R. Shaoul N.L.

Jones

Gastroesophageal reflux and vomiting

Neonatal vomiting

Neonatal vomiting

(Persistent vomiting in an infant aged 03 months)

22

Assess hemodynamic status

Fluid resuscitation if needed

Obtain CBC, urea, creatinine, electrolytes,

glucose, blood gases, transaminases
Urine sample

Bilious vomiting

No

Insert naso-/orogastric tube

Obtain plain abdominal X-ray

Anatomic lesions
(proximal to ampulla of Vater)

Consider anatomic lesions

(distal to ampulla of Vater)
Involve surgeons
Consider upper GI barium study

Projectile

Malrotation and midgut volvulus

Intestinal atresia/webs
Meconium ileus
HD
NEC

Yes

No

R/O pyloric stenosis

Other proximal malformations

Consider upper GI barium study

Nonanatomic lesions

GER/GERD
Inborn errors of metabolism
Congenital adrenal hyperplasia
Milk/soy allergy
Systemic infections
Neurological disorders
Child abuse
Downloaded by:
Verlag S. KARGER AG BASEL
172.16.7.165 - 4/9/2014 12:23:20 PM

Yes

Vomiting in the first few days after birth may be a sign of serious underlying pathology. Bilious emesis is suggestive of congenital obstructive GI malformations such as duodenal/jejunal
atresias, malrotation with midgut volvulus, meconium ileus or
plugs, NEC and HD. The etiology of intestinal obstruction is
identified in 3869% of neonates with bilious emesis. Any neonate with persistent bilious vomiting must have an NG or orogastric tube inserted to decompress the stomach and prevent
any additional vomiting or aspiration before initiating any diagnostic or therapeutic maneuvers. Plain radiographs of the abdomen can demonstrate dilated bowel loops and air-fluid levels,
which strongly suggest bowel obstruction. Contrast imaging
studies are more specific and can help pinpoint a precise diagnosis. Surgical consultation should be obtained urgently when
the diagnosis of bowel obstruction is considered.
There are a number of causes of nonbilious vomiting in the
young infant which should be considered. Acquired obstructive
lesions such as IHPS should be ruled out especially with a history of projectile vomiting. Infections including AGE and UTI
can present with vomiting. Vomiting can be prominent in the
presence of GER and food intolerance such as milk or soy protein allergies. Metabolic diseases and inborn errors of metabolism should also be considered in infants who have persistent
progressive vomiting. A basic laboratory screen that includes
CBC, urea, creatinine, electrolytes, glucose, blood gases, transaminases and a urine sample should be obtained in any infant
with persistent vomiting.

US is the modality of choice for diagnosing pyloric

Selected reading

stenosis. A normal study does not rule out pyloric stenosis and
should be repeated if still suspected.
The following inborn errors of metabolism are associated

with vomiting:
Urea cycle defects
Congenital lysine intolerance
Familial (lysinuric) protein intolerance
Propionic academia
Methylmalonic academia
Isovaleric academia
Maple syrup urine disease
Phenylketonuria
Hereditary tyrosinemia
Hypervalinemia
Galactosemia
Hyperglycinemia
Leighs disease
Idiopathic hypercalcemia
Renal tubular acidosis

Chandran L, Chitkara M: Vomiting in children: reassurance,

red flag, or referral? Pediatr Rev 2008; 29: 183192.
Godbole P, Stringer MD: Bilious vomiting in the newborn.
How often is it pathologic? J Pediatr Surg 2002; 37: 909911.
Malhotra A, Lakkundi A, Carse E: Bilious vomiting in the newborn: 6 years data from a Level III Centre. J Paediatr Child
Health 2010; 46: 259261.
Murray KF, Christie DL: Vomiting. Pediatr Rev 1998; 19: 337
341.
Ramos AG, Tuchman DN: Persistent vomiting. Pediatr Rev
1994; 15: 2431.

A trial of hydrolyzed infant formula is indicated if milk

allergy is suspected.
Common neurological disorders leading to vomiting in

the newborn period include:

Hydrocephalus
Kernicterus
Subdural hematoma
Cerebral edema

Gastroesophageal reflux and vomiting

R. Shaoul N.L. Jones

Neonatal vomiting

Downloaded by:
Verlag S. KARGER AG BASEL
172.16.7.165 - 4/9/2014 12:23:20 PM

23