Table of Contents

 

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal Of The Literature
5. Etiology And Pathophysiology
6. Differential Diagnosis
   1. Obstructive Pathologies
      1. Bilious Etiologies
      2. Nonbilious Etiologies
   2. Nonobstructive Pathologies
      1. Gastroesophageal Reflux And Gastroesophageal Reflux Disease
      2. Overfeeding
      3. Feeding Intolerance
      4. Necrotizing Enterocolitis
      5. Sepsis And Infection
      6. Kernicterus
      7. Inborn Errors Of Metabolism
      8. Increased Intracranial Pressure
      9. Other Nonobstructive Etiologies
7. Prehospital Care
8. Emergency Department Evaluation
   1. History
      1. Quality Of Emesis
      2. Feeding Patterns
      3. Growth
      4. Gastroesophageal Reflux Disease
      5. Hydration Status, Urine Output, And Stooling
   2. Physical Examination
9. Diagnostic Studies
   1. Bedside Tests
   2. Laboratory Studies
   3. Radiographic Imaging Studies
      1. Bilious Emesis
   4. Nonbilious Emesis
      1. Hypertrophic Pyloric Stenosis
      2. Gastroesophageal Reflux Disease
10. Treatment
    1. Management Of Obstructive Etiologies
       1. Malrotation With Midgut Volvulus
       2. Hypertrophic Pyloric Stenosis
       3. Incarcerated Inguinal Hernia
       4. Intestinal Atresias
       5. Hirschsprung Disease
       6. Intussusception
    2. Management Of Nonobstructive Etiologies
       1. Gastroesophageal Reflux Disease
          • Nonpharmacologic Treatment
          • Pharmacologic Treatment
          • Acid Suppressants
          • Prokinetic Agents
       2. Surgical Management
       3. Necrotizing Enterocolitis
       4. Management Of Other Nonobstructive Causes Of Neonatal Vomiting
11. Special Populations
12. Controversies And Cutting Edge
13. Disposition
14. Summary
15. Risk Management Pitfalls For Neonatal Vomiting
16. Time- And Cost-Effective Strategies
17. Case Conclusions
18. Tables and Figures
    1. Table 1. Differential Diagnosis Of Vomiting In The Neonate
    2. Figure 1. Radiographic 'Double Bubble' Sign Associated With Duodenal Atresia
    3. Figure 2. Malrotation On Upper Gastrointestinal Study
    4. Figure 3. Ultrasound Of Hypertrophic Pyloric Stenosis
19. Clinical Pathway For Management Of Neonatal Vomiting In The Emergency Department
20. References

Abstract

Vomiting accounts for up to 36% of neonatal visits to the emergency department. The causes of vomiting can range from benign to life-threatening. Evidence to guide the diagnosis and management of neonatal vomiting in the emergency department is limited. History and physical examination are extremely important in these cases, especially in identifying red flags such as bilious or projectile emesis. A thorough review is presented, discussing various imaging modalities, including plain abdominal radiography, upper gastrointestinal studies, ultrasonography, and contrast enema. A systematic approach in the emergency department, as outlined in this review, is required to identify the serious causes of vomiting in the neonate.

Case Presentations

A 3-week-old boy with emesis is brought to the ED by his parents. He has had persistent nonbilious vomiting occurring after nearly every feed for the past 2 weeks. The parents have changed his formula 3 times, but there has been no change in symptoms. Although the baby has gained weight, he has not gained as expected. No fever has been noted. The remainder of the review of systems is negative. On physical examination, the patient is well-appearing and is not dehydrated. His abdomen is soft, nontender, and nondistended. You observe a brief episode where he arches his back, grimaces, and seems to “tighten up” while lying supine. Considering all the possible diagnoses, you debate what your workup should be...

A 2-day-old girl is then brought to the ED by her parents. The infant has had 5 episodes of vomiting that day. The mother reports that the vomit has changed from the color of colostrum to a green color. The mother and baby had an uncomplicated delivery and were discharged from the hospital earlier that day. The infant passed meconium on day 1 of life and has had 5 wet diapers since birth. The mother has noted that the infant has not been as vigorous when attempting breastfeeding since that morning. The remainder of the review of systems is negative. The physical examination reveals a lethargic neonate who reacts minimally to examination. Her abdomen is distended with quiet bowel sounds, and a slight whimper is elicited with palpation. The patient appears dehydrated, and there is a light green stain on the mother’s shoulder from the emesis. You tell the patient’s mother that you have concerns and that you need to work fast to uncover the cause of her vomiting. What can be the cause of vomiting in this neonate? All bilious emesis is bad, right? Should you call the surgeon right away, or wait until you have the diagnosis? Should you get an x-ray, an ultrasound, or a UGI study?

A 4-week-old boy is sent to the ED after being seen in his pediatrician’s office for vomiting and weight loss. He is noted to have lost 8 ounces since his last office visit 1 week prior. His mother reports that, for the past 2 weeks, he has been spitting up, it has become progressively more frequent, and is now forceful. She states that the color of the emesis is the formula she has been feeding him, and the vomiting occurs after every feed. He still has 4 to 5 wet diapers per day and no diarrhea. The remainder of the review of systems is negative. On physical examination, you find a sleeping neonate who reacts to the examination by crying. You notice that he does not produce many tears and his diaper is dry. On abdominal examination, you palpate a possible small mass in the right upper quadrant, but the baby moves frequently, and the examination is difficult to reproduce. The remainder of the examination is noncontributory. As you think about the orders you want to place, you wonder if a set of electrolytes would be helpful. Should you attempt a bedside ultrasound? Which test is first-line – an ultrasound or a UGI study?

Introduction

Vomiting in the neonate is a common presenting complaint in the emergency department (ED), with etiologies ranging from benign to life-threatening. Vomiting and feeding difficulties have been reported in 11% to 36% of neonates who visit the ED.^1,2 Vomiting (particularly bilious emesis) must be considered a surgical emergency until proven otherwise. The incidence of bilious emesis indicative of a surgical obstruction is reported to be between 20% and 38%.^3-7 A timely and accurate diagnosis is the key to successful management.⁸ Determining the etiology of vomiting in the neonate can be difficult and may involve multiple imaging modalities as well as consultation with subspecialists. This review will focus on the evaluation and treatment of neonates with gastrointestinal causes of vomiting, particularly the life-threatening etiologies.

Critical Appraisal Of The Literature

A literature search was performed in PubMed and Ovid MEDLINE®, using the search terms vomiting, neonate, bilious, emesis, gastroesophageal reflux disease, GERD, malrotation, midgut volvulus, Hirschsprung disease, hypertrophic pyloric stenosis, necrotizing enterocolitis, and incarcerated inguinal hernia. Significant, well-designed, randomized controlled trials and meta-analyses were included as well as older publications that have been frequently referenced in the medical community. A search of the Cochrane Database of Systematic Reviews yielded 1 pertinent publication related to the treatment of neonatal vomiting.⁹ One relevant review was not included in this issue, as it had been withdrawn from the Cochrane Library because the authors were unable to update the review.¹⁰ Guidelines released through the National Guideline Clearinghouse by the American College of Radiology in 2011¹¹ and guidelines from the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) in conjunction with the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) in 2009¹² were reviewed. Both of these guidelines are consensus statements and not systematic, evidence-based guidelines. A search of the American Academy of Pediatrics website did not reveal any clinical practice guidelines on this topic. There is a wide range in the quality of clinical evidence available for the diagnosis and management of neonatal vomiting, with most falling into the moderately strong category. There are limited prospective studies focused on ED management.

Risk Management Pitfalls For Neonatal Vomiting

1. “The infant had bilious vomiting and did not look well, but I decided to wait until completion of the diagnostic study before calling the surgeon.” In a toxic-appearing neonate with bilious vomiting, the diagnosis of a malrotation with midgut volvulus must be considered. Evaluation by a pediatric surgeon as soon as this diagnosis is suspected is warranted, as bowel necrosis is correlated with increased mortality.
2. “I evaluated a well-appearing infant with a history of vomiting. When asked, the mother confirmed the emesis was “bile.” The patient appeared well and had a completely normal examination, but because of the history of bilious vomiting, I proceeded to place an NG tube, call a surgeon, and order a UGI study.” Most caregivers (71%) equate “bile” with the color yellow. Asking the caregiver to describe the color of the emesis and not prompting them with the term “bile” could avoid an unnecessary workup in a well-appearing infant.
3. “I admitted an infant with abdominal distension, irritability, and vomiting, but did not consider a surgical abdomen, as the vomiting was nonbilious and nonprojectile.” Surgical etiologies for neonates with vomiting should still be considered with nonbilious vomiting in the presence of other concerning signs and symptoms, such as abdominal distention and irritability.
4. “For this infant with bilious vomiting, the initial abdominal radiograph did not show air fluid levels, so I determined that further imaging was not necessary.” The sensitivity and specificity of abdominal plain radiographs for obstruction in the presence of bilious emesis have been reported to be 44% to 50% and 80% to 97%, respectively, indicating that > 50% of cases would be missed if the diagnosis is based on radiographs alone.
5. “The infant had been spitting up since birth, so I didn’t think of considering a surgical issue, although the vomiting had become more frequent and more forceful.” In a study of return ED visits, patients diagnosed with reflux and/or vomiting at the first visit had a high frequency of admission (55%) and diagnosis of pyloric stenosis at the second visit (26%).
6. “I made the clinical diagnosis of GERD in a well-appearing infant and started treatment with metoclopramide.” The recommendations for treatment of GERD in well-appearing infants include nonpharmacologic treatments and consideration of pharmacologic treatment. Considerations include avoidance of cow’s milk protein and postprandial position changes. When nonpharmacologic treatment fails, H₂-receptor blockers can be considered. Due to significant side effects and lack of evidence of effectiveness in the treatment of GERD, prokinetic agents (such as metoclopramide) are no longer recommended for the treatment of GERD in infants.
7. “I discharged a 3-week-old baby with vomiting with a diagnosis of GERD because the infant was too young to consider HPS and the laboratory studies did not show hypokalemia, hypochloremia, or metabolic alkalosis.” Several authors have demonstrated that the majority of patients with HPS have normal electrolytes. Up to 88% of patients have no electrolyte abnormalities on admission. If the diagnosis of HPS is suspected, ultrasound should be ordered.
8. “I always recommend mothers with infants with suspected GERD to thicken formula and sit the infant in a car seat after feeds.” Although this was traditionally thought to decrease reflux symptoms, sitting upright in car seats after feeds has been shown to increase reflux symptoms in infants.
9. “I did not feel a palpable olive-sized mass in the abdomen, so I discharged the vomiting infant home with diagnosis of reflux.” Since the advent of ultrasonography for diagnosing HPS, the portion of patients with a clinical finding of a palpable olive-sized mass has fallen from previous reports of 78% to 83% to only 50%. This may be due to earlier diagnosis, which renders the mass smaller and not as palpable.
10. “I suspected the diagnosis of an incarcerated hernia in an infant with a painful inguinal mass and abdominal distension and ordered an abdominal ultrasound to confirm the diagnosis.” Incarcerated inguinal hernia is a diagnosis requiring prompt recognition and involvement of pediatric surgeons to optimize bowel salvage. Typically, history and physical examination are all the clinician needs to diagnose this entity and manual reduction should be attempted in the ED.

Tables and Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study will be included in bold type following the reference, where available. The most informative references cited in this paper, as determined by the author, will be noted by an asterisk (*) next to the number of the reference.

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