Early versus Conventional discontinuation of Caffeine therapy for Apnea of Prematurity- A Randomized Controlled Trial

Apnea of prematurity (AOP) is a common developmental comorbidity of preterm neonates with its incidence increasing with decreasing gestation. Apnea is defined as cessation of breathing for 20 seconds or longer or a shorter pause accompanied by bradycardia (<100 beats per minute), cyanosis, or pallor. On the basis of respiratory effort and airflow, apnea may be classified as central (cessation of breathing effort), obstructive (airflow obstruction usually at the pharyngeal level), or mixed. The majority of apneic episodes in preterm infants are mixed events, in which obstructed airflow results in a central apneic pause, or vice versa. The commonly used interventions to decrease the frequency and duration of apnea  are continuous positive airway pressure and methylxanthine therapy.

The indications for starting caffeine in preterm neonates include treatment of apnea, prophylaxis for apnea and peri-extubation. The use of caffeine is associated with certain adverse effects such as tachycardia, emesis, jitteriness, increased oxygen consumption, energy expenditure and reduced weight gain. Although there is substantial evidence for initiation of caffeine therapy, there is no standard protocol for discontinuation of caffeine therapy and studies are sparse to address this issue. As a general recommendation, most of the neonatal unit continue caffeine till 33 to 34 weeks of gestation when the risk of apnea is low, whereas others stop early, as soon as infants attain a 7-day apnea-free period. The indication and evidence for starting caffeine therapy in preterm neonates is well defined in the literature, however, the time for cessation of caffeine therapy has been consensus-based on the clinician’s decision.

We planned a study to compare the occurrence of apnea in neonates where caffeine will be stopped once the neonate is apnea free and off respiratory support for 5 days and attains the post-menstrual age (PMA) of 33 weeks, with neonates where caffeine will be stopped at 34 weeks of gestation.