Approach to vomiting (newborn and infant): Clinical sciences

Chapters:

Watch video only

Introduction0:00–0:22

Vomiting, also known as emesis, is defined as the forceful expulsion of gastrointestinal contents, and is a common symptom caused by a wide variety of underlying conditions.
Based on the vomitus characteristics, vomiting can be described as bilious or non-bilious. Now, if a newborn or infant presents with vomiting, perform an ABCDE assessment to determine if the patient is unstable or stable.

Unstable Patient0:22–1:30

If unstable, stabilize their airway, breathing, and circulation; obtain IV access, and if needed, provide IV fluids. Next, put your patient on continuous vital sign monitoring, including heart rate, blood pressure, and pulse oximetry, and if needed, provide supplemental oxygen.
You may also need to make your patient NPO and insert a nasogastric tube to decompress the stomach and prevent further vomiting.
Finally, if you suspect an underlying infection, don’t forget to start broad-spectrum antibiotics. Now, here’s a clinical pearl!
Infants who are unstable and present with vomiting may have peritonitis, intestinal perforation, or shock, especially if there’s also abdominal distension or tenderness.
In addition to acute management, consult your surgical team for consideration of an emergent laparotomy, and consider starting broad spectrum IV antibiotics.

Stable Patient1:30–1:56

Now, let’s go back to the ABCDE assessment and take a look at stable patients presenting with vomiting. Start by obtaining a focused history and physical examination.
Next, assess for bilious emesis, which caregivers may describe as green or bright yellow. It’s critical to identify bilious emesis quickly, as it suggests an intestinal obstruction that requires emergency surgical intervention!
Okay, first, let’s focus on nonbilious emesis. In this case, your next step is to assess for projectile vomiting.

Nonbilious, non-projectile, sudden1:56–4:47

If your patient has non-projectile vomiting, assess the onset of vomiting, which could be either sudden or gradual. In this context, a sudden onset means that vomiting developed quickly over the course of 24 to 48 hours.
Let’s start by focusing on infectious gastroenteritis. In this case, caregivers will typically report a known sick contact, diarrhea, and possibly fever.
The physical examination will reveal a soft abdomen, without rebound or guarding. Additionally, you will notice reduced skin turgor, suggesting dehydration.
Here, you can make a clinical diagnosis of infectious gastroenteritis, which can result from viral or bacterial infections.
Next up are urinary tract infections, or UTIs for short. These patients are usually biologically females or uncircumcised males, and their caregivers typically report fever and irritability, as well as strong-smelling urine.
In this case, you should consider a UTI and order a urine dipstick and urine culture. Additionally, order a blood culture if your patient is less than eight weeks old or if they are ill-appearing.
If the urine dipstick reveals positive leukocyte esterase with or without nitrites, blood, or protein; and the urine culture is positive with or without a positive blood culture, diagnose a UTI.
Next up is increased intracranial pressure! In this case, caregivers might report altered mental status, irritability, or even seizures.
They may also report vomiting after waking from sleep. Additionally, the physical exam could reveal a bulging fontanelle, papilledema, abnormal reflexes, or cranial nerve palsy.
You may even detect the Cushing triad of bradycardia, irregular respirations, and widened pulse pressure. With these findings, you should suspect increased intracranial pressure and order a head CT or MRI.
If the imaging reveals findings suggestive of increased pressure within the cranium, you can confirm the diagnosis. Finally, let’s discuss food protein-induced enterocolitis syndrome or FPIES for short.
This is usually associated with episodes of delayed vomiting and diarrhea after food exposure that improves once the offending food is removed from the diet.
For this patient, diagnose FPIES, which is a non-IgE-mediated allergic reaction often caused by proteins found in cow’s milk, soy, rice cereal, or oatmeal.
Alright, let’s switch gears and talk about patients with nonbilious, non-projectile vomiting that has a gradual onset of several days or weeks.

Nonbilious, non-projectile, gradual onset vomiting4:47–6:55

Let’s start with an inborn error of metabolism. Your patient will usually present with episodic vomiting, poor feeding, and lethargy, with or without an abnormal newborn screen.
Additionally, the physical exam may reveal slow growth, a developmental delay, organomegaly, or unusual body odor. In this case, you should consider an inborn error of metabolism, and order labs to evaluate for metabolic disorders, such as amino acid and urea cycle defects.
These labs should include serum amino acids, urine organic acids, urine ketones, carnitine profile, ammonia, lactate, and pyruvate.
The presence of any abnormal findings consistent with an inborn error of metabolism will confirm the diagnosis. Next up is congenital adrenal hyperplasia!
These infants usually present with persistent vomiting during the first weeks of life that progresses to dehydration and lethargy.
In some cases, you might notice an abnormal newborn screening. Additionally, if the patient is biologically female, the physical examination will reveal ambiguous genitalia.
With these findings, consider adrenal insufficiency, so check the 17-hydroxyprogesterone level. If elevated, diagnose congenital adrenal hyperplasia.
Finally, let’s look at gastroesophageal reflux as a cause of vomiting. In this case, caregivers will report that the baby is “spitting up” after feedings, meaning the vomiting is passive and not forceful.
The caregiver may also notice improvement with conservative measures like providing small, frequent feeds or keeping the baby upright after feeding.
Physical examination might be significant for slow weight gain or even weight loss that’s not appropriate for their age.
These findings are highly suggestive of gastroesophageal reflux. Now, let’s back up and look at babies with nonbilious projectile vomiting, which is typically associated with pyloric stenosis, and is most often seen in patients between four and six weeks of age.

Nonbilious, Projectile Vomiting6:55–7:34

Caregivers will often report immediate, postprandial, projectile vomiting, and that their baby always seems hungry. On physical examination, you may detect a palpable “olive-shaped” abdominal mass in the right upper quadrant.
If so, you should consider pyloric stenosis and order an abdominal ultrasound. If the ultrasound reveals a hypertrophic pylorus, diagnose pyloric stenosis.
Now let’s switch gears and look at patients with bilious vomiting. In this case, your next step is to assess your patient’s age, as bilious vomiting can indicate specific conditions, depending on whether your patient is a preterm newborn, term newborn, or an older infant.

Bilious Vomiting7:34–7:53

Bilious Vomiting, Premature Newborn7:53–8:13

Let’s start with premature newborns! In this group, consider necrotizing enterocolitis and order an abdominal X-ray.
If imaging reveals pneumatosis intestinalis, which is visible gas within the intestinal walls, diagnose necrotizing enterocolitis.
On the flip side, if your patient was born full term, consider intestinal malrotation with volvulus, which is twisting of the intestines due to misalignment during development, resulting in obstruction.

Bilious Vomiting, Term Newborn8:13–9:21

Next, obtain an upper GI contrast study, and if it shows a corkscrew appearance of the duodenum, diagnose malrotation with volvulus.
Keep in mind that presentations of intestinal malrotation can vary in severity. Generally, if the malrotation is severe enough that it results in obstruction, it’s considered an emergent situation.
In these cases, you’ll want to place a nasogastric tube for decompression and consult your surgical team for an emergent laparotomy.
Now, here’s a clinical pearl! Some newborn infants with bilious emesis may have also failed to pass meconium.
If so, consider evaluating for an intestinal obstruction with abdominal imaging, such as an X-ray or contrast enema. This can help you identify conditions like intestinal atresia, meconium ileus, or Hirschsprung disease, all of which may present this way.
Finally, let’s go back and take a look at infants with bilious emesis, which is commonly associated with intussusception.

Bilious Vomiting, Infant9:21–10:13

These infants usually present with intermittent colicky abdominal pain, and they often draw their knees up to their chest to relieve it.
In addition, they may have stools mixed with blood and mucus, also called “currant jelly” stools. If you notice a palpable “sausage-shaped” abdominal mass on exam, consider intussusception and order an abdominal ultrasound.
If the ultrasound reveals a “donut” or “target” sign, diagnose intussusception. One last high-yield fact!
You can also use an air enema to diagnose an intussusception while simultaneously reducing it! The pressure created by the air enema reverses the telescoping of the intestines.

Review10:13–11:09

Alright, as a quick recap… If a newborn or infant presents with vomiting, perform an ABCDE assessment and, if needed, stabilize the patient.
Next, assess if the emesis is nonbilious or bilious. Sudden nonbilious, non-projectile vomiting is associated with infectious gastroenteritis, UTI, increased intracranial pressure, and FPIES.
Alternatively, gradual nonbilious, non-projectile vomiting is common in conditions like inborn error of metabolism, congenital adrenal hyperplasia, and gastroesophageal reflux.
However, if the patient presents with nonbilious projectile vomiting, think of pyloric stenosis. On the flip side, common causes of bilious vomiting in newborns include NEC or intestinal malrotation with volvulus.
Finally, if your patient is an infant with bilious emesis,