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Three Part Question

In [infants with apnoeic bronchitis] is [caffeine effective] in [reducing frequency of apnoea]?

Clinical Scenario

During bronchiolitis season at the local paediatric emergency department, you are on shift when a 4 month old child is brought in by ambulance. Mother describes a recent coryzal illness and reduced feeding. She was going to see the GP tomorrow, but called the ambulance when her child stopped breathing for several seconds. This happens again during assessment. Having spent some time previously in SCBU, you wonder whether caffeine will help to reduce apnoea in these infants as it does in neonates.

Search Strategy

Database: Ovid MEDLINE(R) <1950 to September Week 1 2008>
Accessed from BMA.org.uk 13th September 2008.
Search strategy.
{[exp Bronchiolitis/ or exp Bronchiolitis, Viral/] OR [(respiratory syncytial virus or RSV).mp]} AND [exp Caffeine/]

Search Outcome

The search returned three results. One was a letter and is not included in the appraisal. One is a review of apnoea and bronchiolitis and cites the remaining paper. This is discussed below.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Tobias JD 2004 USA	7 infants, with RSV-associated apnoea, ranging in age from 14 to 64 days.	Retrospective review.	The number of apneic episodes per hour for the 2 to 3 hours before the administration of caffeine ranged from 7 to 12, and the number of episodes during the 3 hours after the administration of the first dose of caffeine ranged from 0 to 2.	No child required endotracheal intubation for apnoea.	Small, retrospective study. Not randomised. No comments or incidence of adverse effects.

Comment(s)

RSV bronchiolitis is a common reason for admission to hospital and paediatric intensive care units, with up to 7 % of those admitted to hospital needing intubation and ventilation. Apnoea may occur in 16 - 21 % of infants with bronchiolitis. Caffeine is a commonly used respiratory stimulant in premature infants. It is easily administered by the oral, nasogastric or intravenous routes. It is generally well tolerated with minimal side effects. Although a limited study, this is encouraging in demonstrating the efficacy of caffeine in the treatment of RSV-associated apnoea and avoiding intubation. A larger, prospective RCT would help to confirm or refute these findings.

Clinical Bottom Line

Caffeine is a useful treatment in preventing RSV-associated apnoea and intubation. It is entirely feasible to begin administration in the ED.

References

1. Tobias JD Caffeine in the treatment of apnea associated with respiratory syncytial virus infection in neonates and infants. Southern Medical Journal. . 93(3):294-6, 2000 Mar