Self-weaning versus dose-adjusted caffeine regimens in preterm infants discharged home: a prospective cohort study

Objective: To compare self-weaning and dose-adjusted caffeine regimens in preterm infants discharged home on caffeine for apnea of prematurity (AOP). Design: A prospective cohort study. Setting: Tertiary neonatal unit and outpatient clinics, Karachi, Pakistan, April 2023 to July 2025. Patients: 204 preterm infants (<37 weeks' gestation) discharged home on caffeine for AOP; 94 self-weaning, 110 dose adjusted. Interventions: Self-weaning (absolute dose fixed, so mg/kg/day exposure declined with weight gain) versus dose-adjusted weaning (dose recalculated to current weight at each visit). Both were followed to 36 weeks postmenstrual age (PMA). Main outcome measures: Proportion continuing caffeine beyond 36 weeks PMA and caregiver-reported apnea after discontinuation. Results: Caffeine was continued beyond 36 weeks PMA in 68/94 self-weaning infants (72.3%) and 84/110 dose-adjusted infants (76.4%). No apnea was reported after discontinuation in either group, and all 204 infants survived to 36 weeks PMA. Apnea-related readmission on caffeine occurred in 1/94 (1.1%) versus 2/110 (1.8%). Weight at discontinuation was lower with self-weaning (1917 vs 2157g); the dose-adjusted group was more premature (mean 30.0 vs 30.7 weeks). After adjustment for gestational age and birth weight, regimen was not associated with continuation beyond 36 weeks (adjusted OR 0.82, 95% CI 0.43 to 1.57) or time to discontinuation (adjusted HR 1.21, 95% CI 0.91 to 1.60). Conclusions: Within a structured outpatient follow-up program, no post-discontinuation apnea was reported with either regimen,and apnea-related readmissions were infrequent. Self-weaning avoids repeated dose recalculation. A multicenter randomized trial with objective home monitoring is needed to determine the optimal timing of discontinuation.