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Developing and testing a clinical care bundle incorporating caffeine citrate to manage apnoea of prematurity in a
Grace Irimu1,2, Ferdinand Okwaro3, Jesse Coleman4
1Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya. GIrimu@kemri-wellcome.org.
Insights
A new care bundle using caffeine citrate aims to prevent and treat apnoea of prematurity in resource-constrained settings. This evidence-based approach will improve management for preterm infants where caffeine is not readily available.
Area of Science:
- Neonatal Medicine
- Clinical Pharmacology
- Public Health in Resource-Constrained Settings
Background:
- Apnoea of prematurity (AOP) is common in preterm infants, often managed with methylxanthines like caffeine citrate.
- Caffeine citrate is recommended for AOP due to efficacy and safety but is often unavailable in resource-constrained settings (RCS).
- Challenges in RCS include identifying eligible infants and continuous vital sign monitoring for apnoea detection.
Purpose of the Study:
- To develop an evidence-based, context-sensitive clinical care bundle for preventing and managing AOP in Kenyan tertiary healthcare facilities.
- To address the challenges of implementing caffeine citrate therapy in resource-limited environments.
Main Methods:
- A prospective mixed-methods feasibility study in a Nairobi tertiary-care newborn unit.
- Involves a formative research phase, development of an AOP care bundle prototype, and a subsequent implementation and refinement phase using PDSA cycles.
- Quantitative data collection includes neonates <34 weeks gestation or on aminophylline/caffeine citrate; qualitative data from stakeholder engagement.
Main Results:
- Baseline data provided insights into existing NBU care practices.
- A context-sensitive AOP clinical care bundle prototype was developed.
- The bundle will be tested and refined during the implementation phase.
Conclusions:
- There is a critical need for standardized, evidence-based guidelines for AOP management in RCS.
- Key implementation concerns include apnoea diagnosis, caffeine citrate protocols, monitoring standards, and discharge planning.
- The study aims to deliver a feasible, standardized clinical care bundle for AOP management in low and middle-income settings.
Background:
Apnoea of prematurity (AOP) is a common condition among preterm infants. Methylxanthines, such as caffeine and aminophylline/theophylline, can help prevent and treat AOP. Due to its physiological benefits and fewer side effects, caffeine citrate is recommended for the prevention and treatment of AOP. However, caffeine citrate is not available in most resource-constrained settings (RCS) due to its high cost. Challenges in RCS using caffeine citrate to prevent AOP include identifying eligible preterm infants where gestational age is not always known and the capability for continuous monitoring of vital signs to readily identify apnoea. We aim to develop an evidence-based care bundle that includes caffeine citrate to prevent and manage AOP in tertiary healthcare facilities in Kenya.
Methods:
This protocol details a prospective mixed-methods clinical feasibility study on using caffeine citrate to manage apnoea of prematurity in a single facility tertiary-care newborn unit (NBU) in Nairobi, Kenya. This study will include a 4-month formative research phase followed by the development of an AOP clinical-care-bundle prototype over 2 months. In the subsequent 4 months, implementation and improvement of the clinical-care-bundle prototype will be undertaken. The baseline data will provide contextualised insights on care practices within the NBU that will inform the development of a context-sensitive AOP clinical-care-bundle prototype. The clinical care bundle will be tested and refined further during an implementation phase of the quality improvement initiative using a PDSA framework underpinned by quantitative and qualitative clinical audits and stakeholders' engagement. The quantitative component will include all neonates born at gestation age < 34 weeks and any neonate prescribed aminophylline or caffeine citrate admitted to the NBU during the study period.
Discussion:
There is a need to develop evidence-based and context-sensitive clinical practice guidelines to standardise and improve the management of AOP in RCS. Concerns requiring resolution in implementing such guidelines include diagnosis of apnoea, optimal timing, dosing and administration of caffeine citrate, standardisation of monitoring devices and alarm limits, and discharge protocols. We aim to provide a feasible standardised clinical care bundle for managing AOP in low and middle-income settings.
