Sleep Apnea in Infants: Normal Pauses, Warning Signs, and Testing

A brief pause in a newborn's breathing is not always sleep apnea. Young infants can have periodic breathing, a normal pattern of short pauses followed by several quicker breaths. A pause is more concerning when breathing does not restart promptly or the baby becomes blue, gray, very pale, limp, difficult to wake, or visibly struggles to breathe.

Infant breathing events have several possible explanations. Apnea of prematurity, obstructive sleep apnea, central apnea, mixed apnea, and a brief resolved unexplained event, or BRUE, are not interchangeable diagnoses. A clinician has to consider the baby's age, gestational age at birth, what happened during the event, and whether it occurred during sleep, feeding, or illness.

This guide focuses on newborns and infants, including normal breathing variation and urgent care decisions. For sleep apnea in older children, see children and sleep apnea.

Get emergency help for these signs

Call emergency services now if a baby:

• stops breathing or is gasping and does not promptly resume normal breathing
• has blue or gray lips, tongue, or face, or becomes unusually pale during an event
• is limp, unresponsive, has a seizure, or cannot be woken normally
• is struggling for each breath, has the skin pulling in between or under the ribs, or is grunting
• is choking and cannot breathe, cry, or make a sound

Follow the emergency dispatcher's instructions. Start infant CPR if the baby is not breathing and you know how, or let the dispatcher coach you. Do not wait for a monitor reading or spend time trying to record the event. The American Academy of Pediatrics treats severe breathing difficulty, stopped breathing, blue lips or face, and loss of consciousness as pediatric emergencies ¹.

A baby who has recovered from an episode of abnormal color, breathing, muscle tone, or responsiveness still needs medical advice. Age 60 days or younger, birth before 32 weeks' gestation, a current postconceptional age under 45 weeks, repeated events, an event lasting about a minute or longer, or CPR by a trained provider keep an infant outside the AAP's lower-risk BRUE group ².

Which breathing pattern are you seeing?

Pattern	What it means	What separates it from the others
Periodic breathing	Several brief pauses alternate with quicker breaths in a young infant.	The baby remains comfortable and normal in color, tone, and responsiveness. It is a breathing pattern, not sleep apnea.
Apnea of prematurity	Immature breathing control causes clinically important pauses in a baby born preterm.	It is a neonatal diagnosis based on gestational age and monitored events, often involving a slow heart rate, low oxygen, or color change.
Obstructive apnea	Airflow stops or falls because the upper airway narrows or closes while breathing effort continues.	The chest and abdomen still try to breathe. Noisy or labored breathing may be present, but symptoms alone cannot confirm it.
Central apnea	Airflow and breathing effort stop together because the drive to breathe pauses.	There is no breathing effort during the event. Short central pauses can occur normally, so context and physiologic effects matter.
Mixed apnea	One event has both central and obstructive portions.	Breathing effort is absent during one part and present against a blocked airway during another.
BRUE	A baby younger than 1 year had a sudden, brief, resolved episode involving color, breathing, muscle tone, or responsiveness that remains unexplained after clinical assessment.	BRUE is not a type of sleep apnea and cannot be diagnosed at home. If illness, choking, reflux, a seizure, or another cause explains the event, it is not a BRUE.

A home description can help a clinician, but it cannot reliably tell obstructive from central or mixed apnea. Those distinctions depend on simultaneous measurements of airflow and breathing effort, often with oxygen, carbon dioxide, heart rhythm, and sleep signals ³⁴.

When periodic breathing is normal

Periodic breathing is common during active sleep in newborns. The AAP describes pauses of about 5 to 10 seconds followed by 10 to 15 seconds of faster breathing, without a change in skin color ⁵.

The clock is not the only difference between normal and dangerous breathing. Normal periodic breathing should not make a baby blue or pale, limp, hard to wake, or visibly distressed. A caregiver may also find it difficult to estimate seconds accurately during a frightening event.

Contact the baby's clinician promptly if pauses are becoming longer or more frequent, occur with noisy or labored breathing, happen during feeds, or are accompanied by poor feeding or reduced alertness. If the baby is stable and it is safe to do so, a short video and notes about sleep, feeding, color, movement, and recent illness may help the clinician understand the pattern. Recording should never delay emergency care.

Apnea of prematurity is a distinct neonatal condition

Apnea of prematurity occurs in babies born preterm because respiratory control is still maturing. The AAP clinical report defines it as a breathing pause longer than 20 seconds, or a shorter pause associated with a slow heart rate, low oxygen, pale color, or bluish color, in an infant born before 37 weeks' gestation ⁶.

This definition is used with hospital monitoring and clinical interpretation. It is not a rule for parents to time every pause at home. A shorter event with color change or poor responsiveness can still be urgent.

Apnea of prematurity usually improves as the infant matures, but there is no single week when every baby is guaranteed to stop having events. Babies born at an earlier gestational age and those with lung disease can follow a different course. A new or recurrent event after discharge should not be assumed to be the same NICU condition ⁶.

In the neonatal unit, clinicians may use caffeine or respiratory support when warranted. The choice, dose, settings, monitoring, and stopping plan depend on the infant's maturity and clinical course. These are not treatments to begin, change, or restart at home.

Obstructive, central, and mixed apnea need different explanations

Obstructive sleep apnea

In obstructive sleep apnea, the baby keeps trying to breathe while the upper airway limits airflow. Infants have smaller, more flexible airways than older children. Conditions such as laryngomalacia, a small lower jaw, nasal or throat abnormalities, craniofacial differences, low muscle tone, or chronic lung disease can increase the chance of obstruction. Snoring, stridor, retractions, restless sleep, repeated gasping, feeding difficulty, or poor growth may raise concern, but no one symptom proves OSA ⁴.

Central apnea

In central apnea, both airflow and breathing effort pause. Brief central pauses can occur in healthy infants, including after a sigh or movement ⁷. Clinically important central events may be related to prematurity, infection, neurologic or metabolic disease, medication or substance exposure, or another condition affecting breathing control. The surrounding history and the event's effect on oxygen, heart rate, and the baby matter more than the label alone ⁶².

Mixed apnea

Mixed apnea contains both patterns in the same event. It may begin without respiratory effort and then continue with effort against an obstructed airway, or show the reverse sequence. A sleep study can identify the components, but the result still has to be interpreted for an infant's developmental age ⁷⁴.

Treatment follows the diagnosis and cause. An infant with an airway abnormality, a premature infant with immature breathing control, and an infant with an infection or neurologic condition should not receive the same plan. Prescribed oxygen, positive airway pressure, surgery, or another intervention requires infant-specific specialist oversight ⁶⁴.

A BRUE is not a diagnosis to make at home

The AAP introduced BRUE for a sudden, brief, now-resolved event in a baby younger than 1 year that involved at least one of these features:

• blue or pale color
• absent, reduced, or irregular breathing
• a marked change in muscle tone
• altered responsiveness

A clinician can call an event a BRUE only when an appropriate history and physical examination find no explanation. The guideline's lower-risk pathway applies only to a carefully selected group: babies older than 60 days, born at 32 weeks' gestation or later and now at least 45 weeks' postconceptional age, who had only one event lasting less than a minute, did not need CPR from a trained provider, and have no concerning history or examination findings ².

That pathway is not a home checklist for deciding that a baby is safe. It also does not apply to a baby who is still symptomatic or whose event has an apparent cause. A newborn, a recurrent event, an event around feeding, fever, respiratory symptoms, injury concern, or an abnormal examination can change the assessment and testing.

How clinicians evaluate suspected apnea

The evaluation starts with the event, not a standard bundle of tests. Useful details include:

• gestational age at birth and postmenstrual age now
• whether the baby was asleep, awake, or feeding
• estimated duration and whether the event stopped on its own
• breathing effort, chest movement, noises, color, muscle tone, and responsiveness
• choking, coughing, vomiting, fever, congestion, or other illness
• medicines and possible household substance exposures
• feeding stamina, weight gain, wet diapers, and development
• previous events, NICU history, and relevant family history

The clinician then examines the airway, lungs, heart, neurologic responses, hydration, growth, and signs of infection or injury. Tests are chosen to answer a specific concern. Blood tests, heart testing, imaging, infection testing, feeding or swallowing assessment, airway endoscopy, or inpatient monitoring may be appropriate in some infants and unnecessary in others ²⁴.

An overnight polysomnogram is the main test when the clinical assessment suggests obstructive sleep apnea or selected central sleep-related breathing disorders. It measures sleep and breathing together and can show whether airflow stopped while respiratory effort continued. Clinical observation, a video, snoring, or a questionnaire alone cannot establish OSA ³.

A resolved unexplained event does not automatically require a sleep study. The AAP recommends against routine polysomnography for infants who meet all lower-risk BRUE criteria, while AASM guidance supports it when there is separate clinical evidence of a sleep-related breathing disorder ²³.

Consumer monitors cannot diagnose infant apnea

A sock, mattress sensor, camera, app, or consumer pulse oximeter may display heart rate, movement, or oxygen estimates, but those readings do not show the full pattern of airflow and respiratory effort needed to classify apnea. Inaccurate readings may create false alarms or false reassurance ⁸.

The FDA warns against unauthorized infant vital-sign monitors and states that these products have not been evaluated to support monitoring for apnea, SIDS, SUID, or an infant's overall health. No device has been authorized to prevent SIDS or SUID ⁸.

A clinician may prescribe a medical monitor for a specific condition. If so, use the prescribed equipment and action plan exactly as taught. A medical monitor still does not prevent SIDS, and an alarm threshold should not replace looking at the baby. NICHD's Safe to Sleep program reports that home heart, breathing, or movement monitors were not effective at identifying situations that lead to SIDS ⁹.

Safe sleep still applies

Sleep apnea and safe-sleep guidance address different risks. An infant with suspected or diagnosed apnea still needs a safe sleep environment unless the treating hospital team has given a specific medical plan.

For every sleep:

• place the baby on their back
• use a firm, flat, noninclined sleep surface in a safety-approved crib, bassinet, or play yard
• keep pillows, loose blankets, bumpers, toys, positioners, and weighted items out
• use the baby's own sleep space in the caregiver's room rather than sharing an adult bed
• keep the baby's environment smoke-free

Do not use a wedge, inclined sleeper, side position, or stomach position to treat apnea or reflux. The AAP recommends the back position even for infants with reflux and advises against home cardiorespiratory monitors as a way to reduce SIDS risk ¹⁰. NICHD provides the same back-sleeping and clear-surface guidance ¹¹.

Feeding events need their own assessment

Breathing and feeding have to be coordinated closely in a young infant. Contact the baby's clinician promptly for repeated coughing or choking during feeds, noisy or labored breathing, color change, sweating or exhaustion while feeding, reduced intake, fewer wet diapers, or poor weight gain ¹². Stop the feed and seek emergency help if the baby cannot breathe, becomes blue or limp, or does not recover normally ¹.

Spitting up does not automatically explain a breathing event. In lower-risk BRUE, the AAP recommends against routine reflux testing and acid-suppressing medicine because benefit has not been established. Studies reviewed in the guideline did not prove that reflux generally causes pathologic apnea, although a clinician may identify reflux or another feeding-related explanation in an individual infant ².

Do not thicken feeds, change feeding position, use acid-suppressing medicine, or alter a prescribed feeding plan solely because an event looked like apnea. A pediatrician may need to assess feeding technique, swallowing, the airway, growth, and other possible causes first ².

What to do after a concerning event

After urgent needs are addressed, write down what happened while the details are fresh:

1. Note whether the baby was sleeping, waking, crying, or feeding.
2. Describe color, breathing effort, chest movement, sounds, tone, and responsiveness.
3. Record an estimated duration, what you did, and how the event ended.
4. Include recent illness, fever, vomiting, medicine, possible exposure, and previous events.
5. Tell the clinician about prematurity, NICU apnea, prescribed oxygen or monitoring, and feeding or growth concerns.

Do not rely on constant visual watching, unsafe sleep positioning, or a consumer alarm for reassurance. Ask the clinician what symptoms should trigger emergency care, whether a prescribed monitor is needed, which specialist should evaluate the baby, and how follow-up will occur.

The bottom line

Normal periodic breathing, apnea of prematurity, obstructive apnea, central apnea, mixed apnea, and BRUE describe different patterns. A brief pause without color, tone, responsiveness, or breathing-effort changes can be normal in a young infant. Color change, limpness, poor responsiveness, breathing struggle, choking, or failure to resume normal breathing is not a watch-and-wait situation.

Clinicians distinguish these events through the history, examination, and targeted testing. Consumer monitors cannot make that diagnosis or prevent SIDS. Until a baby receives an individual medical plan, respond to symptoms directly and follow AAP safe-sleep guidance for every sleep.