vomiting in peads

1. MANAGEMENT OF
NEWBORN VOMITING

2. DEFINITION
 Vomiting describes forceful expulsion (engaging
abdominal and respiratory muscles) of the reflux
out of the mouth.
 Recurrent or persistent vomiting warrants
further investigations
 Persistent vomiting can be complicated by:
- Dehydration
- Hypokalemic hypochloremic metabolic alkalosis
- Malnutrition
- Constipation

3.  Vigorous vomiting can result in:
- Esophageal mucosal tear (Mallory- Weis Tear)
- Esophageal rupture (Boerhaave syndrome))
 Vomiting is a common, but nonspecific symptom
 May be acute, chronic or recurrent
 Acute: may be due to viral infections, e.g, Rotavirus
 Chronic:
 Cyclic – ≥ 5 episodes occurring at high intensity (≥4 emesis/hr) and
infrequently (≤2 episodes/week) with normalcy period in between
 Chronic – frequent episodes (≥2/week) at low intensity (1-2 emesis/hr)

4.  In the first day of life, vomiting suggests upper GI tract obstruction or increased
ICP
 A common manifestation of:
 Overfeeding
 Incorrect/ inexperienced technique of feeding
 Normal reflux
 It could rarely be due to:
- Pyloric stenosis
- Milk allergy
- Duodenal ulcer
- Stress ulcer
- Inborn error of metabolism
- Adrenal insufficiency

5. VOMITING SCALE
• Mild: 1 - 2 episodes/day
• Moderate: 3 - 7 episodes/day
• Severe: Vomits everything, nearly
everything or 8 or more episodes/day
• The main risk of vomiting is dehydration.
• The younger the child, the greater the risk
for dehydration.

6. PATHOPHYSIOLOGY
 Violent descent of the diaphragm and constriction
of the abdominal muscles with relaxation of the
gastric cardia actively force gastric contents back
up the esophagus.
 This process is coordinated in the medullary
vomiting center, which is influenced directly by
afferent innervation and indirectly by the
chemoreceptor trigger zone and higher central
nervous system (CNS) centers

8. COMMON
PRESENTATIONS IN
THE HOSPITAL

9. 1. BOWEL OBSTRUCTION
It may be due to the following:
 Hypertrophic pyloric stenosis – presenting with projectile
non-bilious vomiting between 3 - 6 weeks of age
 Bowel atresia
 Malrotation of volvulus
 Meconium plug syndrome
 Hirschprung disease
 Imperforate anus

10.  Level of obstruction determines clinical
presentation:
 Proximal obstruction- early vomiting with minimal
distention
 Distal obstruction – late vomiting with distention
 Electrolyte imbalance and dehydration are common

11. TREATMENT
1. Prompt resuscitation
2. Urgent review by a surgeon
3. Do not give anything orally
4. Insert NGT (esp in vomiting and abdominal distention)
5. IV fluids to use are: half strength Darrow’s solution or normal saline +
5% dextrose
 Shock present: correct with 20ml/kg bolus of normal saline or Ringers lactate
as IV bolus
 No shock but dehydrated: give 10-20ml/kg half strength Darrow’s sol. or
N/Saline +5 % dextrose over 20mins
 Then give maintenance fluid volume + same volume that comes out of NGT
+ any vomit

12. 6. Administer antibiotics:
- Ampicillin (50mg/kg IV q6hrly) plus
- Gentamicin (5mg/kg IV OD) plus
- Metronidazole (15mg/kg as a single loading
dose, followed by 7.5mg/kg q12hrly, starting
24 hrs after loading dose)

13. 2. PYLORIC STENOSIS
 Most common surgical disorder of GI tract in infants
 Pylorus is thickened & elongated with narrowed lumen
due to hypertrophy of circular fibers of pylorus
 4 – 6x more common in boys

14. CLINICAL PRESENTATION
 Non-bilious vomiting gradually increasing in frequency &
severity becoming projectile in nature
 Most present beyond 3 weeks of birth but 20% are
symptomatic at birth
 The following result from recurrent and persistent
vomiting:
- Dehydration
- Malnutrition
- Hypochloremic alkalosis
 Constipation

15. On examination after feeding:
 A palpable olive shaped mass in the mid-epigastric region (75-80%
of cases)
 A vigorous peristaltic wave can be seen move from the left
hypochondrium to umbilicus

16. INVESTIGATION:
 Abdominal USS
- Diagnostic test of choice
- Shows muscle thickness >4mm and pylorus length >16mm
• When in doubt?
 Barium study of upper GI tract
 Upper GI endoscopy

18. TREATMENT
 Rapidly correct dehydration and electrolyte abnormalities
 Refer to surgery:
- Surgical (Ramstedt pyloromyotomy) correction is the tx of
choice

19. 3. MALROTATION

20.  Rotational abnormalities developing during maturation of gut cause
recurrent obstruction, occurring as either the Ladd’s band or volvulus of gut
over the narrow mesenteric pedicle.
 80 -90% occurs in first year of life
 Characterized by abdominal pain with bilious vomiting.
- Abdominal distention may not be a prominent finding

21.  Findings can be confirmed on barium meal follow through showing:
 duodenojejunal junction on right side of spine (instead of left of midline of
pylorus),
 abnormally positioned cecum,
 and small bowel loops on right side of abdomen
If volvulus is present?
> Contrast appears as cockscrew appearance at level of second portion of
duodenum

22. THE CORKSCREW SIGN
DESCRIBES THE SPIRAL
APPEARANCE OF THE DISTAL
DUODENUM AND PROXIMAL
JEJUNUM SEEN IN MIDGUT
VOLVULUS

23. TREATMENT
1. Resuscitate
2. Refer for surgical laporotomy.
Surgical correction is done through the Ladd’s procedure, which
involves the following:
 Derotation of volvulus
 Division of Ladd’s band
 Widening of base of mesentery
 Placement of bowel in state of non-rotation
 Appendectomy

24. 4. DUODENAL ATRESIA

25.  Duodenal atresia is the congenital absence of a portion of the first part of the
small bowel.
 Symptoms typically present shortly after birth.
 Present with either bilious or non-bilious vomiting
 It typically does not present with abdominal distension.
 A classical x-ray finding associated with duodenal atresia is the ‘double
bubble sign.’

26. CLINICAL FEATURES
 Hallmark – bilious vomiting without abdominal distention
on the first day of life
 Peristaltic waves may be visible early in the disease
process
 Jaundice seen in 1/3 of infants

27. DIAGNOSIS
 “double bubble” appearance seen on plain abdominal xray
 Contrast studies are done to rule out malrotation and volvulus
 Diagnosis can be made prenatally by fetal USS which reveals a
sonographic double bubble

28. TREATMENT
1. NGT and OGT decompression
2. IV fluid replacement
3. Evaluate for any associated anomalies
 Echocardiography
 Renal USS
 CXR
 X-Ray of spine
• Definitive treatment is usually delayed until life threatening anomalies are
assessed and managed.

29. 4. Refer for surgery – “Duodenoduodenostomy
- Post op:
 Gastrostomy tube is placed to drain stomach and protect airway
 IV nutritional support on transanastomotic jejunal tube is needed until an infant
starts to feed orally

30. 5. COW MILK
PROTEIN ALLERGY

31.  Most common food allergy in infants who are top fed
 Occasionally occurs in breastfed infants due to passage of cow milk antigen
in breast milk
 Affects 2.5% of children with highest prevalence in 1st year of life
 Family hx of atopy is common
 50% outgrow the allergy by 1yr old and 95% by 5yrs old

32. TWO TYPES OF REACTION
TO COW’S MILK
Immediate – IgE Mediated
 Occurs within minutes of milk
intake
 Characterized by the following:
 Vomiting
 pallor
 Shock like state
 Urticaria
 Angioedema
Delayed – T Cell Mediated
 Has an indolent course
 Presents with GI symptoms

33. SYMPTOMS
 Diarrhea with blood and mucus
 Reflux symptoms (uncommon)
 Hematemesis (uncommon)
 Respiratory symptoms in 20-30% of cases
- Allergic rhinitis
- Asthma
 Atopic manifestations in 50-60% of cases
- Eczema
- Angioedema
 Iron deficiency
 Hypoproteinemia
 Eosinophilia

34. DIAGNOSIS
 Sigmoidoscopy
- Apthous ulcers
- Nodular lymphoid hyperplasia
 Rectal biopsy
- Predominant eosinophils
• Elimination and challenge test
- Gold standard diagnostic test for any food allergy
- Symptoms subside after removal of milk and recur within 48hrs of re-
exposure

35. TREATMENT
1. Remove all animal milk/ milk products from diet
2. Alternatives to cow’s milk
 Soy milk
 Extensively hydrolyzed formula
 Elemental amino acid formula (for those who cannot
tolerate extensively hydrolyzed formula)
3. Counsel and educate parents on diet and calcium
supplements

36.  Symptomatic relief for gastroenteritis can be
achieved through the use of anti-emetic agents such
as Ondansetron in infants and children 6 months of
age and older.
 Assess and treat for dehydration and electrolyte
disturbances.
 Mild dehydration can be treated with
encouragement of oral fluids
 Moderate to severe dehydration should be treated
with IV fluids.

37. Outcomes of full-term infants with bilious vomiting: observational study of a
retrieved cohort
Syed Mohinuddin 1, Pankaj Sakhuja 1, Benjie Bermundo 1, Nandiran Ratnavel 1,
Stephen Kempley 2, Harry C Ward 3, Ajay Sinha 2
 Abstract
 Bilious vomiting in a neonate may be a sign of intestinal obstruction often resulting in transfer
requests to surgical centres. The aim of this study was to assess the use of clinical findings at
referral in predicting outcomes and to determine how often such patients have a time-critical
surgical condition (eg, volvulus, where a delay in treatment is likely to compromise gut viability).
 Methods: 4-year data and outcomes of all term newborns aged ≤7 days with bilious vomiting
transferred by a regional transfer service were analysed. Specificity, sensitivity, likelihood ratios,
correlations, prior and posterior probability of clinical findings in predicting newborns with
surgical diagnosis were calculated.
 Results: Of 163 neonates with bilious vomiting, 75 (46%) had a surgical diagnosis and 23
(14.1%) had a time-critical surgical condition. The diagnosis of a surgical condition in neonates
with bilious vomiting was significantly associated with abdominal distension (χ(2)=5.17,
p=0.023), abdominal tenderness (χ(2)=5.90, p=0.015) and abnormal abdominal X-ray findings
(χ(2)=5.68, p=0.017) but not with palpation findings of a soft as compared with a tense abdomen
(χ(2)=3.21, p=0.073). Abnormal abdominal X-ray, abdominal distension and tenderness had
97%, 74% and 62% sensitivity, respectively, with regard to association with an underlying
surgical diagnosis. Normal abdominal X-ray reduced the posterior probability of surgical
diagnosis from 50% to 16%. Overall, clinical findings at referral did not differentiate between
infants with or without surgical or time-critical condition.
 Conclusions: We recommend that term neonates with bilious vomiting referred for transfer are
prioritised as time critical.

38. REFERENCE
 Nelson’s Textbook of Pediatrics, 19th Edition
 Ghai’s Essential Pediatrics, 9th Edition
 WHO Pocket Book Of Hospital Care for
Children, 2nd Edition
 Drug Doses, Frank Shann, 17th Edition

39. THANK YOU!