Vomiting in the Newborn Infant

Most babies vomit at some time. In most cases this is unimportant. However, there are circumstances when the type of vomiting is important. They are as follows:

  • vomit contains blood (red or black, the colour of the blood will depend upon how long the blood has been in the stomach)
  • vomiting bile (green, not yellow)
  • projectile vomiting
  • the baby is unwell
  • the baby is failing to thrive
  • the baby has gastrooesophageal reflux and could be aspirating
  • the baby also has diarrhoea
  • the abdomen is distended

Where none of the above clinical scenarios apply the vomiting is unlikely to be clinically significant. Small, frequent vomits are referred to as "posits".

Vomit contains blood
The commonest cause is swallowed maternal blood. Swallowed blood often irritates the stomach and causes vomiting. Blood may be swallowed during

  • birth
  • breast-feeding

Birth. No delivery is bloodless, whether vaginal or Caesarean, and hence there is the opportunity to swallow blood at birth. However, the largest amount of blood will be swallowed if there is antepartum haemorrhage associated with bleeding into the amniotic fluid for at least several hours before birth. This blood may then take several days after birth to clear the gastrointestinal tract (GIT). Under these circumstances, as well as vomiting blood, the baby may pass malaena stools, rather than meconium.

Breast-feeding. Many breast-fed babies will swallow blood from a cracked and bleeding nipple. Usually the mother is aware of the nipple problem, but not always, as the bleeding may be deeper and painless.

Management of swallowed maternal blood is expectant. If it is swallowed from birth it will eventually clear from the GIT. The mother's cracked and bleeding nipple will require attention, and she may require lactation advice about nipple attachment. This becomes a transient contraindication to breast feeding if the mother is Hepatitis C positive.

Less commonly, the baby is bleeding. Causes include

  • haemorrhagic disease of the newborn (HDN)
  • stress ulceration
  • swallowed baby blood

HDN rarely occurs with adequate Vitamin K prophylaxis. Babies whose mothers have been taking medications that interfere with Vitamin K metabolism (e.g., anticonvulsants, oral anticoagulants), or babies with liver disease or consumption of clotting factors are at higher risk.

Babies who are very sick can have stress ulceration of the stomach, as can those treated with drugs such as corticosteroids and indomethacin.
Babies can swallow their own blood from upper airway trauma, as may occur from vigorous suctioning, endotracheal tube insertion or with difficulty passing a nasogastric tube.

  • some babies with gastro-oesophageal reflux can develop reflux oesophagitis, which may bleed

Usually the origin of the blood is clear from the history, but if there is doubt the laboratory can perform an Apt test (blood mixed with sodium hydroxide). This distinguishes fetal from adult haemoglobin.

Vomiting bile

  • a baby who vomits bile (green, not yellow, in colour) should be presumed to have a bowel obstruction, until proven otherwise
  • there are many causes of bowel obstruction , but the most potentially dangerous is volvulus related to malrotation of the midgut. The bowel can twist, become ischaemic and necrotic within a matter of hours, so the diagnosis and treatment are urgent
  • Other signs of obstruction, including abdominal distention, and imperforate anus should be sought
  • a supine abdominal X-ray will usually reveal an abnormal gas pattern (e.g., a paucity of gas and distention of the stomach and proximal duodenum in volvulus; more gaseous distention with lower obstructions), and a lateral decubitus X-ray will reveal fluid levels
  • treatment includes urgent surgical referral, IV fluids and gastric drainage

Projectile vomiting

  • occasional projectile vomiting may occur without a specific cause in some neonates.
  • duodenal obstruction should be considered. The commonest cause is duodenal atresia, in whom about half of the infants will have Down syndrome. However, duodenal atresia is more commonly diagnosed antenatally, in a mother who presents with polyhydramnios and in whom the classical "double-bubble" appearance (distention of stomach and first part of duodenum) is seen on ultrasound. If the diagnosis is not made antenatally, the baby may have minimal vomiting until the milk intake increases after the first few days of life. The diagnostic test is an abdominal X-ray, which reveals the classic "double-bubble" appearance.
  • pyloric stenosis usually presents at 2-3 weeks of age, after most babies have been discharged home. However, it occasionally occurs in the convalescing preterm infant before discharge home. Ultrasound will often help to make the diagnosis.

Vomiting in the unwell baby

  • consider
    • infection
    • inborn errors of metabolism
    • congenital adrenal hyperplasia

  • helpful clues include
    • other signs of sepsis
    • excessive weight loss (including dehydration)
    • disordered conscious state
    • metabolic derangements, including metabolic acidosis and electrolyte disturbances (high potassium and low sodium in congenital adrenal hyperplasia)

Vomiting with failure to thrive

  • causes of vomiting leading to failure to thrive include
    • gastro-oesophageal reflux (GOR)
    • infection
    • inborn errors of metabolism

  • GOR usually does not present in the first days after birth, probably because milk intakes are relatively low. Also it is usually much worse with any artificial formulas compared with breast milk, and most babies are at least initially breast-fed. Therefore most term babies present after discharge home
  • GOR is most commonly diagnosed in nurseries in convalescing preterm babies
  • the vomiting is characteristically effortless, and occurs more when the stomach is full (after a feed), and when the baby is lying flat, rather than when upright. Occasionally the vomit may contain blood from reflux oesophagitis
  • in most babies the diagnosis is clinical and partly confirmed by response to anti-reflux measures. Where anti-reflux measures fail, further investigation is necessary for an exact diagnosis
  • treatment includes thickening the baby's feeds, smaller, more frequent feeds, minimal handling after feeds, and occasionally elevation of the head of the cot
  • preterm babies have less GOR when nursed prone, but they must be monitored electronically for apnoea
  • rarely, persistent GOR requires fundoplication

Vomiting causing choking and aspiration

  • all babies are capable of choking
  • sometimes the choking follows vomiting. It is particularly common in the first day after birth, especially if the baby has swallowed any blood or meconium. It is also common when the milk flow is excessive, especially around 3-4 days of age. Most babies cope with these episodes quite well, and either swallow the regurgitated contents or cough them out
  • recurrent aspiration is usually caused by severe GOR

The baby has concomitant diarrhoea

  • gastroenteritis is less common during primary hospitalisation due to
    • higher breast-feeding rates
    • more rooming-in (less care of babies in communal nurseries, where infectious agents such as rotavirus can spread easily)

  • gastroenteritis can, however, still cause vomiting and diarrhoea in newborn infants, and cause dehydration and shock if unrecognised.

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