Infant vomiting

Question 1

In infants, what is normal vomiting?

Answer 1

Effortless regurgitation of milk during feeds

Vomiting between feeds

Question 2

What are the common causes of vomiting in infants?

Answer 2

Reflux
Overfeeding
Pyloric stenosis
UTI

Question 3

What are the more unusual causes of vomiting in infants?

Answer 3

Pharyngeal pouch
Metabolic conditions
Just about any other illness

Question 4

How does pyloric stenosis present in infancy?

Answer 4

Projectile vomiting following feeding

Question 5

What should you do if an infant has billious (green) vomit? What could be the cause?

Answer 5

Get urgent help

consider duodenal obstruction or volvulus

Question 6

What are the typical symptoms of reflux disease in infants?

Answer 6

Frequent regurgitation after meals
Choking or wheezing
Wet burbs or hiccups
Spitting up that is ongoing >1y/o
Irritability or crying after eating
Refusing to eat or only eating small amounts
Failure to gain weight

Question 7

What are the red flag symptoms associated with a vomiting infant?

Answer 7

Frequent, forceful projectile vomiting.
Bile-stained vomit
Haematemesis
Onset of regurg and/or vomiting after 6 months or going on >1y/o
Blood in stool
Abdo distension, tenderness, palpable mass
Chronic diarrhoea

Question 8

What are the red flag symptoms systemically in a vomiting infant?

Answer 8

Appearing unwell, fever
Dysuria
Bulging fontanelle
Rapidly increasing head circumference
Altered responsiveness
Infants with high risk of atopy

Question 9

What diagnosis should you suspect in a vomiting child with chronic diarrhoea?

Answer 9

Cow’s milk protein allergy

Question 10

What diagnosis should be suspected in a vomiting infant with a bulging fontanelle and/or altered responsiveness?

Answer 10

Raised ICP

Meningitis

Question 11

What is the initial management of a child with reflux who is breastfed after exclusion of red flag symptoms?

Answer 11

Breastfeeding assessment
Alginate therapy (gaviscon) for 1-2 weeks

Question 12

What is the initial management of a child with reflux who is bottle fed, after exclusion of red flag symptoms?

Answer 12

Review feeding history and lessen if needed
Trial of smaller more frequent feeds
Thickened feed trial
If above unsuccessful trial of alginates for 1-2 weeks

Question 13

What is the next stage in management of an infant with reflux after feed alteration and alginate therapy?

Answer 13

PPIs and H2RAs
Tube feeding if failure to thrive
Surgical biopsy if all else fails

Question 14

When does pyloric stenosis typically present in infants?

Answer 14

3-8weeks

Question 15

Are males or females more likely to get pyloric stenosis?

Answer 15

Males

Question 16

How is pyloric stenosis differentiated from other causes?

Answer 16

Vomiting contains bile ( if none then obstruction too high)
Diarrhoea (If none, then constipation likely)
Pt is alert, anxious and always hungry
Vomit is in large quantities and within minutea of a feed

Question 17

What are the signs of pyloric stenosis on examination?

Answer 17

L to R LUQ peristalsis during a feed

Olive-sized pyloric mass at teh lateral border of the R rectus in RUQ during a feed

Question 18

What investigations are needed in pyloric stenosis?

Answer 18

Electrolytes - may be severe water and NaCl deficiency

USS if high clinical suspicion but examination normal

Question 19

How is pyloric stenosis managed?

Answer 19

NG tube passed before surgery

Surgery to fix - pyloromyotomy