Neonatal Vomiting: Clinical Evaluation Leaning Tool
Clinical History Assessment
Systematic approach to history taking for a neonate presenting with vomiting
Physical Examination Guide
Systematic approach to examining a neonate with vomiting
Diagnostic Approach
Initial Assessment
For a neonate presenting with vomiting, the initial assessment should include:
- Detailed history focusing on character, timing, and frequency of vomiting
- Complete physical examination to identify signs of dehydration or systemic illness
- Assessment of feeding patterns and techniques
- Evaluation of growth trends
Differentiating Regurgitation from Pathological Vomiting
| Feature | Regurgitation (GER) | Pathological Vomiting |
|---|---|---|
| Effort | Effortless, passive | Often forceful or projectile |
| Timing | During or shortly after feeds | May occur unrelated to feeds |
| Color | White or milk-colored | May be yellow (bilious) or green |
| Volume | Small amounts | Often larger volumes |
| Associated symptoms | Typically absent | Often present (lethargy, poor feeding, etc.) |
| Growth | Normal growth | May have poor weight gain |
Differential Diagnosis
| System | Conditions | Red Flags |
|---|---|---|
| Gastrointestinal Obstruction |
- Pyloric stenosis - Malrotation with volvulus - Duodenal atresia/stenosis - Jejunal/ileal atresia - Hirschsprung's disease - Meconium ileus |
- Projectile vomiting - Bilious vomiting - Abdominal distention - Failure to pass meconium - Visible peristalsis - Olive-like mass in upper abdomen |
| Infectious Causes |
- Necrotizing enterocolitis (NEC) - Sepsis - Urinary tract infection - Meningitis - Pneumonia - Gastroenteritis |
- Fever or hypothermia - Lethargy - Poor feeding - Bloody stool - Respiratory distress - Abdominal tenderness |
| Feeding-Related |
- Overfeeding - Underfeeding - Improper feeding technique - Gastroesophageal reflux (GER) - Gastroesophageal reflux disease (GERD) |
- Poor weight gain - Excessive weight gain - Feeding aversion - Back arching during feeds - Recurrent respiratory symptoms |
| Metabolic/Endocrine |
- Inborn errors of metabolism - Congenital adrenal hyperplasia - Galactosemia - Urea cycle defects |
- Lethargy - Poor feeding - Altered mental status - Hepatomegaly - Seizures - Abnormal odors |
| Neurologic |
- Increased intracranial pressure - Hydrocephalus - Intracranial hemorrhage - Brain malformations |
- Bulging fontanelle - Setting-sun sign - Macrocephaly - Altered level of consciousness - Seizures |
| Other |
- Formula intolerance - Cow's milk protein allergy - Medication side effects - Renal anomalies/failure |
- Diarrhea - Rash - Blood/mucus in stool - Temporal relationship to medications - Oliguria/polyuria |
Laboratory Studies
Consider these studies based on clinical presentation:
| Investigation | Clinical Utility | When to Consider |
|---|---|---|
| Complete Blood Count | Assess for infection, anemia | Fever, lethargy, suspected infection |
| Electrolytes, BUN, Creatinine | Assess hydration status, acid-base disorders | Dehydration, persistent vomiting, poor feeding |
| Liver Function Tests | Evaluate for hepatobiliary disorders, metabolic diseases | Jaundice, hepatomegaly, suspected metabolic disorder |
| Blood Culture | Identify bacteremia/sepsis | Fever, lethargy, signs of systemic illness |
| Urinalysis/Urine Culture | Rule out urinary tract infection | Fever without source, irritability |
| Ammonia Level | Screen for urea cycle defects | Altered mental status, lethargy, suspected metabolic disorder |
| Blood Gas | Assess acid-base status | Respiratory distress, suspected metabolic disorder |
Imaging Studies
| Investigation | Clinical Utility | When to Consider |
|---|---|---|
| Abdominal X-ray | Evaluate for obstruction, pneumatosis intestinalis | Bilious vomiting, abdominal distention, suspected NEC |
| Abdominal Ultrasound | Diagnose pyloric stenosis, assess for other obstructive lesions | Non-bilious projectile vomiting, palpable olive mass |
| Upper GI Series | Diagnose malrotation, anatomic abnormalities | Bilious vomiting, suspected malrotation or anatomic abnormality |
| Contrast Enema | Evaluate for Hirschsprung's disease, meconium ileus | Delayed passage of meconium, abdominal distention |
| Head Ultrasound/CT/MRI | Evaluate for intracranial pathology | Bulging fontanelle, macrocephaly, altered mental status |
| pH Probe/Impedance Study | Diagnose GERD | Suspected GERD with poor response to conservative management |
Diagnostic Algorithm for Neonatal Vomiting
- Assess character of vomiting
- Bilious vomiting → Urgent evaluation for surgical conditions (malrotation, volvulus)
- Projectile non-bilious vomiting → Consider pyloric stenosis
- Non-forceful, non-bilious vomiting → Consider GER, feeding issues, formula intolerance
- Evaluate for signs of dehydration or shock → Stabilize first if present
- Assess for red flags indicating serious pathology
- Bilious vomiting, abdominal distention, bloody stools → Surgical consultation
- Fever, lethargy, poor feeding → Septic workup
- Bulging fontanelle, altered mental status → Neurological evaluation
- Consider timing in relation to feeding
- Immediately after feeding → Consider overfeeding, improper technique
- 1-2 hours after feeding → Consider pyloric stenosis
- Unrelated to feeding → Consider obstruction, infection, metabolic disorders
- Evaluate weight gain trajectory
- Normal weight gain → Less concerning, consider GER or transient issue
- Poor weight gain → Indicates pathological process requiring investigation
- Select targeted investigations based on history and examination findings
Management Strategies
General Approach to Management
Key principles in managing neonatal vomiting:
- Identify and treat underlying cause: Surgical conditions require urgent intervention
- Assess and maintain hydration: Prevent or correct dehydration and electrolyte abnormalities
- Support nutrition: Ensure adequate caloric intake and appropriate feeding methods
- Parent education: Provide guidance on feeding techniques and position
- Regular monitoring: Follow growth parameters and reassess symptoms
Initial Management Based on Presentation
| Presentation | Initial Steps | Level of Urgency |
|---|---|---|
| Bilious vomiting |
- NPO status - IV fluid resuscitation - NG tube placement - Urgent surgical consultation - Immediate imaging (abdominal x-ray, UGI) |
Emergency - requires immediate attention |
| Projectile vomiting with dehydration |
- IV fluid resuscitation - Electrolyte correction - Abdominal ultrasound - Surgical consultation if pyloric stenosis confirmed |
Urgent - requires prompt evaluation |
| Vomiting with fever/lethargy |
- Septic workup - IV antibiotics - Fluid management - Supportive care |
Urgent - requires prompt evaluation |
| Non-bilious, non-projectile vomiting with normal growth |
- Feeding assessment and modification - Position management - Parental reassurance - Close follow-up |
Non-urgent - outpatient management appropriate |
Management of Specific Conditions
| Condition | Management Approach | Follow-up Recommendations |
|---|---|---|
| Pyloric Stenosis |
- Correction of dehydration and electrolyte abnormalities - Surgical pyloromyotomy - Gradual reintroduction of feeds post-operatively |
- Post-operative follow-up at 1-2 weeks - Monitor for complications - Ensure adequate weight gain |
| Malrotation with Volvulus |
- Emergency surgical exploration - Ladd's procedure - Bowel viability assessment - Post-operative critical care |
- Close monitoring for intestinal function - Long-term follow-up for potential complications - Nutritional support as needed |
| Gastroesophageal Reflux |
- Smaller, more frequent feeds - Upright positioning after feeds (30 minutes) - Thickened feeds (if formula-fed) - Avoidance of overfeeding - Proper burping techniques |
- Follow-up in 2 weeks - Monitor weight gain - Reassess symptoms - Consider medication only if significant symptoms persist |
| Gastroesophageal Reflux Disease |
- Conservative measures as for GER - Consider H2 blockers or proton pump inhibitors - Rule out cow's milk protein allergy - Consider impedance/pH study if diagnosis uncertain |
- Regular follow-up every 2-4 weeks - Medication trial for 2-4 weeks - Consider specialist referral if symptoms persist |
| Cow's Milk Protein Allergy |
- Extensively hydrolyzed formula - Amino acid formula if symptoms persist - Maternal elimination diet if breastfeeding - Monitor for improvement (2-4 weeks) |
- Re-evaluate at 2-4 weeks - Monitor growth parameters - Consider challenge at 6-12 months - Refer to allergist if multiple food sensitivities |
| Sepsis/Infection |
- Appropriate antibiotics based on likely pathogens - Supportive care - Fluid management - Source control if focal infection identified |
- Daily assessment during acute illness - Complete antibiotic course - Follow-up within 1 week of discharge |
| Inborn Errors of Metabolism |
- Specific dietary management - Cofactor supplementation - Prevention of catabolism - Management of acute decompensation - Genetic counseling |
- Frequent specialist follow-up - Emergency management plan - Monitoring of metabolic parameters - Long-term developmental follow-up |
Feeding Interventions
| Intervention | Approach | Evidence and Considerations |
|---|---|---|
| Feed Thickening |
- Rice cereal (1 tbsp per 2 oz formula) - Commercial thickened formulas - Thickening agents (caution in premature infants) |
- Moderate evidence for reducing visible regurgitation - May decrease frequency of vomiting episodes - Limited evidence for improved outcomes - Risk of constipation - Not recommended for breastfed infants |
| Feeding Technique Modification |
- Paced bottle feeding - Proper latch for breastfeeding - Smaller, more frequent feeds - Adequate burping (after 30-60 ml or mid-feed) - Avoiding overfeeding |
- Strong evidence for effectiveness - First-line intervention for most cases - No side effects - Improves feeding coordination - May reduce aerophagia |
| Positioning |
- Left lateral position after feeds - Elevate head of bed (30°) - Upright positioning for 30 minutes after feeds - Avoid car seat placement immediately after feeds |
- Moderate evidence for effectiveness - Safe when properly implemented - No positioning for sleep (flat on back for safe sleep) - May reduce frequency and volume of regurgitation |
| Formula Changes |
- Extensively hydrolyzed formula - Amino acid-based formula - Trial for 2-4 weeks |
- Consider when CMPA suspected - Strong evidence if allergy present - Significant cost implications - Limited evidence for routine use in all vomiting |
Pharmacological Management
Generally reserved for GERD with complications or specific diagnoses:
| Medication | Indications | Evidence and Cautions |
|---|---|---|
| Histamine-2 Receptor Antagonists (Ranitidine, Famotidine) |
- GERD with esophagitis - Failure of conservative measures - Feeding refusal due to pain |
- Moderate evidence for symptom improvement - Risk of increased infections - Concerns about long-term safety - Tachyphylaxis with prolonged use - Limited FDA approval in infants |
| Proton Pump Inhibitors (Omeprazole, Esomeprazole) |
- Severe GERD with complications - Documented esophagitis - H2RA failure |
- Limited evidence in infants - Not recommended for routine management - Concerns about micronutrient absorption - Increased risk of respiratory and GI infections - Not approved for infants under 1 year |
| Prokinetics (Erythromycin, Domperidone) |
- Delayed gastric emptying - Refractory GERD - Post-surgical bowel dysmotility |
- Limited evidence for effectiveness - Significant side effect profile - Domperidone not FDA approved in US - QT prolongation risk - Limited use in clinical practice |
| Antiemetics |
- Generally not recommended in neonates - Special circumstances (post-chemotherapy) |
- Not routinely indicated - Risk of adverse neurological effects - May mask underlying pathology - Limited safety data in neonates |
Parent Education and Support
- Explanation of normal vs. pathological vomiting: Distinguish regurgitation from concerning symptoms
- Feeding education: Proper techniques, recognition of hunger/satiety cues
- Warning signs: When to seek immediate medical attention
- Anticipatory guidance: Expected course and natural history of condition
- Support resources: Connection to lactation consultants, feeding specialists
When to Refer
- Surgical consultation: Bilious vomiting, suspected pyloric stenosis, persistent obstruction
- Gastroenterology: Persistent GERD despite interventions, diagnostic uncertainty, failure to thrive
- Allergy/Immunology: Multiple food intolerances, severe CMPA, complex allergic presentations
- Genetics/Metabolism: Suspected inborn error of metabolism, dysmorphic features
- Feeding team: Complex feeding issues, oral aversion, severe feeding difficulties
Follow-up Recommendations
| Condition | Follow-up Timeline | Monitoring Parameters |
|---|---|---|
| Uncomplicated GER | 2-4 weeks initially, then as needed |
- Weight gain - Symptom frequency and severity - Parental coping - Development milestones |
| GERD with medical therapy | 1-2 weeks after starting therapy, then monthly |
- Response to therapy - Medication side effects - Growth parameters - Plan for weaning medication |
| Post-surgical conditions | 1 week post-discharge, then based on surgical protocol |
- Wound healing - Return of normal feeding - Weight gain - Late complications |
| Metabolic disorders | Weekly to monthly depending on severity |
- Metabolic stability - Growth - Developmental progress - Adherence to dietary restrictions |
