Infants on caffeine: Should they be sent home?

A long-standing milestone in neonatal care is the point at which a preterm infant can safely leave the NICU and go home. But while caffeine itself remains a common and widely accepted therapy for those of them who have apnea of prematurity (AOP), the timing of discontinuation, and whether or not to stop it before discharge, appears far less consistent.AOP affects almost all premature babies born before 28 weeks and 50% of those born at 30 weeks. Often such infants are put on caffeine at the beginning of their NICU stay to treat AOP. They are then watched for progress in their ability to breathe steadily, maintain body temperature, stay medically stable, and gain enough weight through oral feeding. Standard practice is loosely that once they are free of apnea for several days, caffeine is removed and they are observed. But emerging data suggest that threshold is not as fixed as it once seemed.A recent European cross-sectional survey found marked variation in how hospitals manage caffeine therapy near discharge, including whether infants were sent home while still receiving caffeine for treatment of AOP. Overall, the findings suggest that there is no clear consensus on what constitutes discharge readiness in infants treated for apnea, particularly when caffeine is involved. Some units prioritize prolonged in-hospital observation after stopping therapy, while others accept earlier discharge with outpatient followup, indicating a shift in some settings toward more flexible, individualized approaches, the survey noted.The survey concluded: “Discharging preterm infants on continued caffeine therapy is a widespread practise among neonatologists in Europe, with considerable variation among regions and differing strategies concerning home-monitoring and discontinuation of treatment.”What about in Canada?“This depends on the NICU and the comfort they have with this practice,” says Dr. Michael Narvey, medical director for the child health transport team, shared health, at Women’s Hospital in Winnipeg. “For example, where I work this does occur, but would only be done after a baby underwent a ‘control of breathing’ study to document that their control of breathing remained immature AND the baby’s respiratory regularity improved after caffeine administration.”Other centres in Canada don’t have the set-up to do a control of breathing study and therefore if they choose to discharge on caffeine, he said, they would be doing so based on clinical indicators of response to caffeine. Examples would be a reduction in apneic events post administration of caffeine on the bedside monitors. “I think as it pertains to discharge on caffeine there is variation,” as in Europe, he said, noting that the Canadian Pediatric Society (CPS) has guidelines on discharging infants. “The CPS does provide some support for discharge (on caffeine) but as stated should be done as a shared decision between care providers and family.”The CPS Discharge planning of the preterm infant states: “While it is preferable to discontinue caffeine in hospital, continuing caffeine at home may be considered as part of a shared decision between the family and healthcare team. Importantly, AOP is not an identified risk factor for sudden infant death syndrome (SIDS), and there is no evidence suggesting clear benefit of home monitoring in the context of AOP or SIDS prevention.”Caffeine’s other benefitsPediatrician Dr. Namrata Todurkar wrote a blog in January 2026 called “Beyond the NICU: Why More Preterm Babies Are Going Home on Caffeine,” published on the Canadian Premature Babies Foundation website. In it, she described a gradual shift away from the traditional requirement that infants be both off caffeine and apnea-free prior to going home. Instead, she says, more hospitals are opting to discharge stable infants on caffeine, without routine use of apnea monitors.The rationale, noted Dr. Todurkar, a fellow in neonatal-perinatal medicine at UBC with a fellowship in Neonatology from National Neonatology Forum India, is partly rooted in evolving understanding of residual respiratory instability. Even when overt apnea has resolved, she notes infants may continue to experience intermittent drops in oxygen saturation that may be almost undetectable but persist for some time. Hence, the wisdom of continuing therapy. Meanwhile, it's increasingly recognized that caffeine’s role in neonatal care extends beyond reducing apnea events, she says, writing, “Perhaps the most compelling reason for staying on caffeine is its role as a neuroprotector. The famous Caffeine for Apnea of Prematurity (CAP) trial and subsequent followups have shown that caffeine isn't just about preventing gasps; it's about better long-term outcomes.” Evidence from major trials associates its use with reductions in certain complications in premature babies, such as bronchopulmonary dysplasia. Dr. Todurkar notes studies also show better neurodevelopmental scores, and reduced rates cerebral palsy, pointing to this research published in Children, which found the practice of sending infants home with caffeine had the same safety as treating them in hospital.Writes Dr. Todurkar: “Discharging a baby on caffeine isn't a sign that they ‘aren't ready’ to be home. Rather, it is a proactive strategy to support their developing brain and lungs during the transition to the outside world. By keeping the respiratory system ‘caffeinated’ until about two weeks past their original due date, we give these tiny graduates the best possible start.”As NICUs balance patient safety with pressures on capacity and length of stay, discharging selected infants home on caffeine may represent a pragmatic approach for some centres. The European survey suggests that more evidence-based standardized practices are needed, which may be true here as well.

Infants on caffeine: Should they be sent home?

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