Baby with Vomiting Approach

– History –

• CC: most likely will present as vomiting (might be bilious, or not)
  • Onset: first time? When? Sudden\gradual? Continuous\intermittent? Worse\better?
  • Timing and frequency: day\night? Related to feeding? How frequent?
  • Character: color (green)? Food content? Fecal matter? Blood? Projectile? Did it come out of the nose? Amount? Baby still hungry after vomiting?
  • Aggravating\relieving factors: food?
  • Severity: how’s the baby sleeping? Tolerating food? Activity and energy?

• Associated sx:
  • General: fever, weight loss\failure to thrive, sleep, irritability, lethargic?
  • Upper GI: choking, increased salivation, frothy saliva?
  • Mid GI: vomiting, abdominal distension\masses, jaundice?
  • Lower GI: diarrhea\constipation, color of stool, blood in stool?
  • Resp: difficulty breathing, nasal flaring, turning blue?

• PMHx:
  • Diseases:
    • GI or resp ds (CF)
    • Infections
    • Congenital ds (down syndrome)
    • Congenital anomalies (limbs, spine, anus, cardiac, renal; VACTREL)
  • Surgery, hospitalization, trauma
  • Medications, vaccinations, allergies

• Prenatal:
  • Following up? Any complications? Any abnormal US findings?
• Natal:
  • Delivery: vaginal\C-section? Complications?
  • Full-term\preterm?
  • Birth weight?
  • APGAR score?
• Postnatal:
  • Complications or admissions?
  • First feed?
  • Passed meconium? When?

• FMHx:
  • Similar complaint?
  • Exposed to anyone sick?
  • Same diseases as in PMHx

– Physical Exam –

1. Vital signs
2. General inspection of the baby: lethargic, difficulty breathing
3. Signs of dehydrations
4. Abdominal exam:
   • Inspection: distension, scars
   • Palpation\percussion: tenderness, masses, organomegaly
5. PR exam

– Investigations –

• X-rays:
  • Coiled NGT -> esophageal atresia\TEF
  • Double-bubble -> duodenal atresia
  • Dilated bowel loops + air-fluid levels -> obstruction
• US:
  • Target\donut sign -> intussusception
  • Pylorus > 3mm thick + > 19mm long -> pyloric stenosis
• Contrast studies:
  • Mushroom sign, streak sign -> pyloric stenosis
  • Duodenojejunal junction right to the spine, cock-screw sign, bird’s beak sign -> malrotation\volvulus
  • Micro colon -> intestinal atresia
  • Convex intracolic mass + “coiled spring” pattern -> intussusception
  • Narrowed rectum + proximal bowel dilatation, transition zone, retained colonic barium > 24 hrs -> Hirschsprung’s disease

– Management –

(in general, but definitive treatment will depend on the cause)

• NGT
• NPO
• IVF and electrolytes (D5 1\4 NS +KCL)
• Abx
• Surgery:
  • Pyloric stenosis -> Ramstedt pyloromyotomy
  • Malrotation -> Ladd’s procedure: reduction w\counter clockwise rotation, ligation of Ladd’s bands, and appendectomy
  • Intussusception -> air\barium enema hydrostatic reduction -> if unsuccessful -> open manual reduction
  • HD -> confirm with rectal biopsy -> diverting colostomy or definitive repair
  • Duodenal atresia -> duodenoduodenostomy or duodenojejunostomy

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