Caffeine<\/span> Concentrations in Preterm Neonates.<\/a><\/p>\nIn this paper the authors armed with knowledge of the half life of caffeine at different gestational ages were able to calculate the clearance of the drug at different postnatal ages to demonstrate in a model of a 28 week male infant weighing 1150g. The authors further took into account predicted weight changes and were able to calculate what the expected caffeine levels would be in the fictional infant at various time points.\u00a0 The target caffeine levels for this patient were a trough level of 15 -20 mg\/L which are the currently acceptable ranges in the literature.\u00a0 The testing was first done using a standard load of 10 mg\/kg (base) followed by 2.5 mg\/kg\/d (base) and demonstrated levels which yielded the following graph over time. What this demonstrates is that if the dose is unchanged over the first 7 weeks, this hypothetical infant will only achieve effective concentrations for the first week.\u00a0 Interesting isn’t it that the Cochrane review found clinical effect over the first 2-7 days? What if you were to double the dose to really “hit” the infant with a good dose of caffeine from the start and maintain at that level based on their weight gain as shown next. Well, you will get what you are hoping for and keep the trough level above 15 mg\/L but you will hit 30 mg\/L that some have said is too high and can lead to adverse effects (ever seen SVT with these high doses? I have).\u00a0 Like Goldilocks and the Three Bears could there be a dosing strategy that might be just right?\u00a0 The authors put in another model based on the knowledge of caffeine clearance over time and suggested a strategy in which after the first week the adjusted maintenance doses would be 3 mg\/kg\/day and 3.5 mg\/kg\/day in the third to fourth weeks and lastly 4 mg\/kg\/d in the 5th to 8th week.\u00a0 Using that dosing schedule the model produced this curve. As you can see, the infant would have a therapeutic target without reaching levels above 30 mg\/L and potential for side effects. As many of you read this however you may ask the obvious question. Each of us have seen infants who require higher doses than this to rid themselves of significant apnea and escape reintubation.\u00a0 Given that this is a mathematical model it assumes that this fictional infant will respond beautifully to a trough level of 15 to 20 mg\/L but some will not. Even in the curve shown it is clear that there is some room to go higher in the dosing as the curve is just touching 20 mg\/L.<\/p>\n
A Suggestion For The Future<\/h3>\n
What grabbed my attention here is the possibility that we could take a proactive rather than reactive approach to these infants.\u00a0 Once a small baby is controlled on their dose of caffeine whether it is 2.5, 3, 5 or even 6 mg\/kg\/d of caffeine should we wait for more events to occur and then react by increasing caffeine?\u00a0 What if we are too late to respond and the patient is intubated.\u00a0 What effect does this have on the developing lung, what about the brain that is subjected to bradycardic events with resultant drops in cardiac output and cerebral perfusion.\u00a0 Perhaps the solution is to work with our pharmacists and plan to increase dosing at several time points in the infants journey through the NICU even if they aren’t showing symptoms yet.\u00a0 No doubt this is a change in approach at least for the unit I work in but one that should start with a conversation!<\/p>\n","protected":false},"excerpt":{"rendered":"
This has been a question that has befuddled Neonatologists for years.\u00a0 Get ten of us in a room and you will get a variety of responses ranging from (talking about caffeine base) 2.5 mg\/kg\/day to 10 mg\/kg\/day.\u00a0 We will espouse all of our reasons and question the issue of safety at higher doses but in […]<\/p>\n","protected":false},"author":2,"featured_media":4919,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_et_pb_use_builder":"","_et_pb_old_content":"","_et_gb_content_width":"","jetpack_post_was_ever_published":false,"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_publicize_message":"","jetpack_publicize_feature_enabled":true,"jetpack_social_post_already_shared":true,"jetpack_social_options":{"image_generator_settings":{"template":"highway","enabled":false}}},"categories":[84,45,66,113,42],"tags":[83,234],"jetpack_publicize_connections":[],"jetpack_featured_media_url":"https:\/\/allthingsneonatal.com\/wp-content\/uploads\/2018\/01\/27818379485_a3261aa3d2_b.jpg","jetpack_sharing_enabled":true,"jetpack_shortlink":"https:\/\/wp.me\/p91QDZ-1hf","jetpack_likes_enabled":true,"jetpack-related-posts":[],"_links":{"self":[{"href":"https:\/\/allthingsneonatal.com\/wp-json\/wp\/v2\/posts\/4913"}],"collection":[{"href":"https:\/\/allthingsneonatal.com\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/allthingsneonatal.com\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/allthingsneonatal.com\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/allthingsneonatal.com\/wp-json\/wp\/v2\/comments?post=4913"}],"version-history":[{"count":3,"href":"https:\/\/allthingsneonatal.com\/wp-json\/wp\/v2\/posts\/4913\/revisions"}],"predecessor-version":[{"id":4930,"href":"https:\/\/allthingsneonatal.com\/wp-json\/wp\/v2\/posts\/4913\/revisions\/4930"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/allthingsneonatal.com\/wp-json\/wp\/v2\/media\/4919"}],"wp:attachment":[{"href":"https:\/\/allthingsneonatal.com\/wp-json\/wp\/v2\/media?parent=4913"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/allthingsneonatal.com\/wp-json\/wp\/v2\/categories?post=4913"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/allthingsneonatal.com\/wp-json\/wp\/v2\/tags?post=4913"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}