|
1. |
3 days to
allow the caffeine to fall to subtherapeutic level, then 5 days free
(total 8 days) |
|
2. |
It is rare
that a 35 week baby has been without apneas for only one week in my
experience. Most babies are not on caffeine for that long |
|
3. |
NO data that
I am aware of. We stop our caffeine long before the babies are ready to
go home usually so this is not a problem. We feel that if an infant is
still having significant episodes than he/she should not be going home
anyway. |
|
4. |
We rarely use
home monitoring, do not follow caffeine levels, and do not discharge on
caffeine. |
|
5. |
We
discontinued theophylline when the baby reach 33week PGA and very rarely
we reintroduce this therapy, also if the baby was oxygen-dependent
|
|
6. |
When we
discontinue the caffeine the time we use is 7 days for the caffeine to
leave the infants system and then 5 days to observe for apnea or
bradycardia If all goes well they are then discharged |
|
7. |
We assume
level is subtherapeutic in 3-5 days with an additional 5-7 day
countdown. |
|
8. |
No clear data
available in the literature at this time. Most decision are opinion
based. |
|
9. |
In my opinion
Apnea of prematurity shouldn't be called AOP beyond 34 weeks. if
occurring one should rule out all other possibilities for Apnea. there
is little evidence that apnea monitors save lives. |
|
10. |
we generally
do not use caffeine past 32 weeks unless baby is extremely small and not
likely to go home in the next 2 weeks. We would not have treated a 34
weeker with caffeine, but rather would have used Theolair. (originally
had to do with availability of caffeine for home) Theo keep about 5 days
then discharge. |
|
11. |
we check
levels weekly and bolus based on levels. If a patient is on caffeine and
has A/B's we check a level then bolus (before we get the level back).
|
|
12. |
Very rarely
discharge infants on caffeine. Do not see many infants at 35+ weeks PCA
who have apnea. But if so, I discontinue caffeine for 5 days and
discharge if no apnea episode documented. |
|
13. |
On the basis
of no data except the 5-day halflife of Caffeine, I do not discontinue
Caffeine within 2 weeks of expected discharge. I fear the return of
threatening apnea at home where it cannot be effectively managed. If I
do not have that much time to watch for the return of symptoms, I leave
the child on the same dose at home, and discontinue it 2-3 months
later--after 50 weeks PCA (and without true monitor alarms for at least
2 months if they are monitored). By this time, the dose is homeopathic
for current weight, and one can stop with little worry of recurrent
spells. |
|
14. |
Also depends
how significant the episodes are and if they are associated with feeds.
|
|
15. |
Spell free 8
days AND off caffeine for 5 days. |
|
16. |
Not much
supportive data. I like the article below, that outlines differences
between hospitals in practice, but also suggests infants are mature
around 35 weeks, for apnea. Eichenwald EC, Blackwell M, Lloyd JS, Tran
T, Wilker RE, Richardson DK. Inter-neonatal intensive care unit
variation in discharge timing: influence of apnea and feeding
management. Pediatrics. 2001 Oct;108(4):928-33 |
|
17. |
We always
discontinue caffeine before discharge and it requires a 7 day apnea free
interval after cessation of caffeine to let the child go home.
|
|
18. |
I require a
month free of significant events off caffeine to discontinue monitor,
which works out to six weeks after med stopped as "Off caffeine"
interpreted and none given for two weeks, so two weeks after caffeine
stopped start counting. If never treated with caffeine will not monitor
if low risk and no recorded events for two weeks. Our unit has a very
high monitor rate but a very early average age at discharge. Cost of one
month on home monitor equals cost of 12 hours in NICU |
|
19. |
I wait those
days based on the half life of Caffeine. |
|
20. |
We are pretty
sure ther are NO data, and we always have a long discussion with
pareants about illness and recurrent apnea |
|
21. |
We generally
discontinue caffeine at ~34 wks of PMA and wait for about 1 wk off
cafcit before d/c. |
|
22. |
I am not
aware of any supportive data |
|
23. |
In Chile the
National Guide of Neonatology suggests the following managing: "The
treatment must extend up to a period of 7 days without apnea or in case
of apneas persistent up to 34-36 weeks of postconceptional age. Period
of observation post-suspension of the therapy of at least 5-7 days
without apneas." José M. Novoa MD President Section of Neonatology.
CHILEAN SOCIETY OF PEDIATRICS |
|
24. |
approach
recognized as consensus, non evidenced based, observational period for
expectant resolution with maturation. My area of concern is the
relationship between higher incidence of SIDS in prematures and apnea of
prematurity. I suspect prematurity is underestimated in infant mortality
statistics as the underlying causation, but I dont have data. Any
evidenced role for pneumograms? |
|
25. |
No.
|
|
26. |
Generally I
stop caffeine at 1.8 kg. Most of my patients are still struggling with
feeding, and as we are a breast feeding unit, I will be able to observe
the baby for at least a week before the feeding if going well. I also
generally ask for home apnoea monitors and parental training in BLS in
all high risk infants. |
|
27. |
In my country
there is no caffeine in the medical market, so theophylline is the first
drug for the treatment of apnea of prematurity. I placed theophyilline
instead of caffeine and I answered the questions. |
|
28. |
Thank you for
this survey - it is incredibly difficult to determine the "right" thing
to do. I am eager to learn other practices. |
|
29. |
No data to
support the practice. Baby not on Caffeine, we wait for 48 hours of
"apnea free" interval before discharging, whether the baby goes home on
a monitor or without the monitor. |
|
30. |
no need to
monitor levels |
|
31. |
no
|
|
32. |
if caffeine
is included in the discharge, then we do a 5 channel, 12h,
pneumocardiogram 48h before discharge; if normal we discharge without a
monitor. |
|
33. |
We
discontinue caffeine if the baby has been apnea free for 7 days. We
monitor for at least 7 days after the caffeine has been discontinued. If
the baby is on caffeine, and ready for discharge (and NOT apnea free for
7 days) we would give a prescription for caffeine good with one month
supply and send home on a home apnea monitor. |
|
34. |
We do car
seat study: OXYCRG screen download for 90 min and if we find that the
infant has desaturations below 80 or bradycardia or apnea associated
with prolonged periodic breathing spells, then we send them on home
apnea monitor considering them high risk for apnea events following URI/
smoke exposure/ LRTI etc. I do not think that it is proved by any study
|
|
35. |
I use
Kattwinkle's data for an 8 day apnea free period before discharge. I
discontinue the caffeine by 34 weeks so I have time to observe the baby
before discharge. |
|
36. |
I applaud the
effort that went into this survey. No, I am not aware of any existence
evidence supporting this clinical practice other than the half life of
caffeine citrate. My second comment is to recommend you to launch
another survey regarding practice of using (or futility of using) pulse
oximeter in addition to the use of cardiorespiratory monitor in stable
growing premature infants who are not on any supplemental oxygen. I
discontinue caffeine 1-2 wk before anticipated date of discharge
(generally beyond 33-34 wk) Personally, I discontinue pulse oximeter
beyond 1500g or 32 wk in all infants who are not receiving supplemental
oxygen and manifest only apnea or bradycardia. I have virtually never
discharged any infant on caffeine after 35 wk PMA. |
|
37. |
for this
infant I would DC the caffeine and observe for 5-7 days discharging the
infant without monitor |
|
38. |
yes. One
should use the caffeine level or Caffeine half life. If the infant is
Apnea free for 7 days on Caffeine at 34-35 weeks GA d/c Caffeine and
observe for 3 days. This is enough time for the long caffeine half life
to reach sub therapeutic levels. If the infant is symptom free the
infant can be d/c with out monitors. There is no level effect
relationship with Caffeine and that is why a prolonged observation
period is necessary. |
|
39. |
Darnell et al
Pediatrics (1997); 100:795 showed that (it in a cohort of 91 infants
mean birth GA 28wk, mean BW 1162g) no apnea occurred *8days after an
apnea-free interval unless there was a specific cause (e.g., sepsis). To
my knowledge, this is the only quality data supporting the practice of a
7 day caffeine-free period prior to discharge. |
|
40. |
We do not
routinely discontinue caffeine prior to discharge. All of our pts on
caffine go home with monitors. |
|
41. |
There is no
need to monitor caffeine levels. after loading and maintenance dosage
unless the infant is symptomatic frequent A&B or tachycardia no levels
are done dosage is rarely adjusted . So infant probably outgrows the
dosage and by the time infant is closer to discharge or PMA 35 weeks
levels are probably subtherapuetic . Another strategy is discontinue
medications if A&B free for 7 days or more and infant * 32 to 33 weeks
PMS so by the time discharge time infant's caffeine levels are
subtherapeutic |
|
42. |
I'm aware of
caffeine discontinuation protocols, based on measuring levels. We have
"no data" except for some facts: - We have been using caffeine
exclusively since about 1990, and initially measured levels on therapy.
We decided they were not useful because dosing adjustments were rarely
needed, and also when we found that routine (unintended) 2-fold dosing
was well tolerated. - The "7-day apnea free off caffeine, no levels"
practice has been going on for over 15 years, and these babies are not
coming back with apnea. If they did, we would hear about it, since we
are the only game in town... |
|
43. |
There are no
good data on this subject in the literature. |
|
44. |
I would have
discontinued caffeine by ~34 - 34.5 weeks corrected gestational age.
These babies may still have an occasional apnea, but not requiring
ongoing caffeine Rx as they are in a monitored NICU environment. Once
this baby meets other criteria for discharge (po feeding, maintaining
temps, gaining wt), I would also want an apnea-free period of 5-7 days.
Meeting all of these criteria may take longer than 5-7 days from the
date of actually stopping caffeine. |
|
45. |
I am not
aware of any data supporting my practice. I try to discontinue caffeine
at least a week before anticipated discharge (though it does not happen
consistently as I am in a group practice and do not round on the same
patients consistently). I only do it if the patient is apnea free or the
episodes are infrequent - 1or2/24hr. If the infant continues with apneas
no matter the frequency s/he goes home on a monitor. Threshold for
sending home on a monitor is real low and probably a reflection of my
insecurity in this climate of law suits rather than the real medical
necessity. |
|
46. |
We always
discontinue caffeine around 34 weeks PMA. If apnea continues, we
prescribe a home monitor. In my memory, we have never sent a baby home
on caffeine. |
|
47. |
This is a
good question. We try not to send infants home on Cafcit. We are
constantly trying to discontinue the cafcit sooner than later so we are
able to observe the infants for an adequate period off cafcit. With a
3-4 day half life, we probably should watch them off cafcit for a couple
of weeks (the more preemie, the longer the observation). However, many
of our babies are found to be approaching discharge by all other
criteria, but have only recently been taken off cafcit. We came up with
a consensus opinion (no evidence) to observe these relatively low risk
infants for one week. If they exhibit any respiratory events, they go
home on a monitor. I still believe this is overkill, and our criteria
for using the monitor is partly defensive medicine. The AAP's statement
was somewhat helpful, but still doesn't do it medicolegally.
|
|
48. |
Published
half-life data for caffeine of up to 100 hours. |
|
49. |
We have no
specific data to support. We actually do not always abtain a caffeine
level. We will discontinue caffeine, wait 7 days. If no episodes, we
will start a 5 day A & B free period before going home. We will hardly
ever send home on a monitor. |
|
50. |
There is no
do data against my practice |
|
51. |
Do not use
caffeine that often. mostly use aminophylline |
|
52. |
Unaware of
any data. |
|
53. |
Sorry, We do
not use caffeine at all. We use aminophyllin instead, as it can be used
both enterally and parenterally. So my answers are related to
aminophyllin, if it helps you. |
|
54. |
Community
standard of care. |
|
55. |
We cease
caffeine generally at 34 weeks and therefore this situation does not
arise |
|
56. |
I discontinue
caffeine at ~ 32 weeks |
|
57. |
I do not have
my teaching files with me while I am doing this at home - However, there
was a study about 15 years ago on duration of significant apnea free
days prior to discharge of premature infants. Their conculsion was 5
days. |
|
58. |
no good data
|
|
59. |
No data but
caffeine has a long half life. Since I have also done consulting
pediatrics for years I have consulted on many infants admitted to
pediatrics with ALTE who were sent home from other institutions right
after caffeine was discontinued. We try to learn from the mistakes of
others as well as our own. |
|
60. |
Monitor for
10-12 days assuming half life of 7 days and 5 days off caffeine without
event/s. |
|
61. |
given wide
therapeutic index we have found monitoring levels to be of little use
|
|
62. |
The half-life
appears to be ~98[+32] or 130 hours. So by waiting 5-7 days (120-168
hours), the level should be 1/3 to 1/2 (at most) of the level when the
drug is being given. Pediatrics. 1985 Nov;76(5):834-40. Maturational
changes of caffeine concentrations and disposition in infancy during
maintenance therapy for apnea of prematurity: influence of gestational
age, hepatic disease, and breast-feeding. Le Guennec JC, Billon B, Pare
C. Twenty-three premature infants receiving caffeine maintenance therapy
were followed prospectively for several months. Three to nine
determinations of caffeine half-life (peak and trough caffeine levels)
were made in each baby. This first longitudinal study confirmed that the
half-life of caffeine is prolonged during the neonatal period (97.6 + 32
hours and for as many as 38 weeks' gestation in several very premature
babies). |
|
63. |
Would
discontinue caffeine - allow 7 days for caffeine to be eliminated then
need to observe for 7 days to document a 7 day apnea free interval. I
have been unable to find ANY supportive data. Most babies go home with a
monitor for this reason. |
|
64. |
we do not
have monitors enough to send babies home with. We have not seen any
problem with these practice |
|
65. |
there is a
study done several years ago on how long an infant should be monitored
for post Caffeine discontinuation...I can't remember the author and I
have read the article...not a huge sample size but a well done
study...that is what we have based our practice on. By the way, we have
sent home about 2 babies in the past 12 years requiring a monitor at
home.. |
|
66. |
All of the
physicians in our practice rarely if ever obtain caffeine levels
anymore.... |
|
67. |
Try to stop
caffeine at 32 weeks / apnea free for 7 days. Sometimes get caught with
a baby off caffeine for a few days and ready to go home. Will sometimes
send them on monitor for 2-4 weeks to expedite the discharge.
|
|
68. |
I wait
exactly 7 days |
|
69. |
thank you for
this opportunity to participate in this needed survey |
|
70. |
If we have
any doubt, discharge home with a monitor |
|
71. |
In our
hospital, we usually discontinue caffeine after a baby has been caffeine
free several days, then monitor at least five days prior to discharge
for any apnea. I am curious to know what groups consider high levels.
|
|
72. |
I think that
each individual patient is different. There have been babies that have
been sent home on caffeine because of their inabilities to become apnea
free without it in the designated time period that our unit has set as a
requirement which is usually 7-10 days. All of these infants will go
home on monitors. |
|
73. |
We
discontinue caffeine and wait about 5 days at which time we feel it to
be sub-therapeutic. At this point we still observe for an additional 5
consecutive days without a/b's. We do not feel it is best for our
patients to go home on a monitor and set the parents up with that
responsibility. I am not aware of any data to support this practice, but
I work in 2 level III units and it is the practice in both. |
|
74. |
We usually
try to discontinue caffeine several weeks before any possible discharge,
stopping when there has been no apnea requiring stimulation for seven
days. We don't restart caffeine unless recurrent apnea is severe. We
keep the baby until apnea free for seven days, residual caffeine levels
are rarely an issue, I think we might have waited an extra three days on
the rare occasion when it was possibly going to be an issue.
|
|
75. |
None that
specifies 5 days |
|
76. |
We routinely
do pneumograms instead of waiting for an extended length of time to be
spell free, if the infant appears clinically ready for discharge. Of
course if you have kust stooped caffeine, you would want to be sure it
is subtheraputic. |
|
77. |
We routinely
discontinue caffeine at around 34-35 weeks usually regardless of apnea &
bradycardia. Our unit policy is not to discharge prior to 35 weeks
adjusted age even without A&B's. We almost never discharge preemie
patients on an apnea monitor just for A's & B's |
|
78. |
i
accidentally answered # 3&4 (disregard). |
|
79. |
no comments
|
|
80. |
Based on the
half life of caffeine of 3-4 days. We usually will discharge at 7 days
off of caffeine without monitor as long as no break thru apnea/bradycardia.
|
|
81. |
Why would a
35 weeker still be on caffeine? In my practice an infant who is 35 weeks
and is still having apnea the etiology is not central in origin and
would not be responsive to caffeine. |
|
82. |
My answer in
#5 would really be 5-10 days depending on which neonatologist is the
boss that day. |
|
83. |
We use a 14
count down when d/c'ing caffeine. As it takes 96 hours to reach a
sub-therapeutic level, this is 4 days of the count. The last 10 days are
the "event free" portion of the count. |
|
84. |
At Advocate
Lutheran General, at 32-34 wks, we will attempt to discontinue caffeine
if 5 days or more spell free, or have events that are mild and
infrequent (1 mild event per day) If on caffeine, patients all go home
on monitors. Will do event recordings if still spelling on caffeine and
otherwise ready for discharge. Or if 8 days spell free and on caffeine
and ready for discharge, will go home with a monitor. |
|
85. |
We would not
wait until 35 wk to d/c caffeine. If caffeine is to be d/c'ed we do it
at 34 wk, wait a week and then do a 48 h apnea trend monitor. If it is
normal we discharge the baby, if abnormal goes home on a monitor. If I
have a baby at 35 wks still on caffeine, he is committed to a home
monitor. You are right, there is damn little science out there, but
that's what we do.... |
|
86. |
10 days
total, 5 days to eliminate caffeine from the infant's system and then 5
days more to monitor for apnea "off caffeine" |
|
87. |
All infants
in our developmental nursery are placed on memory cardio-respiratory
monitors with built-in oximetry. If nursing records events during the
5-7 days prior to anticipated discharge, we can download the monitor and
review the waveforms to determine if the events recorded at the bedside
were true events. This prevents delay in discharge due to false
interpretation of alarms which could also result in the ordering of a
home monitor(when one is truly not indicated). Reference PREDISCHARGE
MONITORING OF PRETERM INFANTS Pediatric Pulmonology 27:113-116 (1999)
|
|
88. |
Once Caffeine
is discontinued, we wait 7 days for it to get out of the baby's system
(based upon the half life of the drug) and then begin a 7 day apnea free
countdown before discharge home. We routinely make an attempt to
discontinue the caffeine at 33 wks CGA, so hopefully don't get into the
scenario described |
|
89. |
If the baby
is symptomatic the dose is increased to usually maximum of 4.5
mg/kg/day, ( caffeine base) Usually not higher since it may cause GER.
We do not routinely send a baby home on caffeine. we will try to wean
the baby off after 34 weeks gestation, so they are off the medication
well before discharge. They all have car seat testing prior to D/C home.
We will keep them in the hospital until that time. Babies are not
routinely sent home on apnea blankets. |
|
90. |
I rarely
check levels. Once this child was event free, I would stop the caffeine
and wait 5-7 days for the levels to fall. After 5-7 MORE event-free
days, I'd be comfortable discharging. |
|
91. |
there is none
|
|
92. |
I do not
think I have ever had a family not want to take a preemie home on a
monitor who was on caffeine but currently apnea free. |
|
93. |
Elimination
kinetics of caffeine at various PCA well documented, which is the basis
of some of our decisions about dose free duration. |
|
94. |
I think Alan
Spitzer had an abstract on this. Wally |