Finding that a baby has stopped breathing in their sleep is one of the most frightening moments a caregiver can face. This situation demands immediate, decisive action, and understanding the proper steps can make a difference in an emergency. This article provides information on how to respond to a respiratory event and offers guidance to reduce the likelihood of such incidents. This information is for educational purposes only and is not a substitute for formal, in-person training in infant cardiopulmonary resuscitation (CPR) or the advice of emergency medical professionals.
Immediate Emergency Protocol
The first step upon finding an unresponsive baby who is not breathing is to attempt to rouse them by gently tapping the bottom of their foot or speaking loudly. If the infant does not respond, immediate intervention is required. If you are alone, start CPR immediately for two minutes before calling emergency services. If a second rescuer is present, one person should call for help right away.
Begin chest compressions immediately by placing the infant on a firm, flat surface. For a single rescuer, use the tips of two fingers placed in the center of the chest, just below the nipple line and avoiding the breastbone. The compression depth should be about 1.5 inches (one-third the depth of the chest), at a consistent rate of 100 to 120 compressions per minute.
After 30 compressions, deliver two rescue breaths. The infant’s head should be tilted into a neutral or “sniffing” position, meaning it is not overly extended or flexed. For an infant, the rescuer’s mouth covers both the baby’s mouth and nose to form a seal. Each breath should last about one second and be enough to make the baby’s chest visibly rise.
If the chest does not rise with the first breath, reposition the head and try the second breath. If the chest still does not rise, an obstruction may be present. Continue this cycle of 30 compressions and two breaths without interruption until the infant shows signs of life, emergency medical personnel arrive, or you become too exhausted to continue.
Two-Rescuer CPR
If two rescuers are present, the compression-to-breath ratio changes to 15 compressions followed by two breaths. Rescuers should switch roles every two minutes to prevent fatigue.
Recognizing Normal and Concerning Breathing Patterns
Infant breathing patterns are naturally different from those of older children and adults. A common phenomenon in newborns and infants up to six months of age is periodic breathing, which involves short, irregular pauses in breath. These pauses typically last between 5 and 10 seconds and are followed by a period of rapid, shallow breaths.
This pattern is not concerning unless the pauses exceed 15 to 20 seconds, or if they are accompanied by changes in heart rate or skin color. True apnea is defined as a cessation of breathing lasting 20 seconds or longer, or a shorter pause associated with a slow heart rate (bradycardia) or a drop in blood oxygen levels (cyanosis). Apnea can be classified as central (the brain fails to send the signal to breathe) or obstructive (the airway is physically blocked).
Certain physical signs indicate serious respiratory distress that requires immediate medical attention. Visible signs of the baby struggling to breathe include nasal flaring (nostrils widen with each inhalation) and retractions (skin pulling in around the ribs, sternum, or collarbone). A respiratory rate consistently above 60 breaths per minute, especially when the infant is calm or sleeping, signals the body is working too hard to take in oxygen. Skin color changes, such as pallor or a bluish tint to the lips, tongue, or nail beds, indicate inadequate oxygenation.
Establishing a Safe Sleep Environment
Prevention of sleep-related incidents is centered on establishing a safe sleep environment, summarized by the ABCs of safe sleep. “A” stands for Alone: the infant should sleep in their own separate sleep area, such as a crib or bassinet, and never share a bed with another person or pet. “B” stands for Back: infants should always be placed on their back for every sleep, whether napping or overnight. Sleeping on the back is the most effective strategy for reducing the risk of sudden unexpected infant death syndrome (SUIDS).
The “C” stands for Crib, referring to a safe, approved sleep surface with a firm, flat mattress and only a tightly fitted sheet. Loose items that pose a suffocation or strangulation risk must be kept out of the crib. The risk of suffocation increases when soft materials cover the baby’s face or become bunched up.
- Blankets
- Pillows
- Stuffed animals
- Bumper pads
- Any soft bedding
Proper temperature regulation is another factor in creating a safe sleep space, as overheating can increase risk. The room temperature should be comfortable for an adult. The infant should be dressed in no more than one layer more than an adult would wear. Instead of blankets, a wearable blanket or sleep sack is recommended to keep the baby warm safely.
Maintaining a completely smoke-free environment, both before and after birth, is important, as smoke exposure is a known risk factor. While room-sharing is recommended (it can reduce risk by up to 50%), bed-sharing is never advised. Offering a pacifier at naptime and bedtime, after breastfeeding is well established, has also been shown to decrease the risk of SUIDS.
Medical Evaluation and Follow-Up Care
After an infant experiences a severe breathing event and is stabilized, medical evaluation is necessary to determine the underlying cause. Medical professionals now refer to this as a Brief Resolved Unexplained Event (BRUE), replacing the older term Apparent Life-Threatening Event (ALTE). Infants who have a BRUE are typically admitted to the hospital for observation and continuous cardiorespiratory monitoring for at least 24 hours.
The medical team will conduct a thorough assessment, which may include testing for various possible causes. These causes often fall into categories such as:
- Gastrointestinal issues (e.g., severe reflux)
- Neurological problems
- Respiratory infections
- Metabolic or cardiac conditions
About half of these events have an identifiable cause, which guides the subsequent treatment plan.
In some cases, a physician may prescribe a home cardiorespiratory monitor for continued surveillance after discharge. This is usually reserved for infants with specific risk factors, such as extreme prematurity, certain neurological disorders, or a history of a severe BRUE. The monitor is designed to alarm if the baby’s breathing stops for a set time or if the heart rate drops below a certain threshold.
Experiencing a severe breathing scare with an infant is a traumatic event for caregivers. Seeking support, such as counseling or joining parent groups, can be helpful for processing the anxiety and stress that often follow a crisis. Caregivers should maintain close follow-up with their pediatrician and specialists to manage any underlying conditions and ensure the ongoing safety of the infant.