Caffeine citrate is commonly used for prophylaxis and treatment of apnea in preterm babies [1,2]. Its pharmaceutical form is presented as a solution used intravenously and orally. In clinical use, caffeine citrate needs generally a dilution protocol to be administrated in newborns. Such calculating may increase the risk of medication errors and so the risk of toxic side effects or therapeutic inefficiency. Medication errors inducing toxicity are frequently reported in pediatric inpatients [3,4] but therapeutic inefficiency seems to be not described.
