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.
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?
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.
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.
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.
Kristin Ratnayake, MD; Tommy Y. Kim, MD
November 1, 2014