CPAP in the NICU: Everything You Need To Know

If you’re new to my blog, welcome! I’m Sophia, NICU nurse for over 10 years with a goal of simplifying information for parents. This post breaks down what CPAP. It is probably the most common type of breathing support you’ll see in the NICU. It stands for Continuous Positive Airway Pressure

CPAP is most commonly used for premature babies whose lungs are still developing.

One of the biggest misconceptions about CPAP is that it breathes for your baby. It does not. Your baby is still taking every breath on their own. CPAP simply provides gentle, constant air pressure that helps keep the lungs open, making each breath easier to take.

Your baby will remain on CPAP until their lungs are mature or strong enough to stay open without that extra support.

How Does CPAP Work?

Your lungs are made up of millions of tiny air sacs called alveoli (pronounced al-VEE-oh-lie). These tiny sacs are where oxygen enters the bloodstream and carbon dioxide leaves the body. This exchange is the primary job of the lungs.

Think of the alveoli like tiny balloons.

When a balloon is fully inflated, it’s easy to keep it open. But if you let half the air out, the balloon becomes floppy and takes much more effort to inflate again. If you let all the air out, it collapses completely.

The same thing can happen with a premature baby’s alveoli.

CPAP gently helps keep these tiny air sacs inflated between breaths so your baby doesn’t have to work as hard to reopen them every time they inhale. This makes breathing much more efficient and helps oxygen move into the body more easily.

Without enough support, many alveoli can partially collapse or close altogether. When this happens, your baby has to work much harder just to breathe.

Signs a Baby May Need CPAP

If a baby needs CPAP, you may notice signs that they’re working harder to breathe, including:

• Retractions (the muscles pulling in between the ribs, under the ribs, or above the collarbones)
• Tachypnea (Aka- Fast breathing. often more than 60–70 breaths per minute)
• Lower oxygen saturation levels
• Grunting—a soft noise made during exhalation that helps babies try to keep their lungs open

Grunting is actually your baby’s way of creating a little bit of their own positive pressure to prevent the alveoli from collapsing.

How To Know If The CPAP Is Helping

Your baby’s healthcare team looks at several things when deciding whether CPAP is needed or whether the pressure can be adjusted.

These include:

• Your baby’s work of breathing
• Oxygen needs
• Blood gas results (when appropriate)
• Chest X-rays

Although an X-ray cannot show the alveoli themselves, it does show how well the lungs are expanded.

If the lungs appear under-expanded, your baby may benefit from more CPAP support. If the lungs are well expanded and your baby is breathing comfortably, your healthcare team may consider gradually lowering the pressure.

Every baby is different, so CPAP settings are based on the whole clinical picture—not just one X-ray.

What CPAP Pressure Means

You may hear your baby’s nurse or provider talk about their PEEP.

PEEP stands for Positive End-Expiratory Pressure.

This is the amount of pressure that remains in the lungs after your baby exhales. That gentle pressure helps keep the alveoli from collapsing before the next breath.

Most NICUs commonly use CPAP pressures between 5 and 8 cm H₂O, although the exact settings depend on your baby’s condition, your NICU’s equipment, and your healthcare team’s preferences.

Most babies come off CPAP from a pressure of 5 or 6. Typically if they are requiring pressures of 7 or 8, they will need a little more time on the CPAP.

Why Can’t Most Babies Bottle Feed on CPAP?

Many NICUs do not allow premature babies to bottle feed while they are on CPAP.

Feeding is actually hard work for babies. They must coordinate sucking, swallowing, and breathing all at the same time.

If a baby’s lungs still need CPAP to support breathing, feeding by mouth may require more energy than they can safely manage.

Instead, babies usually receive nutrition through a feeding tube until their breathing has improved enough to safely begin oral feeds.

There is some research that supports allowing babies who are older and on CPAP to start practicing bottles. This is limited to babies who are months old and very stable on CPAP (typically those diagnosed with bronchopulmonary dysplasia (BPD) who are still requiring CPAP due to lung damage as opposed to lung prematurity.)

This allows them to start developing bottlefeeding skills and a positive oral experience. Every NICU has its own policies, so ask your healthcare team what they recommend for your baby.

Can Babies Breastfeed on CPAP?

This goes hand-in-hand with the previous section. A premature baby cannot safely eat (by bottle or breast) if they are still on CPAP. However, there is a safe way for them to start practicing their latch and developing a postitive oral experience with breastfeeding. It is called non-nutritive breastfeeding! It is one of my favorite things to talk to momma’s about!

Many NICUs allow non-nutritive breastfeeding while a baby is on CPAP.

With non-nutritive breastfeeding, mom pumps first, then places baby at the breast for comfort and practice rather than nutrition. This helps babies learn breastfeeding skills and enjoy skin-to-skin bonding without needing to coordinate swallowing large amounts of milk. It is a terrific bonding experience for both baby and mom!

A baby needs to be at least 28 weeks corrected and stable on their CPAP before praciticing non-nutritive breastfeeding. Not every baby is ready for this, so your baby’s healthcare team will help determine whether it is appropriate.

What Is The Earliest My Baby Could Come Off CPAP?

Many NICUs wait until around 32 weeks corrected gestational age before attempting to discontinue CPAP in very premature infants.

Research has shown that many babies are not developmentally ready to consistently keep their alveoli open before this age.

However, this is only a guideline—not a rule.

Some babies are ready earlier, while many require CPAP well beyond 32 weeks.

If your baby still needs CPAP after 32 weeks, try not to worry. Every baby’s lungs develop at their own pace. Again, just because a baby could potentially be ready to come off CPAP around 32 weeks corrected age, it is very common if they are still needing it much longer after that!

Oral Care

Oral care is something you will seen routinely done with cares while your baby is on CPAP.

During oral care, the nurse (or you) will sterile water or expressed mom’s milk to gently clean inside and around your baby’s mouth.

You will notice your baby will have lots of slobber or need more frequent suctioning. This is normal as the CPAP humidity and pressures can contribute to extra secretions from your baby’s mouth. The secretions should subside once your baby is off CPAP.

This is great way to get involved in your baby’s care times.

Why Does My Baby Have a Tube in Their Mouth?

While on CPAP in the NICU, your baby will usually have a feeding tube that goes through the mouth into the stomach.

This tube serves two important purposes.

First, it allows your baby to receive milk since babies will not feeding by mouth while on CPAP.

Second, it helps remove extra air from the stomach.

CPAP does a great job of keeping lungs open, but it does not do a great job at discriminating between the lungs and belly. It is common for air to travel into the stomach as well. Your nurse should “vent” the tube to release this trapped air in between gavage feedings.

Think of it as giving your baby a little burp.

CPAP Masks and Nasal Prongs

CPAP is usually delivered using either:

• Soft nasal prongs that sit inside the nostrils
• A small mask that fits over the nose

Your baby’s nurse will regularly switch between the two to reduce pressure on the skin and help prevent irritation or skin breakdown.

Although the equipment may look uncomfortable, nurses carefully monitor your baby’s skin and make adjustments throughout the day to keep them as comfortable as possible.

I have noticed that babies do typically seem more uncomfortable when they are in their prongs. There are many positioning and comforting techniques the nurses (and you!) can use to help them be more comfortable. Hand hugs/containment, repositioning, nonnutritive suck (pacifier) or swaddling are some of the most useful tools I have found to help calm a baby in prongs.

Here are two other extremely comforting items for your baby!

Scent Cloths:  you leave one with your baby and keep one to sleep with/keep in your clothes. When you visit your baby, you swap! This provides your baby comfort because they will smell you. This is great for both mom + dad. Bonus: it will help increase mom’s milk supply as her body will smell baby if she uses the one baby had while pumping! (so cool!)

Crochet Octopus: These are genius! The tentacals resemble the umbilical cord. This comforts your baby as it’s something that resembles the womb.

If you’re looking for more NICU Comfort Item recommendations, check out my post here: 12 Items That Can Actually Comfort Your Baby and You While in the NICU

If your baby needs CPAP while in the NICU, it can feel overwhelming at first. However, CPAP is one of the most common and effective forms of breathing support used in the NICU.

Remember: CPAP does not breathe for your baby. It simply helps keep the lungs open so your baby can breathe more easily while their lungs continue to grow and mature.

For many premature babies, CPAP is an important stepping stone on the journey toward breathing completely on their own!

Medical Disclosure: The content on this website is provided for informational and educational purposes only and is not intended as medical advice. While I am a NICU nurse, the information shared on this website is based on personal experience, general knowledge, and educational background. It is not a substitute for professional medical advice, diagnosis, or treatment.

Always seek the advice of your physician, pediatrician, or other qualified healthcare provider regarding any medical concerns you may have about yourself or your child. Never disregard professional medical advice or delay seeking it because of something you have read on this website. Use of the information on this site is solely at your own risk.

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