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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