cells to carry oxygen to the body’s tissues [13]. When oxygen levels are low, the brainstem may become less stable, leading to more frequent apnea and bradycardia events [14]. If a baby’s hemoglobin (the protein in red blood cells that carries oxygen) is too low, the medical team may consider a blood transfusion to help stabilize their breathing [15][16].

The Reflux Question

It is very common for parents and even some staff to notice a baby having a spell after a feeding and blame GERD (Gastroesophageal Reflux Disease). However, medical research has found that the link between the two is often misunderstood:

  • Coincidence vs. Causation: While reflux and apnea often happen at the same time, studies show that reflux is rarely the cause of the apnea [17].
  • Treatment Evidence: There is currently no strong evidence that giving babies anti-acid medications reduces the frequency of apnea events, and these medications may even carry their own risks for premature infants [18].

In many cases, it is the act of feeding itself—the physical work of sucking and swallowing or the stretching of the stomach—that triggers a temporary pause in breathing, rather than the “burn” of acid reflux [19].

When It Is ‘Just’ Prematurity

If the infection tests are negative, the brain ultrasound is clear, and the blood counts are stable, the team will likely conclude the events are just normal Apnea of Prematurity. This means the baby simply needs more time for their nervous system to “catch up” to the world outside the womb [1].

Common questions in this guide

Is my premature baby's apnea caused by an infection?
Doctors routinely check for infections like sepsis when a baby starts having frequent breathing spells. They run blood tests and monitor heart rate patterns to rule out infections, as inflammation can affect the brain's ability to control breathing.
Can anemia cause my premature baby to stop breathing?
Yes, anemia of prematurity can lead to more frequent apnea events. If a baby does not have enough red blood cells to carry oxygen effectively, the medical team may perform a blood transfusion to help stabilize their breathing.
Does acid reflux cause apnea in premature babies?
While reflux and apnea often happen at the same time, studies show that reflux is rarely the actual cause of the breathing pauses. Often, the physical effort of feeding or a full stomach triggers the temporary pause in breathing, rather than stomach acid.
What tests are done to check a premature baby's brain during apnea spells?
NICU teams commonly use head ultrasounds to check for intracranial hemorrhage, or bleeding in the brain. If they suspect subclinical seizures are causing the breathing pauses, they may also perform an EEG to monitor the brain's electrical activity.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.Since my baby is having more spells, what tests are you running to make sure there isn't an infection?
  2. 2.What was my baby's most recent hemoglobin level, and could anemia be making these spells worse?
  3. 3.Has a head ultrasound been done recently to check for any signs of bleeding in the brain?
  4. 4.If the apnea isn't caused by reflux, why does it seem to happen more often after a feeding?
  5. 5.Are there any signs that these spells could actually be subclinical seizures?

Questions For You

Tap a prompt to share your answer — we'll use it plus this page's context to start a tailored conversation.

References

References (19)
  1. 1

    Treating Apnea of Prematurity.

    Pergolizzi J, Kraus A, Magnusson P, et al.

    Cureus 2022; (14(1)):e21783 doi:10.7759/cureus.21783.

    PMID: 35251853
  2. 2

    Apnea of Prematurity.

    Eichenwald EC,

    Pediatrics 2016; (137(1)) doi:10.1542/peds.2015-3757.

    PMID: 26628729
  3. 3

    Apnea, Intermittent Hypoxemia, and Bradycardia Events Predict Late-Onset Sepsis in Extremely Preterm Infants.

    Kausch SL, Lake DE, Di Fiore JM, et al.

    medRxiv : the preprint server for health sciences 2024; doi:10.1101/2024.01.26.24301820.

    PMID: 38343825
  4. 4

    Chorioamnionitis, Inflammation and Neonatal Apnea: Effects on Preterm Neonatal Brainstem and on Peripheral Airways: Chorioamnionitis and Neonatal Respiratory Functions.

    Vitaliti G, Falsaperla R

    Children (Basel, Switzerland) 2021; (8(10)) doi:10.3390/children8100917.

    PMID: 34682182
  5. 5

    Neonatal Sepsis: Aetiology, Pathophysiology, Diagnostic Advances and Management Strategies.

    Raturi A, Chandran S

    Clinical medicine insights. Pediatrics 2024; (18()):11795565241281337 doi:10.1177/11795565241281337.

    PMID: 39371316
  6. 6

    The usefulness of C-reactive protein as a biomarker in predicting neonatal sepsis in a sub-Saharan African region.

    Bunduki GK, Adu-Sarkodie Y

    BMC research notes 2020; (13(1)):194 doi:10.1186/s13104-020-05033-1.

    PMID: 32238170
  7. 7

    A nomogram for predicting neonatal apnea: a retrospective analysis based on the MIMIC database.

    Huang H, Shi Y, Hong Y, et al.

    Frontiers in pediatrics 2024; (12()):1357972 doi:10.3389/fped.2024.1357972.

    PMID: 39301040
  8. 8

    Serum amyloid A - A prime candidate for identification of neonatal sepsis.

    Bengnér J, Quttineh M, Gäddlin PO, et al.

    Clinical immunology (Orlando, Fla.) 2021; (229()):108787 doi:10.1016/j.clim.2021.108787.

    PMID: 34175457
  9. 9

    Intraventricular hemorrhage in preterm babies.

    Özek E, Kersin SG

    Turk pediatri arsivi 2020; (55(3)):215-221 doi:10.14744/TurkPediatriArs.2020.66742.

    PMID: 33061747
  10. 10

    Mycotic Cerebral Aneurysm in a Premature Infant.

    Meadows JT, Hayes D, Moscote-Salazar LR, Calderon-Miranda WG

    Journal of pediatric neurosciences 2017; (12(4)):367-370 doi:10.4103/jpn.JPN_94_17.

    PMID: 29675080
  11. 11

    Diagnostic prediction of neonatal hyperbilirubinemia combined with germinal matrix-intraventricular hemorrhage based on cranial ultrasound hemodynamics: a retrospective case-control study.

    Ye Z, Chen X, Wu D, et al.

    Frontiers in medicine 2025; (12()):1606892 doi:10.3389/fmed.2025.1606892.

    PMID: 41020227
  12. 12

    Seizures in Pre-term Infants Less than 29 Weeks: Incidence, Etiology, and Response to Treatment.

    Raghuveer TS, Zackula RE, Gibson LC, et al.

    Kansas journal of medicine 2020; (13()):134-142.

    PMID: 32612745
  13. 13

    [Clinical practice guidelines for the diagnosis and treatment of anemia of prematurity (2025)].

    Zhongguo dang dai er ke za zhi = Chinese journal of contemporary pediatrics 2025; (27(1)):1-17 doi:10.7499/j.issn.1008-8830.2407094.

    PMID: 39825646
  14. 14

    Risk factors for anemia of prematurity among 30-35-week preterm infants.

    Kitaoka H, Shitara Y, Kashima K, et al.

    Fukushima journal of medical science 2023; (69(2)):115-123 doi:10.5387/fms.2022-21.

    PMID: 37164765
  15. 15

    Thresholds for Red Blood Cell Transfusion in Preterm Infants: Evidence to Practice.

    Andersen CC, Stark MJ, Kirpalani HM

    Clinics in perinatology 2023; (50(4)):763-774 doi:10.1016/j.clp.2023.07.001.

    PMID: 37866846
  16. 16

    The Role of Erythropoietin in Preventing Anemia in the Premature Neonate.

    Costescu OC, Boia ER, Boia M, et al.

    Children (Basel, Switzerland) 2023; (10(12)) doi:10.3390/children10121843.

    PMID: 38136044
  17. 17

    Sleep and Nocturnal Gastroesophageal Reflux: An Update.

    Lim KG, Morgenthaler TI, Katzka DA

    Chest 2018; (154(4)):963-971 doi:10.1016/j.chest.2018.05.030.

    PMID: 29859888
  18. 18

    Antacid therapy for gastroesophageal reflux in preterm infants: a systematic review.

    Dermyshi E, Mackie C, Kigozi P, et al.

    BMJ paediatrics open 2018; (2(1)):e000287 doi:10.1136/bmjpo-2018-000287.

    PMID: 30019019
  19. 19

    Continuous versus bolus intermittent intragastric tube feeding for preterm and low birth weight infants with gastro-oesophageal reflux disease.

    Richards R, Foster JP, Psaila K

    The Cochrane database of systematic reviews 2021; (8()):CD009719 doi:10.1002/14651858.CD009719.pub3.

    PMID: 34355390

This page provides educational information about apnea and breathing pauses in premature infants. Always consult your NICU team or neonatologist for medical advice regarding your baby's specific diagnosis and care.

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