18 • 2022 • Developmental Observer Do preemie babies need their “cup of coffee” each day to improve feeding skills at breast or bottle when they are adjusted to 34 weeks ges- tation or above? Caffeine is a common pharmacolog- ic treatment for apnea, and for extremely premature infants who are born at 24, 25, 26 weeks gestation,1 continuing caffeine may be just what the doctor ordered. Just like you and I need our coffee in the morning to function, does an extremely premature infant benefit from their “coffee” through their daily dose of caffeine through the adjusted age of 34-37 weeks? This is the time they are working on coordination of suck/swal- low/breathe, improved intake and main- taining stable vital signs during feeding experiences at the breast or bottle. Research shows that caffeine affects respiration in the following ways: in- creased minute ventilation, improved carbon dioxide sensitivity, decreased pe- riodic breathing, and decreased hypoxic depression of breathing.2 If a baby maintains the intervention of caffeine while setting the foundation for feeding skills, would they be able to maintain stable vital signs, improve organization of behavior, and improve intake in a shorter amount of time? Therefore, decreasing time spent in the hospital? The literature also shows that caffeine is safe and effective, but the therapeutic window for use has not been established. Eichenwald3 suggests that a baby be free of apnea/bradycardia events off positive pressure for five to seven days or at 33-34 weeks PMA. But could the baby continue caffeine support while working on suck/swallow/breathe coor- dination at breast and/or bottle, which may begin around 34 weeks PMA? If babies are given the support of caffeine during this time, when an additional ac- tivity, such as breast and bottle feeding, is being presented, it may improve the positive experience of feeding and lead to improved intake and the main goal of full oral feeding for discharge home. The transition to oral feeding re- quires that a baby demonstrates physio- logical stability. To assist the infant, we need to understand how they maintain optimal oxygenation during oral feeding and how they can self-regulate their oxy- gen status.4 Swallowing momentarily in- terrupts breathing, which requires work for organization with the suck/swallow/ breathe pattern. Could caffeine support the organization needed to achieve full oral feeds more quickly? Many authors discuss the use of caffeine with suggestions to be proactive, rather than reactive to apnea episodes at rest and during oral feeds. Some sug- gest that caffeine may be needed longer for the extremely premature infant to support the developing lung. It is dis- cussed that the common practice is to discontinue caffeine between the 33-34 PMA. It was noted that apnea still occurs and is not trivial in the 35-39 PMA. It is suggested that continuing caffeine past 35 weeks is a possible treatment plan that could have a significant clinical impact. However, physicians seem reluctant to keep an infant on caffeine past 34 weeks with concern that it may delay discharge. It may be possible that staying on caffeine longer could in fact, speed up discharge. If de-saturations are closely observed and recorded, the need to extend the use of caffeine will become Does Caffeine Use Support Suck/Swallow/Breathe Coordination at Breast and Bottle, and Lead to an Earlier Discharge? Brenda Takata, OTR/L, MHA, SWC, NLP Emanate Health - Queen of the Valley Hospital, Los Angles, California DOI: 10.14434/DO.V15I2.34362 Infant bottle feeding. Us ed w ith p er m is si on 2022 • Developmental Observer • 19 evident. If the medication was not dis- continued until three to five days post last incident of a desaturation, the baby has support while feeding, and could in fact discharge from the unit sooner avoiding the need to prolong hospitalization to monitor for desaturations to ensure that the baby is stable. Caffeine’s favorable effect on car- diorespiratory physiology in stabilizing systemic and cerebral hemodynamics and its capacity to mitigate hypoxic respiratory depression may play a part in neuroprotection.5 Kumar and Lipshultz5 suggest that the therapeutic window for caffeine will need continued research to understand the favorable outcomes that may be achieved for premature infants. Dabin2 discussed the wide varia- tion in discontinuing caffeine, and the need for more studies to assist with the balance of avoiding apnea episodes and delaying discharge if caffeine is not dis- continued soon enough. Along my journey as an Occupa- tional Therapist in the NICU, I had the privilege of working with two wonderful premature babies born at 24.6 weeks gestation and 24.4 weeks gestation. They were similar weight, 715 grams, and 760 grams. Both needed oxygen support and caffeine support. My focus was on the caffeine support and how it may assist with improved success with breast and bottle feeding. Baby A, was born at 24.6 weeks gestation and had caffeine discontinued at 36.3 weeks. At that time, we only ex- pected the baby to attempt to bottle feed every other feeding due to respiratory effort made during feeds, and difficulty with completing his feeds. He always seemed to need to “catch his breath” and would take 35-70% of his feeds, but remember, he was only trying to nipple feed every other feeding. He was too tired the rest of the time. Baby B, was born at 24.4 weeks gestation and had the caffeine discontin- ued at 37.6 weeks gestation. Baby B was able to take advantage of the benefits of caffeine for 10 days longer than Baby A. At the time that the caffeine was discon- tinued for Baby B, he was consistently taking above 50% of his feeds and was bottle feeding on a cue based schedule and showing an appropriate coordina- tion of suck/swallow/breathe. Baby A was discharged home at 42.5 weeks and had a gastrostomy tube placed due to the inability to maintain enough energy to complete oral feeds. Baby B was discharged home at 40.5 weeks, taking full oral feeds. When looking back at the journeys of these two babies, it may have been advan- tageous for Baby A to continue caffeine longer as he continued to improve with breast and bottle feeding skills. It may have assisted him to have a better foun- dation for coordinating suck/swallow/ breathe during feeding if the discontinu- ation of caffeine was considered when the baby was above 35 weeks corrected age, on cue based feeds, and taking 50% or more of each feeding orally. And, most impor- tantly, continuing caffeine if the baby had experienced any desaturations or brady- cardias in the last three to five days. Further studies would benefit outcomes and help to establish guide- lines for using caffeine and considering feeding skills and intake at the time of discontinuing the support that caffeine offers.6 A solution may be in correctly and efficiently charting and recognizing a desaturation and/or bradycardia and keeping a close eye on the baby’s stability when nipple feeding and at rest. References: 1. Abdel-Hady H, Nasef N, Shabaan AE, Nour I. Caffeine therapy in preterm infants. World J Clin Pediatr. 2015, 4(4):81-93. doi: 10.5409/wjcp.v4.i4.81. 2. Ji D, Smith PB, Clark R, Zimmerman K, Laughon M, Ku L, Greenberg R. Wide variation in caffeine discontinuation timing in premature infants. Journal of Perinatology, 2020, 40, 288-293. doi: 10.1038/s41372- 019-0561-0. 3. Eichenwald EC: Committee on Fetus and Newborn, American Academy of Pediatrics. Apnea of prematurity. Pediatrics. 2016, 137(1). doi: 10.1542/peds.2015-3757. 4. Thoyre SM, Carlson JR. Preterm infants’ behavioural indicators of oxygen decline during bottle feeding. Journal of Advanced Nursing. 2003, 43(6):631-41. doi: 10.1046/j.1365-2648.2003.02762.x. 5. Kumar VHS, Lipshultz SE. Caffeine and clinical outcomes in premature neonates. Children (Basel). 2019 Oct 24;6(11):118. doi: 10.3390/children6110118.  6. Moschino L, Zivanovic S, Hartley C, Trevisanuto D, Baraldi E, Roehr CC. Caffeine in preterm infants: where are we in 2020? ERJ Open Research. 2020, 6(1):00330- 2019. doi: 10.1183/23120541.00330-2019. “Swallowing momentarily interrupts breathing, which requires work for organization with the suck/swallow/ breathe pattern.” Thank you for the new look issue of the Developmental Observer. I particularly enjoyed the first article “NIDCAP from a Parent’s Perspective” - it’s incredible to hear that baby Benjamin was a week old before he was even put in his bed! And the way the NICU/health system is set up to have them progress to a family room and the neonatal home care is inspirational. – Catherine Piasini Clinical Nurse Specialist Australasian NIDCAP Training Centre Letters to the Editor (continued from p.11)