Methylxanthines for the treatment of apnea associated with bronchiolitis and anesthesia

Caffeine to prevent intermittent hypoxaemia in late preterm infants: randomised controlled dosage trial

OBJECTIVE

To establish the most effective and best tolerated dose of caffeine citrate for the prevention of intermittent hypoxaemia (IH) in late preterm infants.

DESIGN

Phase IIB, double-blind, five-arm, parallel, randomised controlled trial.

SETTING

Neonatal units and postnatal wards of two tertiary maternity hospitals in New Zealand.

PARTICIPANTS

Late preterm infants born at 34+0-36+6 weeks' gestation, recruited within 72 hours of birth.

INTERVENTION

Infants were randomly assigned to receive a loading dose (10, 20, 30 or 40 mg/kg) followed by 5, 10, 15 or 20 mg/kg/day equivolume enteral caffeine citrate or placebo daily until term corrected age.

PRIMARY OUTCOME

IH (events/hour with oxygen saturation concentration ≥10% below baseline for ≤2 min), 2 weeks postrandomisation.

RESULTS

132 infants with mean (SD) birth weight 2561 (481) g and gestational age 35.7 (0.8) weeks were randomised (24-28 per group). Caffeine reduced the rate of IH at 2 weeks postrandomisation (geometric mean (GM): 4.6, 4.6, 2.0, 3.8 and 1.7 events/hour for placebo, 5, 10, 15 and 20 mg/kg/day, respectively), with differences statistically significant for 10 mg/kg/day (GM ratio (95% CI] 0.39 (0.20 to 0.76]; p=0.006) and 20 mg/kg/day (GM ratio (95% CI] 0.33 (0.17 to 0.68]; p=0.003) compared with placebo. The 20 mg/kg/day dose increased mean (SD) pulse oximetry oxygen saturation (SpO2) (97.2 (1.0) vs placebo 96.0 (0.8); p<0.001), and reduced median (IQR) percentage of time SpO2 <90% (0.5 (0.2-0.8) vs 1.1 (0.6-2.4); p<0.001) at 2 weeks, without significant adverse effects on growth velocity or sleeping.

CONCLUSION

Caffeine reduces IH in late preterm infants at 2 weeks of age, with 20 mg/kg/day being the most effective dose.

TRIAL REGISTRATION NUMBER

ACTRN12618001745235.

(Rad 8)Caffeine prophylaxis to improve intermittent hypoxaemia in infants born late preterm: a randomised controlled dosage trial (Latte Dosage Trial)

INTRODUCTION

Infants born late preterm (34+0 to 36+6 weeks' gestational age) have frequent episodes of intermittent hypoxaemia compared with term infants. Caffeine citrate reduces apnoea and intermittent hypoxaemia and improves long-term neurodevelopmental outcomes in infants born very preterm and may have similar effects in late preterm infants. Clearance of caffeine citrate increases with gestational age and late preterm infants are likely to need a higher dose than very preterm infants. Our aim is to determine the most effective and best-tolerated dose of caffeine citrate to reduce transient intermittent hypoxaemia events in late preterm infants.

METHODS AND ANALYSIS

A phase IIB, double-blind, five-arm, parallel, randomised controlled trial to compare the effect of four doses of oral caffeine citrate versus placebo on the frequency of intermittent hypoxaemia. Late preterm infants will be enrolled within 72 hours of birth and randomised to receive 5, 10, 15 or 20 mg/kg/day caffeine citrate or matching placebo daily until term corrected age. The frequency of intermittent hypoxaemia (events/hour where oxygen saturation concentration is ≥10% below baseline for ≤2 min) will be assessed with overnight oximetry at baseline, 2 weeks after randomisation (primary outcome) and at term corrected age. Growth will be measured at these timepoints, and effects on feeding and sleeping will be assessed by parental report. Data will be analysed using generalised linear mixed models.

ETHICS AND DISSEMINATION

This trial has been approved by the Health and Disability Ethics Committees of New Zealand (reference 18/NTA/129) and the local institutional research review committees. Findings will be disseminated to peer-reviewed journals to clinicians and researchers at local and international conferences and to the public. The findings of the trial will inform the design of a large multicentre trial of prophylactic caffeine in late preterm infants, by indicating the most appropriate dose to use and providing information on feasibility.

TRIAL REGISTRATION NUMBER

ACTRN12618001745235; Pre-results.

Caffeine treatment for bronchiolitis-related apnea in the pediatric intensive care unit

INTRODUCTION

Apnea is commonly encountered in children with bronchiolitis. Despite the lack of recommendations regarding bronchiolitis-related apnea (BRA) management, some pediatric intensive care unit (PICU) practitioners use caffeine treatment based on extrapolation from the recommendations for prematurity-related apnea management. The objectives of this study were to describe the management of BRA in our PICU, evaluate the caffeine prescription rate for this indication, and explore its potential effects on clinical outcomes.

METHODS

This was a retrospective study in a university hospital PICU between January 1st, 2009 and December 31st, 2016. All children under 1 year of age admitted to the PICU with a diagnosis of BRA were included. Patients were allocated to a control group or a caffeine group depending on the administration of caffeine.

RESULTS

In total, 54 infants were included and caffeine treatment was administered to 49 (91%) of them. Patient characteristics were similar between the two groups. Ventilatory support was initiated for 50 patients (93%). Supportive care and length of PICU stay were similar between the two groups. Caffeine was not associated with adverse events.

CONCLUSION

Caffeine treatment in BRA could be considered as a local standard practice. This retrospective study was underpowered to show any benefit of caffeine treatment on clinical outcomes. This treatment was not associated with significant adverse effects. We raised the question of the appropriate caffeine dosing regimen for BRA in this postterm population. Further studies on this topic are warranted.

Pharmacology in the very young: anaesthetic implications

Anaesthesia dosing in infants (0-2 years) should be based on pharmacokinetic-pharmacodynamic considerations and adverse effects profiles. Disease processes and treatments in this group are distinct from those in adults. Absorption, distribution and clearance change dramatically during this period because of maturation of anatomical and physiological processes as well as behavioural changes. Pharmacogenomic expression also matures in this period. Population-based and physiological-based pharmacokinetic modelling has improved the understanding of maturation and subsequent dose approximation. Postmenstrual, rather than postnatal, age is a reasonable measure for maturation. There remains a need for clinically applicable tools to assess pharmacodynamics which can provide response feedback; this has been achieved for neuromuscular monitoring, but not yet fully for depth of anaesthesia, sedation or pain. Morbidity and mortality associated with paediatric anaesthesia have historically been highest in this age group and continue to be so. Some of this morbidity was attributable to a poor understanding of developmental pharmacology; this facet continues to plague the specialty.

Ventilation non invasive des nourrissons ayant une infection respiratoire sévère présumée à virus respiratoire syncitial : faisabilité et critères d'échec

Beneficial effect of continuous positive airway pressure (CPAP) during non invasive ventilation (NIV) has been reported in infants with respiratory syncytial virus (RSV) infection, but no study has analyzed the predictors of its failure.

OBJECTIVE

To evaluate the feasibility of NIV and to determine NIV failure criteria.

POPULATION AND METHODS

All infants hospitalized in one PICU with presumed RSV infection between 2002 and 2006 were prospectively included. When respiratory support was needed, NIV was first started according to a pre-established protocol.

RESULTS

One hundred and one infants, 43 females, 58 males, median age 49 days (range: 10-334), median weight 3.9 kg (range: 2,4-12) were included. RSV infection was confirmed in 84/101. Sixty-seven infants were transported by the paediatric medical transport system, 27 with NIV and 15 with invasive ventilation (IV). Fifteen infants were in IV at admission, 69 received NIV during their PICU stay (12 secondarily requiring IV) and 17 were never ventilated. A significant decrease in PCO2 with increase in pH was observed within 2 hours of NIV. Parameters associated with NIV failure were apneas, high values of admission PCO2 and H24 PRISM score. The 17 non-ventilated infants were older and had a lower severity score than those who were ventilated.

CONCLUSION

In infants with RSV and needing respiratory support, NIV represented the sole method of respiratory support in 68% of cases. NIV failure criteria were apneas, high values of admission PCO2 and H24 PRISM score.

Utilisation du citrate de caféine pour le traitement des apnées idiopathiques du prématuré dans les équipes françaises de médecine néonatale

Caffeine citrate is commonly used for prophylaxis and treatment of apnea in preterm babies.

OBJECTIVE

To evaluate the use of caffeine citrate in french neonatal units.

MATERIALS AND METHODS

Postal survey in 100 neonatal units.

RESULTS

Answers were obtained from 81 units. Sixty-three units use systematic prophylactic treatment and the threshold of gestationnal age (weeks gestation) for this systematic treatment is 32 weeks. Caffeine citrate is administered as a loading dose of 20 mg/kg followed by a maintenance dose of 5 mg/kg in 95% of the units. Discontinuing the treatment occurs between 33 and 35 weeks in 37% of the units and between 35 and 37 weeks in 53%. Two third of neonatologits describe recurrent apnea beyond 37 weeks, with the need to continue treatment. Fourteen units sometimes discharge babies at home with ambulatory caffeine citrate treatment and discontinue treatment by 42 to 46 weeks'gestation. A mean duration of 5 days without apnea is required before discharge.

CONCLUSION

French teams respect "recommendations" concerning doses and duration without apnea before discharge. Indication of treatment, threshold for systematic treatment, duration of treatment and ambulatory treatment differ among teams.