Caffeine Discontinuation Survey

Editor’s Note: We have noticed a wide variety of practices, and little supportive data, for how long to observe premature infants in hospital after discontinuation of caffeine for apnea of prematurity. On August 18, 2006 we prepared a survey on this topic and sent it out to the NeoNotes subscribers, the NICU-net listserv, and the Vermont-Oxford NICQ listserv. Within 1 week, we received 263 responses to this survey. More than 70% of the respondents were neonatologists or NICU Medical Directors. In this edition of NeoNotes, we will examine the results of this survey, and review some literature on this topic. The results provide valuable information for all of us. There were many (94) survey respondents who added additional comments about their management of premature infants on caffeine, and some gave references to support their practice. Click HERE to review all of the comments submitted. I wish to extend a special note of thanks to those of you who took the time to participate in this survey. ABK.

Survey Results

Clinical Scenario: For each of these questions, assume that we are discussing the management of a 35+ week PMA baby who has been apnea-free on caffeine for 7 days. The baby is clinically stable and otherwise ready for discharge. The parents do not wish to take the baby home on an apnea monitor.

1. How often would you discharge this type of infant on caffeine and without home monitoring?
	Response Percent	Response Total
Almost Always	10.5%	27
Frequently	5.2%	13
Sometimes	6.2%	16
Rarely	8.1%	21
Almost Never	70.2%	181
Total Respondents:		258
Skipped this question:		5

Comment: I was somewhat surprised to see that 16% of respondents would routinely send premature infants home on caffeine and without home monitors. As one respondent commented, “There is little evidence that apnea monitors save lives." ABK.

2. You have decided to discontinue caffeine prior to discharge. Do you routinely measure caffeine levels and document a sub-therapeutic level prior to discharge? If NO, go to question 5.
	Response Percent	Response Total
Yes	12%	29
No	87.2%	211
Total Respondents:		240
Skipped this question:		23

Comment: Very few respondents (only 12%) rely on caffeine levels to document a sub-therapeutic level prior to discharge. One respondent commented that "given wide therapeutic index we have found monitoring levels to be of little use." Another said: “there is no level-effect relationship with caffeine”. ABK

3. What caffeine level do you consider sub-therapeutic?
mcg/mL	Response Percent	Response Total
< 10	20.5%	16
< 5	41%	32
< 2	9%	7
Zero	2.6%	2
Other	26.9%	21
Total Respondents:		78
Skipped this question:		185

Comment: There was a wide variety of opinion about what constituted a sub-therapeutic level Several respondents commented that the half life of caffeine in premature infants could be up to 130 hours (5 days or so), so it may take a very long time to clear the drug from the baby. ABK.

4. After obtaining a subtherapeutic caffeine level, what apnea-free observation period do you require before hospital discharge without a home monitor.
Days	Response Percent	Response Total
0 – 3	12.2%	10
3 – 5	15.9%	13
5 – 7	46.3%	38
7 – 10	11%	9
> 10	0	0
Other	14.6%	12
Total Respondents:		82
Skipped this question:		181

5. Answer if you do NOT check caffeine levels: After discontinuing caffeine, what apnea-free observation period do you require before hospital discharge without a home monitor.
Days	Response Percent	Response Total
0 – 3	4.6%	11
3 – 5	10%	24
5 – 7	54.8%	131
7 – 10	24.3%	58
> 10	6.3%	15
Total Respondents:		239
Skipped this question:		24

Comments: The most common apnea-free observation period off of caffeine was 5-7 days. 87% of respondents indicated that they would start the clock at the time the drug was discontinued. The remainder would start the observation period after documenting a sub-therapeutic level. See the Next Article (Zupancic et al, 7-035) to examine the cost effectiveness of these "apnea watches". ABK

Additional comments:

Click Here to review 94 additional comments submitted during survey completion.

Date: 29 Aug 2006
Time: 09:27:55

The comment quoted at the end of question #1, 'That apnea monitors have not been shown to save lives' is true only as it applies to reducing the incidence of SIDS. It does not apply to the use of apnea monitors for "Apnea of Prematurity" upto 44 weeks gestation. In this setting, and especially when apnea may be enhanced by a viral illness, apnea monitors may very well save lives.

UserName: Harold Perl MD
Institution: Hackensack University Medical Center/ SIDS Center of New Jersey
telephone: 201-996-5362
email: hperl@humed.com

Date: 10 Sep 2006
Time: 17:33:59

We typically stop caffeine, resume pulse oximetry if off, & wait a total of 10 days, with a requirement for no events needing intervention for the last 5 to 7 days of that 10 day period. If events occur that are concerning (bradycardia or severe desaturations)we will do a sleep study to assess safety. We have had several infants "crash" about 7 to 10 days after stopping caffeine with severe apnea & desaturations. The resumption of pulse oximetry allows us to pick up the infant who is repetitively desaturating & then further evaluate the infant.

UserName: Lee Harker, MD
Institution: Rogue Valley Medical Center, Medford, OR
telephone: 541-789-4233
email: lharker@asante.org

From: Jack Owens [mailto:owens92@bellsouth.net]
Sent: Monday, October 02, 2006 2:31 AM
To: Andrew B. Kairalla
Subject: Re: Results: Caffeine discontinuation survey

I found your summary interesting. I have reconsidered my clinical endpoint with caffeine, and try to stop Cafcit at 33-34 weeks assuming apnea events are few and mild. If events continue to be mild, I do not re-start caffeine. This gives me to chance to watch the resolution of apnea (which usually occurs at 35-40 wks PMA using 7 days without an event). This plan is not always possible, but it takes away the possibliity of having caffeine in the bloodstream at discharge and also takes away the temptation to send an infant home on cafcit/monitor. Once this happens, it is typical to continue these for 2-4 months which is expensive. Our VON LOS is average. I did not see where early discontinuation was an option on your query, but it is possible that many respondents who do not check levels do this.

thanks,

Jack Owens, MD
Email: owens92@bellsouth.net

Jackson, MS

Thanks for your interesting comments. Early discontinuation of caffeine is EXACTLY the point I was trying to make when I published this survey. My suggestion was that the "trigger point" for discontinuation of caffeine needs to be geared to the practice of the most conservative person in your group. We try to target discharge for most "well" preemies at 35 weeks PMA. If everyone in the group is comfortable with a 5-7 day apnea-free observation period, then stopping caffeine by 34 weeks should be adequate. On the other hand, if ANYONE in the group requires a longer observation period (or documentation of a "subtherapeutic" caffeine level before starting the observation period), then the trigger point for caffeine discontinuation needs to be set back to 33 weeks. I contend that it is far more expensive to keep a well preemie in the hospital an extra week for an "apnea watch", than to send him home with a monitor for 2-4 months.

Andy

Andrew B. Kairalla MD
Medical Director, Neonatology
Baptist Children's Hospital
8900 N. Kendall Drive
Miami FL 33176
786-596-6669
AndrewK@baptisthealth.net

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