3: The infant with vomiting
Red flags: What to look for in a vomiting infant
- Exclude infection
- Always consider raised intracranial pressure: bulging fontanelle, climbing head circumference centiles
- Be alert to factitious or induced illness
Causes
Neonate
- Overfeeding: usual intake is 150–200 mL/kg/day
- Gastro-oesophageal reflux ± cow’s milk intolerance/allergy
- Bowel obstruction: duodenal web, small bowel atresia, volvulus, malrotation, Hirschsprung’s disease, imperforate anus
- Infection: gastroenteritis, septicaemia, urinary tract infection, pneumonia, meningitis
- Neonatal abstinence syndrome: opiate or amphetamine withdrawal
- Intracranial bleed or injury: bulging fontanelle
- Inborn error of metabolism, e.g. urea cycle disorder, fructosaemia
- Congenital adrenal hyperplasia: abnormal serum electrolytes
- H-type tracheo-oesophageal fistula: cough, recurrent aspiration
- Upper airway or ENT anomaly: apnoea, cough, choking
Older infant
- Overfeeding: usual intake is 120–150 mL/kg/day
- Gastro-oesophageal reflux
- Pyloric stenosis: blood gas for alkalosis, ultrasound scan, refer to surgeon for test feed
- Cow’s milk protein intolerance/allergy: trial of hypoallergenic feed, or maternal milk/soya restriction
- Infection: gastroenteritis, urinary tract, otitis media, pneumonia, meningitis, septicaemia
- Intracranial mass, bleed or head injury: consider CT scan
- Bowel obstruction: abdominal radiograph, refer to surgeon
- Testicular torsion: urgent referral to surgeon
- Intussusception: ultrasound scan, refer to surgeon, air enema reduction
- Ketoacidosis: blood sugar, blood gas for acidosis
- Appendicitis: fever and abdominal pain, ultrasound scan, refer to surgeon
- Cystinosis: hypophosphataemia, renal tubular leak
Screening investigations (see Algorithm 3.1)
- Blood pressure
- Urine dipstix: ketones, sugar
- Blood sugar
- Septic screen if febrile or unwell
- Blood gases ± metabolic disease screen: blood ammonia, serum amino acids, urine amino and organic acids
- Serum biochemistry: U&E, LFT, bone profile
- Abdominal radiograph if obstruction suspected
- Barium swallow and follow through to the duodenal–jejunal flexure to exclude malrotation
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