Aim Apnoea of prematurity is common in babies born at less than 34 weeks gestation due to immature respiratory control systems.1–4 The current mainstay of treatment in the UK is a methylxanthine – caffeine – which acts as a respiratory stimulant. Our local guideline follows the Caffeine for Apnea of Prematurity (CAP) study with a single loading dose followed by 24-hourly maintenance doses, given either intravenously or orally1.
In August 2012 a UK licenced oral caffeine product was launched, however various safety concerns were raised over this product and its presentation which led to delays in use on our Neonatal Units (NNUs). Unfortunately the single patient, single use product would also lead to a massive increase in our oral caffeine spend – with the cost of an average dose of oral caffeine rising from just £0.13 to £24.41. This equates to an annual cost increase of approximately £53,140 – around a 150-fold increase from the previous £360 per annum. We have therefore considered and implemented a new initiative to avoid unacceptable cost pressures within the neonatal service.
Methods Consideration was made to administering caffeine doses in ‘rounds’ on NNU to allow doses for more than one patient from a single bottle.
However, there were a number of issues to overcome – the oral caffeine rounds would require the product to be used outside of its licence. We also needed to be sure that limiting the timing of caffeine administration to standard times on the NNUs – provisionally twice daily rounds at 10:00 and 22:00 – would not affect its therapeutic and potentially toxic effects in this vulnerable patient group.
Savings as a result of this initiative were to be tracked for one year post implementation.
Results Total savings in the first 10 months following implementation were £15,945 – a projected saving of £19 134 per annum. There have been no reports of any adverse clinical outcomes related to timing of caffeine doses.
Conclusion Given the success of this initiative we plan to move towards a once daily oral caffeine round on our NNUs at 10:00. The majority of babies currently receive their dose at this time but formal implementation will lead to further cost savings. A morning oral caffeine round will also help to minimise the at least theoretical risk of the CNS stimulant effects and cardiac effects of caffeine, principally tachycardia, disrupting a baby’s sleep pattern. There is some evidence of this in the literature although these effects are more common at supratherapeutic levels.
Nottingham Neonatal Service. Clinical guideline B7 – Use of caffeine in apnoea of prematurityMay 2016.
Schmidt B, Roberts RS, Davis P, et al. Caffeine for Apnea of Prematurity Trial Group. Caffeine therapy for apnea of prematurity. N Engl J Med2006;354(20):2112–21.
Henderson-Smart DJ, Steer PA. Caffeine versus theophylline for apnea in preterm infants. Cochrane Database of Systematic Reviews2010:Issue 1.Art No:CD000273.
Henderson-Smart DJ, De Paoli AG. Methylxanthine treatment for apnea in preterm infants. Cochrane Database of Systematic Reviews2010:Issue 12.Art. No:CD0001.
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