– 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
- Diseases:
- 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 –
- Vital signs
- General inspection of the baby: lethargic, difficulty breathing
- Signs of dehydrations
- Abdominal exam:
- Inspection: distension, scars
- Palpation\percussion: tenderness, masses, organomegaly
- 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