4jd~an3. I'dd~am 411: 379. 1979
VOMITING IN THE NEW BORN INFANT* K. Y^t,^v ^ s o S.K. S ^ s o n u
Chandigarh There c a n b e few infants who do not vomit occasionally during the early weeks of life. Vomiting during the neonatal period maY be caused by conditions which are trivial or life threatening. Ir~ the majority of neonates the cause of vomiting is easily ascertained from history, physical examination and simple investigations; however, a small number would require exhaustive work up in a well equipped hospital. A neonate must be referred to a hospital for a successful 9outcome before his general condition deteriorates. Conditions leading to neonatal vomiting may be grouped as medical and surgical (Table 1).
Cmronon medical problems presenting with vomiting (a) Habitual vomiting or posseting. Almost all babies bring up some milk, but some babies who are otherwise gaining weight satisfactorily have an increased tendency to vomit. These babies are usuaUy highly active, cheerful, interested in their surroundings and exhibit rapid mo~:ements of arms and legs. This type of vomiting is usually more troublesome during the first few weeks o f life but it may continue as a nuisance for some months. The timing and frequency of vomiing are irregular. Typically no sooner has *From the Department of Paediat~ic Surgery, Postgraduate Institute of Medical Education and Kesearch, Chandigarh. Reprints ~o Dr. K. Yadav, Lecturer in Paediatric Surgery, P.G.I., Chandigarh--India. Received on January 19, 1979
an infant been cleaned up, varying amounts o f milk may be brought up. This leads to intense concern in the mother who is usually already over-anxious. The mother should be reassured. Sometimes mild sedation of the infant may help--chloral hydrate 60-200 mg before each feeding is often helpful. In.some babies milk shoots out when the baby belches and this type of projectile vomiting may lead a doctor to diagnose congenital pyeioric stenosis; Mothers usually. exaggerate the quantity brought up, Weight gain is normal. The cause of excessive flatulence in breast fed babies is prolonged sucking, which may ue because of insufficient milk at times or the baby just keeps on sucking longer than required. Babies fed on bottles sometime.~ gulp very rapidly, and this might also cause vomiting. A teat with a very small h ule also leads to excessive air swallowing and later on to vomiting. Some mothers do not tilt the bottles properly and the teat instead of containing milk contains a lot of air and some milk_ Some infants have relative incompetence of the cardio-oesophageal region, and they tend to vomit when placed in a cot. Such babies should be placed on their right side with the head slightly higher than the body. t b) Mucous Bastritis. This is a common cause o f vomiting during the first few days of life. It may follow abnormal labour and birth asphy:da, but quite frequently is seen following normal delivery. It appears t o - b e an attempt to get rid of swallowed blood, mucus and meconium. Secondary gastric
380
INDIANJOURNAL OF I'P,DIATRIC$
VOL. 46, NO. ~81
Table I. Conditions causing vomiting in neonates. Medical
Surgical I
1.
Neonatal intestinal obstruction a. Duodenal obstruction Atresia Stenosi Annular pancreas Malrotation of bowel b.
Small bowel obstruction Jejunal and ileal Atresia and stenosis Meconium ileus
c.
Large bowel obstruction Meconium plug Hirschsprung's disease
d.
Sphincteric abnormalities either end of stomach Congenital hypertrophic py!oric stenosis Gastro-oesoplaageal reflux
irritation with excessive mucus production may follow. These bab:es appear quite well otherwise. The stomach should be aspirated. If vomiting still continues, gastric lavage with normal saline or 1~ sodium bicarbonate should be performed. The baby should be fed milk feeds. The condition is usually resolved within three to four days.
Jl
]
Vomiting within 48 hours of birth Mucous gastritis Hypoglycaemia Cerebral irritation lleus of prematurity Infections acquired in utero
Later vomiting
Infections Gastro-enteritis Urinary tract infection Meningitis Respiratory infection Subdural haematoma Heart failure Adrenogenital ~, ndrome Galactosaemia Underfeeding Possetting or Habitual vomiting Milk allergy
Sometimes the baby may require more than One gastric lavage. (c) Vomiting as a manifestation of neonatal infection. Neonatal infection is one of llar dreaded conditions of the neonatal period. Early diagnosis can often be made if the physician is aware of the possibility. Loon-
,~0AV AND S A N D I I U ~ V O M I T I N G IN Tills Nm'W BORN INFANT
lld~g signs are frequently absent. Low birth weight babies are especially prone to develop infection. The first indications are sudden t~luetance to feed, vomiting, drowsiness or irritability, loss of or static weight. Lnter 0n the baby develops a greyish pallor and looks anxious. He may develop diarrhoea, lbdominal distension, oedema, purpura, jaundic~ and convulsions. Hepatosplenomegaly {s common in sepsis neonatorum. Fever may or may not be present. A preterm infant may develop hypothermia and scleraema. As soon as there is suspicion of infection, the neonate Should be sent to a hospital for management. Important investigations to be done are white cell count, urine examination for white cells, urine culture and sensitivity, blood culture, lumber puncture and X-ray of the chest. The baby should be treated with appropriate antibiotics. Neonatal infections are commonly caused by Gram negative bacilli and staphylococci. Ampicillin and gentamycin combination should cover the majority of eases. In suspected staphylococcal infection, doxicil!in and gentamycin combination should be given parenterally. The baby would require supportive treatment, such as, intravenous fluids, gastric suction and temperature control measures. (d) Vomiting secondary to severe birth asphyxia or intracranial haemorrhage should be kept in mind in cases of prolonged and difficult delivery and following instrumental or operative deliveries. These babies may present with irregularities of respiration, irritability, lethargy, convulsions, vomiting, depressed neonatal reflexes and sometimes lecalising signs pointing towards a difficult delivery. (e) Metabolic disorders producing vomiting. The adrenogenital syndrome and galac~o-
381
saemia are some of the important causes. In babies with salt losing adrenogenitai syndrome, symptoms may start shortly after birth. Vomiting is a prominant symptom. The baby fails to regain the birth weight, becomes dehydrated a n d might die if not treated with extra salt and steroids as DOCA. In galactosaemia the infants appear normal at birth, and symptoms appear as soon as milk feeds are started. They present with vomiting, difficult feeding, loss of weight, dehydration and later on with jaundice, hepatosplenomegaly and catract. Galactose can be detected in the urine by Fehling's solution, Withdrawal of milk is essential. N o food containing galact0se should be given. Tetany as a cause of vomiting should also be considered. Passive addiction to narcotics or barbiturates. This problem is increasing in advanced countries, but is still uncommon amongst us. The occurrence of withdrawal symptoms in the neonate are directly related to the duration and amount of narcotics taken by the mother. Symptoms occur during the first 48 hours in symptomatic infants. Clinical findings include jitteriness, irritability, high pitched cry, snee~ing, vomiting, hypertonia, respiratory distress and low birth weight. The baby may present with convulsions. These babies are treated wilh phenobarbitone, diazepan or chlorpromazine for 4-5 days. Surgical conditions resulting in neonatal vomiting. There is a dictum in paediatric surgery that presistent bile stained vomiting in a neonate should be considered as due to intestinal obstruction until proven otherwise. In practice it has been proved true. with excep-
~2
INDIAN J()UItNAL OF ~'ltDIATItlC~I
tion where obstruction of the duodenum was complete and situated proximal to the ampulla of yater. Though the baby vomits frequently the vomitus is without bile. In duodenal obstructio~ (partial or complete) the vomiting starts early after birth, occurs with every feed and contains bile. The diagnosis is difficult due to certain traps; firstly, the child may pass meconium even in the presence of complete obstruction of the duodenum, secondly the baby continuously accepts feeds hungriily, the abdomen remains scaphoid, and in the early period the weight loss is negligible. The reason is ithat the foe'tus ha.~ been fed parenterally so long that the stomach and duodenum above the obstruction has been allowed to dilate to an amazing degree. This produces ..the typical double bubble appearance in ~plain straight X-rays of the abdome~a (Plate I, Fig. 1). Secondly, the gut is full of fluid, re~utting in the absence of fluid levels. The diagnosis is made oh the history of persistent vomiting and plain roentgenogran pictures. In doubtful cases the stomach is emptied by an intragastric tube and at the same time air is injected, producing the typical picture which makes the diagnosis. In cases where doubt still remains a study of the upper gastrointestinal tract is done w;th gastro-graffin. The presentation of small bowel obstruction in neonates is somewhat similar to adults with regard to distension of the abdomen and constipation. In roentgenograms the distinction between small and large bowel is difficult to make. The baby with meconium ileus (the early presentation of cystic fibrosis), at birth presents with a soft distended abdomen where coils of intestines can be easily felt. On plain upright and
V o L . 4 6 s N o ~m
supine X-rays the distended bowel is SeOEIR be filled with a ground glass material ~I~ no fluid level. In neonatal Hirschsprtnfll disease when the baby fails to pass r a ~ nium within 12 hours after birth, at t i m plain X-rays are diagnostic. The bowel 01J truction due to imperforate anus could Ill complete or incomplete depending on ~] presence of a fistula. For lower gastroinlz tinal tract lesions contrast study by metw of an enema is carried out with gastrograt~ A small microcolon implies that it has nevM been filled with meconium as seen in m~,,~ nium ileus. The presence of malrotation iii diagnostic if the colon is found to be lvi~ or~ the left -side. The evidence, of H i r b sprung's disease is obtained by using Inn unprepared bowel, interest being f o e ~ only on the possibility of an abrupt ehar• in calibre of the colon. In case of meconium plug syndrome, the obstruction is relie~! following :the gastrografin enema and tI~ frequently becomes overt Hirschsprungm disease. Tracheo-oesophageal hstula 0t atresia lJroduces not so much vomiting u choking on feeds. Recurrent vomiting in the late neonatl period could be due to pyloric stenosil Pyloric stenosis rarely starts from b'~tln though at times the syndrome may begi~l from the age of one week. The text-boo description mentions projectile vomiti~ following every feed (during or at the end by a very hungry baby with a lean, scaphoifl abdomen showing golf ball peristalsis~ tumour is palpable in the right hypochon drium following test feeding before or aft9 a vomit. This is mobile and varies in hat/! ness following contractions of t h e stomar This above picture is absent in the earlw phase. The other surgical conditions whiell
PI.ATE
JNoIAN JOUaNAL OF PEI~IA'rRICS
Fig. 1.
Typical double bubble a p p e a r a n c e in a b d o m e n .
YADAV AND SANDHU--VOMITING IN THE NEW BORN INFANT.
I
P L A T E |l
rr~Dt^s JoUa~AL OF r'gDIATar~
Fig. i. Microphotograph of angioblastic merfingioma showing prominent vasc,~lar networks surrounded by a denseb cellular background. H & E " i00.
. S A R A D A El" A L . ~ A N G I O B L A S T I C
MEN[NGIOMA.
fhDAV AND SANDIIU~VOMI'FINOiN TIII~ Ng~V 8ORN INFANT
can rarely occur and present with vomiting iJlelude, torsion of the testcs, obstructed ingu;nal hernia and ttppcndicitis which can be ,ery difficult to diagnose because of poor ioealisation of inflammation in neonates. To sum up, the cause of vomiting might be trivial in most neonates while other conditions might prove fatal. A general practitioner should be aware of these problem~ to handle each case according to its merits. An ill neonate with vomiting is a paediatrie
383
emergency. Before transferring the baby to hospital, a catheter should be passed into the stomach to aspirate the contents. Preferably a medical attendant should accompany the baby, as stomach aspiration may have to be repeated to avoid aspiration into the respiratory tract. All cases where the underlying cause for vomiting is in doubt should be admitted. This policy might lead to some unnecessary admissions but would help to arrive at a diagnosis before the baby becomes malnourished and seriously sick.
VOMITING IN THE NEW BORN INFANT* K. Y^t,^v ^ s o S.K. S ^ s o n u
Chandigarh There c a n b e few infants who do not vomit occasionally during the early weeks of life. Vomiting during the neonatal period maY be caused by conditions which are trivial or life threatening. Ir~ the majority of neonates the cause of vomiting is easily ascertained from history, physical examination and simple investigations; however, a small number would require exhaustive work up in a well equipped hospital. A neonate must be referred to a hospital for a successful 9outcome before his general condition deteriorates. Conditions leading to neonatal vomiting may be grouped as medical and surgical (Table 1).
Cmronon medical problems presenting with vomiting (a) Habitual vomiting or posseting. Almost all babies bring up some milk, but some babies who are otherwise gaining weight satisfactorily have an increased tendency to vomit. These babies are usuaUy highly active, cheerful, interested in their surroundings and exhibit rapid mo~:ements of arms and legs. This type of vomiting is usually more troublesome during the first few weeks o f life but it may continue as a nuisance for some months. The timing and frequency of vomiing are irregular. Typically no sooner has *From the Department of Paediat~ic Surgery, Postgraduate Institute of Medical Education and Kesearch, Chandigarh. Reprints ~o Dr. K. Yadav, Lecturer in Paediatric Surgery, P.G.I., Chandigarh--India. Received on January 19, 1979
an infant been cleaned up, varying amounts o f milk may be brought up. This leads to intense concern in the mother who is usually already over-anxious. The mother should be reassured. Sometimes mild sedation of the infant may help--chloral hydrate 60-200 mg before each feeding is often helpful. In.some babies milk shoots out when the baby belches and this type of projectile vomiting may lead a doctor to diagnose congenital pyeioric stenosis; Mothers usually. exaggerate the quantity brought up, Weight gain is normal. The cause of excessive flatulence in breast fed babies is prolonged sucking, which may ue because of insufficient milk at times or the baby just keeps on sucking longer than required. Babies fed on bottles sometime.~ gulp very rapidly, and this might also cause vomiting. A teat with a very small h ule also leads to excessive air swallowing and later on to vomiting. Some mothers do not tilt the bottles properly and the teat instead of containing milk contains a lot of air and some milk_ Some infants have relative incompetence of the cardio-oesophageal region, and they tend to vomit when placed in a cot. Such babies should be placed on their right side with the head slightly higher than the body. t b) Mucous Bastritis. This is a common cause o f vomiting during the first few days of life. It may follow abnormal labour and birth asphy:da, but quite frequently is seen following normal delivery. It appears t o - b e an attempt to get rid of swallowed blood, mucus and meconium. Secondary gastric
380
INDIANJOURNAL OF I'P,DIATRIC$
VOL. 46, NO. ~81
Table I. Conditions causing vomiting in neonates. Medical
Surgical I
1.
Neonatal intestinal obstruction a. Duodenal obstruction Atresia Stenosi Annular pancreas Malrotation of bowel b.
Small bowel obstruction Jejunal and ileal Atresia and stenosis Meconium ileus
c.
Large bowel obstruction Meconium plug Hirschsprung's disease
d.
Sphincteric abnormalities either end of stomach Congenital hypertrophic py!oric stenosis Gastro-oesoplaageal reflux
irritation with excessive mucus production may follow. These bab:es appear quite well otherwise. The stomach should be aspirated. If vomiting still continues, gastric lavage with normal saline or 1~ sodium bicarbonate should be performed. The baby should be fed milk feeds. The condition is usually resolved within three to four days.
Jl
]
Vomiting within 48 hours of birth Mucous gastritis Hypoglycaemia Cerebral irritation lleus of prematurity Infections acquired in utero
Later vomiting
Infections Gastro-enteritis Urinary tract infection Meningitis Respiratory infection Subdural haematoma Heart failure Adrenogenital ~, ndrome Galactosaemia Underfeeding Possetting or Habitual vomiting Milk allergy
Sometimes the baby may require more than One gastric lavage. (c) Vomiting as a manifestation of neonatal infection. Neonatal infection is one of llar dreaded conditions of the neonatal period. Early diagnosis can often be made if the physician is aware of the possibility. Loon-
,~0AV AND S A N D I I U ~ V O M I T I N G IN Tills Nm'W BORN INFANT
lld~g signs are frequently absent. Low birth weight babies are especially prone to develop infection. The first indications are sudden t~luetance to feed, vomiting, drowsiness or irritability, loss of or static weight. Lnter 0n the baby develops a greyish pallor and looks anxious. He may develop diarrhoea, lbdominal distension, oedema, purpura, jaundic~ and convulsions. Hepatosplenomegaly {s common in sepsis neonatorum. Fever may or may not be present. A preterm infant may develop hypothermia and scleraema. As soon as there is suspicion of infection, the neonate Should be sent to a hospital for management. Important investigations to be done are white cell count, urine examination for white cells, urine culture and sensitivity, blood culture, lumber puncture and X-ray of the chest. The baby should be treated with appropriate antibiotics. Neonatal infections are commonly caused by Gram negative bacilli and staphylococci. Ampicillin and gentamycin combination should cover the majority of eases. In suspected staphylococcal infection, doxicil!in and gentamycin combination should be given parenterally. The baby would require supportive treatment, such as, intravenous fluids, gastric suction and temperature control measures. (d) Vomiting secondary to severe birth asphyxia or intracranial haemorrhage should be kept in mind in cases of prolonged and difficult delivery and following instrumental or operative deliveries. These babies may present with irregularities of respiration, irritability, lethargy, convulsions, vomiting, depressed neonatal reflexes and sometimes lecalising signs pointing towards a difficult delivery. (e) Metabolic disorders producing vomiting. The adrenogenital syndrome and galac~o-
381
saemia are some of the important causes. In babies with salt losing adrenogenitai syndrome, symptoms may start shortly after birth. Vomiting is a prominant symptom. The baby fails to regain the birth weight, becomes dehydrated a n d might die if not treated with extra salt and steroids as DOCA. In galactosaemia the infants appear normal at birth, and symptoms appear as soon as milk feeds are started. They present with vomiting, difficult feeding, loss of weight, dehydration and later on with jaundice, hepatosplenomegaly and catract. Galactose can be detected in the urine by Fehling's solution, Withdrawal of milk is essential. N o food containing galact0se should be given. Tetany as a cause of vomiting should also be considered. Passive addiction to narcotics or barbiturates. This problem is increasing in advanced countries, but is still uncommon amongst us. The occurrence of withdrawal symptoms in the neonate are directly related to the duration and amount of narcotics taken by the mother. Symptoms occur during the first 48 hours in symptomatic infants. Clinical findings include jitteriness, irritability, high pitched cry, snee~ing, vomiting, hypertonia, respiratory distress and low birth weight. The baby may present with convulsions. These babies are treated wilh phenobarbitone, diazepan or chlorpromazine for 4-5 days. Surgical conditions resulting in neonatal vomiting. There is a dictum in paediatric surgery that presistent bile stained vomiting in a neonate should be considered as due to intestinal obstruction until proven otherwise. In practice it has been proved true. with excep-
~2
INDIAN J()UItNAL OF ~'ltDIATItlC~I
tion where obstruction of the duodenum was complete and situated proximal to the ampulla of yater. Though the baby vomits frequently the vomitus is without bile. In duodenal obstructio~ (partial or complete) the vomiting starts early after birth, occurs with every feed and contains bile. The diagnosis is difficult due to certain traps; firstly, the child may pass meconium even in the presence of complete obstruction of the duodenum, secondly the baby continuously accepts feeds hungriily, the abdomen remains scaphoid, and in the early period the weight loss is negligible. The reason is ithat the foe'tus ha.~ been fed parenterally so long that the stomach and duodenum above the obstruction has been allowed to dilate to an amazing degree. This produces ..the typical double bubble appearance in ~plain straight X-rays of the abdome~a (Plate I, Fig. 1). Secondly, the gut is full of fluid, re~utting in the absence of fluid levels. The diagnosis is made oh the history of persistent vomiting and plain roentgenogran pictures. In doubtful cases the stomach is emptied by an intragastric tube and at the same time air is injected, producing the typical picture which makes the diagnosis. In cases where doubt still remains a study of the upper gastrointestinal tract is done w;th gastro-graffin. The presentation of small bowel obstruction in neonates is somewhat similar to adults with regard to distension of the abdomen and constipation. In roentgenograms the distinction between small and large bowel is difficult to make. The baby with meconium ileus (the early presentation of cystic fibrosis), at birth presents with a soft distended abdomen where coils of intestines can be easily felt. On plain upright and
V o L . 4 6 s N o ~m
supine X-rays the distended bowel is SeOEIR be filled with a ground glass material ~I~ no fluid level. In neonatal Hirschsprtnfll disease when the baby fails to pass r a ~ nium within 12 hours after birth, at t i m plain X-rays are diagnostic. The bowel 01J truction due to imperforate anus could Ill complete or incomplete depending on ~] presence of a fistula. For lower gastroinlz tinal tract lesions contrast study by metw of an enema is carried out with gastrograt~ A small microcolon implies that it has nevM been filled with meconium as seen in m~,,~ nium ileus. The presence of malrotation iii diagnostic if the colon is found to be lvi~ or~ the left -side. The evidence, of H i r b sprung's disease is obtained by using Inn unprepared bowel, interest being f o e ~ only on the possibility of an abrupt ehar• in calibre of the colon. In case of meconium plug syndrome, the obstruction is relie~! following :the gastrografin enema and tI~ frequently becomes overt Hirschsprungm disease. Tracheo-oesophageal hstula 0t atresia lJroduces not so much vomiting u choking on feeds. Recurrent vomiting in the late neonatl period could be due to pyloric stenosil Pyloric stenosis rarely starts from b'~tln though at times the syndrome may begi~l from the age of one week. The text-boo description mentions projectile vomiti~ following every feed (during or at the end by a very hungry baby with a lean, scaphoifl abdomen showing golf ball peristalsis~ tumour is palpable in the right hypochon drium following test feeding before or aft9 a vomit. This is mobile and varies in hat/! ness following contractions of t h e stomar This above picture is absent in the earlw phase. The other surgical conditions whiell
PI.ATE
JNoIAN JOUaNAL OF PEI~IA'rRICS
Fig. 1.
Typical double bubble a p p e a r a n c e in a b d o m e n .
YADAV AND SANDHU--VOMITING IN THE NEW BORN INFANT.
I
P L A T E |l
rr~Dt^s JoUa~AL OF r'gDIATar~
Fig. i. Microphotograph of angioblastic merfingioma showing prominent vasc,~lar networks surrounded by a denseb cellular background. H & E " i00.
. S A R A D A El" A L . ~ A N G I O B L A S T I C
MEN[NGIOMA.
fhDAV AND SANDIIU~VOMI'FINOiN TIII~ Ng~V 8ORN INFANT
can rarely occur and present with vomiting iJlelude, torsion of the testcs, obstructed ingu;nal hernia and ttppcndicitis which can be ,ery difficult to diagnose because of poor ioealisation of inflammation in neonates. To sum up, the cause of vomiting might be trivial in most neonates while other conditions might prove fatal. A general practitioner should be aware of these problem~ to handle each case according to its merits. An ill neonate with vomiting is a paediatrie
383
emergency. Before transferring the baby to hospital, a catheter should be passed into the stomach to aspirate the contents. Preferably a medical attendant should accompany the baby, as stomach aspiration may have to be repeated to avoid aspiration into the respiratory tract. All cases where the underlying cause for vomiting is in doubt should be admitted. This policy might lead to some unnecessary admissions but would help to arrive at a diagnosis before the baby becomes malnourished and seriously sick.
