Premature infant with bradycardia and apnea

  My wife and I have gave birth to a beautiful son 12 weeks premature. My wife was in an antenatal unit for a week previous to the birth due to a Premature Rupture of the amniotic sac (beta-strep) positive in mother, on the sac but negative with our child.  He is now just thirteen weeks old (1 week adjusted).  He spent 9 weeks in NICU level 3 hospital.  He spent a week on respirator and oxygen, battled a close call with NEC and suffered daily bradycardia/apnea spells while in the NICU (at least one a day). Since being home the past 4 weeks, and on a home monitor, he has had only a handfull of apnea spells which have all been self resolved.  He has continued to have daily bradycardia episodes, sometimes more than a couple a day. Most are self resolved and relatively brief.  Some require some stimulation to help him pull out. Our pediatrician has required us to come see her weekly.  He had issues with reflux in the NICU which required him to be on Zantax & Cisperide for about 5 weeks while in the hospital.  Our Neonatalogist stopped the meds. a few days before my son was released at 4 lbs. (born 2 lb 5 oz.).  Our pediatrician has placed my son back on these meds in case the episodes are related to the reflux.  My questions are: Can bradycardia &/or reflux be caused by reflux?  What are the side effects/hazards of the Cisperide and Zantax (particularly with the prolonged use)? Will he outgrow the bradycardia?  Could his anemia be causing his bradycardia (low blood oxygen levels)?  Are there any ped. in the Fort Worth metroplex that specialize in premies?
  Sincerely,
  
  JH  

[HFHS.MD-HSW]

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Dear John:
I am glad that your son is doing so well. He would seem to have an excellent prognosis (outlook). Apnea and bradycardia can indeed be provoked by gastroesophageal reflux. Management entails positioning (if reflux is severe, this is one circumstance where prone  positioning may have a role, combined with elevation of the head of the bed), thickening of feedings with rice cereal , and, at times, medications. Cisapride helps empty the stomach and is very effective at controlling reflux. However, it is being used more sparingly these days, because its use has been associated in certain circumstances with potentially dangerous dysrhythmias (erratic heart beats). This is more likely to occur when cisapride is combined with certain other medications. Ranitidine (zantac) is used when the reflux leads to irritation of the esophagus. This can be either inferred or documented by inspecting the esophagus. Usually it is inferred by the presence of unusual irritability in the baby. Ranitidine and cisapride are compatible for simultaneous use. In most instances, the reflux itself is outgrown in the first year of life. Use of cisapride and ranitidine for that period of time, if indicated by the clinical situation, is not known at present to have any lasting effects. As a general principle, all medications should be used for only as long as absolutely necessary. Anemia is quite common among premature infants. If your son's red blood count were unusually low, this could contribute to apnea. Your son's physicians will keep track of this. At times, a special medication may be administered to bolster red cell production. Rarely, small transfusions are given if absolutely necessary. Fort Worth is blessed with rich resources. I would suggest you review possibilities with your son's neonatologist. I am impressed with the apparent careful care being offered your son's pediatrician as evidenced in her close follow-up. I hope these comments will be helpful. They are presented for educational purposes only. Your son's physicians have the ultimate responsibility for care decisions.
HFHS.MD-HSW
Keywords: apnea, gastroesophageal reflux, prematurity