Background <p>Bronchopulmonary Dysplasia (BPD) is the most common complication associated with prematurity. Caffeine citrate is a commonly used medication in the neonatal intensive care unit (NICU) for apnea of prematurity (AOP). In the Caffeine Therapy for Apnea of Prematurity study, or CAP trial, infants who received caffeine at 5 mg/kg had reduced rates of BPD compared to the placebo group. Recently, there have been questions regarding the optimal dose of caffeine and if higher doses may have increased benefit on decreasing rates of BPD.</p> Objective <p>The objectives of this study were to determine if infants who received a higher maintenance dose of caffeine have decreased rates of BPD, decreased severity of BPD and improved neurodevelopmental outcomes compared to those who received a lower maintenance dose of caffeine.</p> Design/methods <p>This was a retrospective, observational cohort study at a level IV NICU including infants less than 28 weeks gestational age (GA) receiving caffeine. Maternal and infant demographics and clinical data from the infant’s hospital course were collected. Infants were assigned to low-dose (<i>n</i> = 62) or high-dose (<i>n</i> = 111) cohorts based on average daily caffeine dose. The low-dose cohort received an average daily dose of ≤6 mg/kg/day, while the high-dose cohort received an average daily dose of &gt;6 mg/kg/day. BPD rates and severity were then evaluated for each subject. Neurodevelopmental follow-up Bayley scores were assessed at 6, 12, 18, and 24-month follow-up visits. Chi-square test, <i>T</i> test, Mann–Whitney <i>U</i> Test, Logistic regression, and Linear regression statistics were completed to evaluate data.</p> Results <p>Demographics and clinical characteristics were similar between the low and high-dose caffeine groups. The duration of caffeine in each group was similar as well. The percentage of individuals requiring invasive ventilation was similar between the two groups, however, infants in the high-dose group required less intense forms of ventilation and were on invasive ventilation for a shorter time than the low-dose group (Table 1). The rates of BPD were similar in the two groups (79% vs 78%, <i>p</i> = 0.92), however the severity of BPD based on Jensen Criteria was significantly different between the two groups, with lower rates of severe BPD in the high-dose group (<i>p</i> &lt; 0.001) (Tables 2 and 3). Patients in the higher-dose caffeine group had higher Bayley composite scores at 6 months (<i>p</i> &lt; 0.02). No significant differences were noted at later follow-up (Table 3).</p> Conclusions <p>The decreased rates of severe BPD in the high-dose group, along with improved Bayley scores at 6-month follow-up suggest the potential benefit of high-dose maintenance caffeine in the extremely premature and extremely low birth weight population. Additional large, prospective studies are required to evaluate the efficacy of high-dose caffeine in preventing BPD and improving long-term outcomes in this most vulnerable population.</p>