Neonatal GIT problems including vomitting, colic, constipation & diarrhea

2. Prof. Mohamed El Kalioby
Prof. of Pediatrics & Neonatology
Suez Canal University

3. COMMON
NEONATAL
GASRTINTESTINAL
PROBLEMS

4. ITEMSITEMS
• Vomiting
• Constipation
• Diarrhea
• Abdominal Colic
• NEC
• Congenital Anomalies
Cleft lip / palate
TEF
CHPS
Atresia
kalioby@gmail.com

5. NEONATAL VOMITINGNEONATAL VOMITING

6. NEONATAL VOMITINGNEONATAL VOMITING
Vomiting or, more often, regurgitation is a
relatively frequent symptom during the
neonatal period.
kalioby@gmail.com

7. NEONATAL VOMITINGNEONATAL VOMITING
In the first few hours after birth, infants may
vomit mucus, occasionally blood streaked.
This vomiting rarely persists after the first few
feedings.
It may be due to irritation of the gastric mucosa
by material swallowed during delivery.
If the vomiting is protracted, gastric lavage with
physiologic saline solution may relieve it
kalioby@gmail.com

8. NEONATAL VOMITINGNEONATAL VOMITING
Many babies vomit at some time.
In most cases this is unimportant and unlikely to
be clinically significant.
Small, frequent vomits are referred to as
‘posits’.
kalioby@gmail.com

9. NEONATAL VOMITINGNEONATAL VOMITING
• Spitting up (About 40%)
Not forceful.
Small volumes (< 5-10 mL) during or shortly
after feeding, often when being burped.
Typically caused by rapid/overfeeding and air
swallowing.
Gentle patting on the infant's back should be all
that is required during a spitting up episode.
kalioby@gmail.com

10. NEONATAL VOMITINGNEONATAL VOMITING
• Infant regurgitation
Vomiting ≥ 2 times/day for at least 3 weeks in the
first 1-12 months of life in an otherwise healthy
infant.
Often transient in nature and due to immature
gastrointestinal tract (GER).
kalioby@gmail.com

11. NEONATAL VOMITINGNEONATAL VOMITING
Management of Infant regurgitation
Reassurance is the only treatment needed.
Conservative measures:
Upright positioning after feeding,
Elevating the head of the bed
?Domperidone:
Dose: (0.25–0.5 mg/kg/dose (3-4
times/day. Maximum 2.4 mg/kg/d or 80 mg/ d).
kalioby@gmail.com

12. NEONATAL VOMITINGNEONATAL VOMITING
WarningWarning
• Vomit contains blood (red or black)
(Colour depends upon how long
blood has been in the stomach)
• Vomit is bile (green, not yellow)
• Vomiting is projectile
• Baby is unwell
• Baby is failing to thrive
• Baby has GER (could be aspirating)
• Associated diarrhea
• Abdomen is distended
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13. NEONATAL VOMITINGNEONATAL VOMITING
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Vomiting occurs shortly after birth and
persistent:
Intestinal obstruction,
Metabolic disorders, and
?Increased intracranial pressure.
A history of maternal hydramnios suggests upper
gastrointestinal (esophageal, duodenal, ileal)
atresia.
Bile-stained emesis suggests intestinal obstruction
beyond the duodenum.

14. NEONATAL VOMITINGNEONATAL VOMITING
Abdominal roentgenograms:
air-fluid levels,
distended bowel loops,
characteristic patterns of
obstruction (double bubble:
duodenal atresia), and
pneumoperitoneum
(intestinal perforation).
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air-fluid levels

15. NEONATAL VOMITINGNEONATAL VOMITING
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Double bobble
shadow
Distended
bowel loops

16. NEONATAL VOMITINGNEONATAL VOMITING
Pneumoperitoneum (intestinal perforation).
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17. NEONATAL VOMITINGNEONATAL VOMITING
• A barium swallow roentgenogram with small
bowel follow-through is indicated in the
presence of bilious emesis.
• Ultrasonography (CHPS)
kalioby@gmail.com

18. NEONATAL VOMITINGNEONATAL VOMITING
A 7 day old baby, born at term, presented to the
neonatal unit with a history of vomiting with each feed
and 20% weight loss (birth weight 3270 g).
Vomiting started soon after birth and it was described
by the parents as being projectile; it occurred during
or after feeds and was non-bilious.
The baby was dehydrated on admission (dry skin and
mucous membranes), but was otherwise well. Clinical
examination was otherwise unremarkable including no
visible peristalsis and no masses palpable. The parents
interacted appropriately with the baby and there were
no causes for concern among the nursing or medical
staff. Initial capillary blood gas analysis showed a
metabolic alkalosis.
kalioby@gmail.com

19. NEONATAL VOMITINGNEONATAL VOMITING
What is the main diagnosis to exclude?
Hypertrophic pyloric stenosis:
ABG classically shows hypochloraemic
hypokalaemic metabolic alkalosis.
kalioby@gmail.com

20. NEONATAL VOMITINGNEONATAL VOMITING
What investigations would you perform to
diagnose this?
Ultrasound scanning:
non-invasive, does not use radiation, and can
differentiate between several diagnoses
(hypertrophic pyloric stenosis, gastro-
oesophageal reflux disease, and duodenal
anomalies).
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21. NEONATAL VOMITINGNEONATAL VOMITING
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22. NEONATALNEONATAL
CONSTIPATIONCONSTIPATION

23. Normal bowel habits
First bowel movement: within 36 h of birth (later in preterm).
90 % of normal newborns pass meconium within 24 h.
During the first week of life:
approximately four soft or liquid bowel movements per day
(generally more in breast- compared with bottle-fed infants).
During the first three months of life:
breastfed infants have about three soft bowel movements
per day. Some breastfed infants have a bowel movement
after each feeding, whereas others have only one bowel
movement per week. kalioby@gmail.com

24. DEFINITION
Definition of constipation is relative and
depends on:
•stool consistency,
•stool frequency, and
•difficulty in passing the stool.
“a delay or difficulty in defecation, present for
two or more weeks, sufficient to cause
significant distress to the patient”
kalioby@gmail.com

25. A normal child may have a soft stool only
every 2 or 3 days without difficulty; this is
not constipation.
However, a hard stool passed with
difficulty every 3rd day should be treated
as constipation.
kalioby@gmail.com

26. Constipation is common and varies considerably
in its severity
The clinician has an important role in identifying
the small fraction of children with organic
causes of constipation.
kalioby@gmail.com

27. ETIOLOGY
Constipation may arise from:
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I. defects in filling
the rectum
II. defects in
emptying the rectum
or
colonic stasis
excessive drying of stool
failure to initiate reflexes
from the rectum
Weak defecation reflex
initiated by pressure
receptors in the rectal
muscle

28. ETIOLOGY
I. Defective rectal filling (colonic peristalsis is
ineffective):
hypothyroidism or
opiate use and when
bowel obstruction (by a structural anomaly or
by Hirschsprung disease).
kalioby@gmail.com

29. ETIOLOGY
II. Defective emptying the rectum:
lesions involving rectal muscles,
lesions of sacral spinal cord afferent and
efferent fibers, or
lesions affecting muscles of the abdomen and
pelvic floor.
Disorders of anal sphincter relaxation may
also contribute to fecal retention
kalioby@gmail.com

30. ETIOLOGY
Most children with constipation do not have an
underlying medical problem.
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WarningWarning
 Don’t pass meconium after 36 h.
 Dietetic Causes: Underfeeding /
Cow's milk intolerance.
 Associating vomiting.

31. kalioby@gmail.com

32. MANAGEMENT
Breast Feeding
Infants who breastfeed are rarely constipated
Glycerin suppositories or rectal stimulation with
a lubricated rectal thermometer can be used
occasionally if there is very hard stool in the
rectum.
These interventions should not be used
frequently because tolerance may develop; in
addition, glycerin may irritate the anus or rectal
mucosa.
kalioby@gmail.com

33. NEONATAL DIARRHEANEONATAL DIARRHEA

34. DEFINITION
WHO: passage of three or more loose or watery
stools per day.
Nevertheless, absolute limits of normalcy are
difficult to define; any deviation from the child's
usual pattern should arouse some concern
kalioby@gmail.com

35. kalioby@gmail.com
 Ill appearance,
 Dehydration,
 Passage of blood or
mucus,
regardless of the actual
number of stools or
their water content.

36. NEONATAL COLICNEONATAL COLIC

37. Colic is commonly described as a behavioral
syndrome in neonates and infants that is
characterized by excessive, paroxysmal crying.
Colic is most likely to occur in the evenings, and
it occurs without any identifiable cause.
Possible other causes of excessive crying (eg,
having hair in the eye, strangulated hernia,
otitis, sepsis); colic remains a diagnosis of
exclusion.
kalioby@gmail.com

38. ETIOLOGY
Gastrointestinal causes (eg, GERD, over- or
underfeeding, milk protein allergy, early
introduction of solids)
Inexperienced parents (controversial) or
incomplete or no burping after feeding
Exposure to cigarette smoke and its
metabolites
Food allergy
Low birth weight
Characteristic intestinal microflorakalioby@gmail.com

39. ETIOLOGY
Weight loss,
Difficult or painful
swallowing,
Significant vomiting,
Chronic severe diarrhea,
Blood in stool
Unexplained fever,
Urinary symptoms
kalioby@gmail.com

40. MANAGEMENT
Rule out common causes of crying
Recommend that the parents not exhaust
themselves, and encourage them to consider
leaving their baby with other caretakers for
short respites
Consistent follow-up and a sympathetic
physician are the cornerstones of management
kalioby@gmail.com

41. MANAGEMENT 2
Drug treatment generally has no place in
management of colic unless GERD appears
likely.
?Anticholinergic agents: effective but has rare
serious adverse effects and cannot be
recommended.
kalioby@gmail.com

42. MANAGEMENT 3
Various benign but unproven treatment modalities are
available, including the following:
Maternal low-allergen diet (ie, low in dairy, soy, egg,
peanut, wheat, shell fish) may offer relief from
excessive crying in some infants.
Lactobacillus reuteri (Probiotics)
Simethicone
Oral hypertonic glucose
Nutritional supplements and other complementary
medicines
kalioby@gmail.com

43. Necrotizing Enterocolitis
(NEC)

44. Necrotizing Enterocolitis 1
Risk Factors:
•Premature infants
•Feeding of concentrated formulas
•GIT infections
•Polycythemia, CHD
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45. Necrotizing Enterocolitis 2
C/P
•Nonspecific
•History of formula feeding
•Vomiting, diarrhea, feeding intolerance and
high gastric residuals following feedings.
•More specific: abdominal distention and frank
or occult blood in the stools
kalioby@gmail.com

46. Necrotizing Enterocolitis 3
C/P (Cont)
GI signs: any or all of the following:
•Increased abdominal girth
•Visible intestinal loops
•Obvious abdominal distention and decreased bowel sounds
•Change in stool pattern
•Hematochezia
•Palpable abdominal mass
•Erythema of the abdominal wall
Systemic signs: any of the following:
•Respiratory failure
•Decreased peripheral perfusion
•Circulatory collapsekalioby@gmail.com

47. Necrotizing Enterocolitis 4
Management:
•NPO
•Nasogastric tube to decompress gas
•IV fluid
•Antibiotics
•Extra oxygen
•Abdominal x-rays to monitor progress
•Measure abdominal girth every four hours
kalioby@gmail.com

48. CONGENITAL ANOMALIESCONGENITAL ANOMALIES

49. Cleft Lip and PalateCleft Lip and Palate

50. kalioby@gmail.com

51. Incomplete
Cleft Palate
Unilateral
Complete cleft
lip & Palate
Bilateral
Complete
cleft lip &
Palate
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52. Treatment
Plasticsurgery.org
Isolated Cleft lip
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53. Treatment 2
Goals of surgery:
Close the defect
Cosmetic: Symmetrical appearance of face
Timing of surgery:
2 to 3 months
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54. Z-plasty is the most commonly used technique
Treatment 3
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55. Treatment 4
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56. Treatment 5
Pre Surgery Care
Construction of a plastic obturator to assist in
feedings.
Use of soft artificial nipples with large
openings, a squeezable bottle, and proper
instruction
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57. Treatment 6
Post Surgery Care
Airway management
Pain control
Position in infant seat – upright position
Elbow restraints
Wound care
Minimizing crying
Feeding techniques
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58. Treatment 7
Cleft Palate Repair
Goals of surgery:
Union of the cleft segments,
Intelligible and pleasant speech,
Reduction of nasal regurgitation, and
Avoidance of injury to the growing maxilla.
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59. Treatment 8
Timing of Surgery:
Variable according to:
size, shape, and degree of deformity.
adequacy of the existing palatal segments,
morphology of the surrounding areas (e.g., width of the
oropharynx),
neuromuscular function of soft palate and pharyngeal
walls.
Ideally: before 1 yr of age to enhance normal speech
development.
Babies should be weaned from bottle or breast.
When surgical correction is delayed beyond 3rd yr, thekalioby@gmail.com

60. Treatment 9 Palate Repair
Pre-surgery feeding
Alternate nipple design
Breast feeding consultant
ESSR
Enlarge / stimulate / swallow / rest
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61. Treatment 12
Post Surgery Care
Position on side
NPO for 48 hours
Suction with bulb syringe only
Avoid injury to palate with syringes, straws,
cups etc.
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62. EA & TEF
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Esophagus ends
in a blind pouch.
Failure of the esophagus to
recanalize between 4th
& 6th
W of development.

63. ES & TEF 2
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Type A – Esophageal atresia without tracheoesophageal fistula (8-10 %)
Type B – Esophageal atresia with proximal tracheoesophageal fistula (<1
percent)
Type C – Esophageal atresia with distal tracheoesophageal fistula (85-87 %)
Type D – Esophageal atresia with tracheoesophageal fistula to both the proximal
and distal esophageal segments (<1 percent)

64. ES & TEF 3
Symptoms and Signs:
 Excessive salivation / frothy mucus
 Respiratory Distress
 Inability to pass NG tube (Except ?)
 Choking and coughing on feeding (The
rationale for giving sterile water for the first
feed).
Diagnosis:
–Clinical
–CXR
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65. ES & TEF 4
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66. X-ray Findings
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68. kalioby@gmail.com

70. kalioby@gmail.com