VOMITING IN THE NEWBORN

Vomiting is the forceful expulsion of gastric

contents through the mouth.

1. Frothy mucoid vomit

Cause: Oesophageal atresia with trecheooesophageal fistula
Features: vomiting, coughing, cyanosis when
the infant begins the first feed.(drool frothy
material continuously
2. Bilestained vomit
Causes- Intestinal obstruction

Atresia of SI

Stenosis of SI

Volvulus of SI

Necrotising enterocolitis

Congenital intestinal agaglionosis

( Hirschsprungs disease) of LI
Features:

Abdominal distension

Visible peristalsis

Plain erect radiograph- fluid levels,

dilated loops of gut proximal to the
obstruction, absence of gas shadows
distally.
3. Bloodstained vomit
Causes:

Trauma from a feeding tube

Swallowed maternal blood

Haemorrhagic disease of the

newborn
4. Milk
Causes:

Infections ( Gastroenteritis, UTI,

septicaemia, meningitis)

Feeding problems

Necrotising enterocolitis

Intracranial haemorrhage

Drugs ( Ex: Digoxin)

Pyloric stenosis
must be considered in every infant less than
3 months of age who vomits.
Rarely -first week of life, but usually -second
or third week

Usually the vomit is produced

forcefully and reaches some distance
from the infant.

The infant often accepts another feed

immediately after vomiting.

Stools are infrequent.

If symptoms for more than few days

-->loss of weight due to dehydration
and loss of subcutaneous fat.
Scanty urine is associated with
dehydration.

Dx

Pyloric mass palpated during a test

feed.

Even if no pyloric mass is felt during the first test

feed, if the diagnosis of pyloric stenosis is probable
the infant should be admitted for rehydration and
the examination repeated.

Preliminary aspiration and

measurement of gastric contents is

helpful(if no feed has been given during
the preceding 4 hours.)

Metabolic alkalosis strongly suggests the

diagnosis.

The diagnosis may be confirmedultrasound study.

barium study- rarely.

Intestinal obstruction
greenish yellow bile vomitus
Abdominal distension , peristalsis may be
visible.

Duodenal stenosis-first few days of

life

Malrotation of the gut with associated

volvulus -any time during childhood.

An inguinal hernia is more likely to

incarcerate in the early months of life
than later. ( should be suspected if
the hernia is tender or is not reduced
easily; immediate surgery is required.
The risk of obstruction is always
present)

intussusception partial/complete
obstruction due to invagination of a
portion of the gut into a more distal
portion.
at any age, maximum incidence is at 311
months.
Distinctive feature

The periodicity of the attacks , may

consist of severe screaming, drawing
up of the legs, and severe pallor.

The attack lasts a few minutes and

may recur about 20 minutes later.

May be vomiting and one or two

loose stools may be passed initially

Bloodstained mucus may be passed

rectally or shown by rectal
examination.

Between attacks the infant appears

normal and may have no abnormal
signs apart from a palpable mass.

It is difficult to examine the abdomen during an

attack because the child cries continuously, but
between attacks a mass, most commonly over the
right upper quadrant, can be felt in 70% of
children.

If surgical shock -rapid resuscitation

+intravenous fluids, including blood
Ix

Plain radiograph of the abdomen evidence of intestinal obstruction or a

density in the area of the lesion.
Ultrasound - doughnut configuration
with hypoechogenic rims and a dense
central echogenic core.

Mx
Symptoms < 48 hours+ no signs of intestinal
perforation air or barium enema( In
over75% of cases it is possible to reduce the
intussusception by theenema.)

If not reduced-immediate laparotomy is

needed to reduce the lesion manually or to
perform an intestinal resection.
( In about 6% of cases there is a persisting
mechanical cause of the intussusception and this
will not be detected by the enema)

Gastro-oesophageal reflux
first week of life
vomitus- may be blood stained.
Aspiration into the lungs may cause recurrent
bronchospasm
severe vomiting may cause failure to thrive,
dysphagia, stricture formation.
(During the first year the lower oesophageal
sphincter pressure increases and oesophageal

Adrenogenital syndrome
The adrenogenital syndrome (salt losing
type) commonly presents with vomiting as
the only symptom in boys.
diagnosis is easier in girls- virilisation of the
external genitalia noticed at birth.
Symptoms usually begin between the 7th
and 10th days and may be fatal within a few
days if extra salt and salt retaining

mobility becomes more organised. These factors

reduce the regurgitation of gastric contents into
the oesophagus when the intra-abdominal pressure
rises, for example during crying.)

Dx confirmed by 24 hour pH monitoring of

the lower oesophagus.( A probe the size of
anasogastric tube is placed just above the gastrooesophageal sphincter. The pH recording is
analysed by computer)

Barium swallow examination is often

negative despite typical symptoms.
Mx
Vomiting usually resolves by the age of one
year without specific treatment.
If symptoms are severe feeds can be
thickened with carob seed flour or ground
rice and the infant may be nursed with his
head higher than his feet on his side.
Whooping cough
Vomiting may be so severe in infants with
whooping cough
During the first five days of the illness
(catarrhal phase) a short, dry nocturnal
cough.
Later bouts of 1020 short coughs occur
day and night.
Cough-dry and each cough is on the same
high note or goes up in a musical scale. The
long attack of coughing is followed by a sharp
indrawing of breath, which causes the whoop
Feeding often provokes a spasm of coughing
and this may culminate in vomiting.
Afterwards there is a short refractory period
during which the baby can be fed again
without provoking more coughing. In
uncomplicated cases there are no abnormal
signs
in the respiratory system.
adrenocorticosteroids are not given.
Intravenous fluids are essential.
Dx confirmed by raised plasma 17 OHprogesterone concentrations, high plasma
potassium, and low
plasma sodium concentrations. (The plasma
electrolyte concentrations are normal at birth and
pronounced changes may occur suddenly.)