 |
Infants normally spit up small amounts (usually < 5 to 10 mL) during or soon after feedings, often when being burped; rapid feeding and swallowing of air may be a cause, though spitting up occurs even without these factors. It may be a sign of overfeeding. Occasional vomiting may also be normal, but persistent vomiting, especially if associated with poor growth, much more often signals a serious condition. Causes include serious infection (eg, sepsis, meningitis), gastroesophageal reflux, obstructive GI disorders such as pyloric stenosis or bowel obstruction (eg, from duodenal stenosis or volvulus), neurologic conditions (eg, meningitis, tumor or other space-occupying lesion), and metabolic disorders (eg, adrenogenital syndrome, galactosemia). In older children, vomiting often results from acute gastroenteritis or appendicitis.
Evaluation
History:
History focuses on the frequency and estimated amount of vomiting, feeding pattern, stool frequency and consistency, urinary output, and presence of abdominal pain.
Because vomiting can be caused by many disorders, a careful review of systems should be done. The combination of vomiting and diarrhea suggests acute gastroenteritis. Fever suggests infection. Projectile vomiting suggests pyloric stenosis or other obstruction. Yellow or green (bile-stained) emesis suggests obstruction distal to the ampulla of Vater. Vomiting accompanied by extreme crying and absent or currant jelly stools can result from intussusception. Irritability, choking, and respiratory signs such as stridor may be manifestations of gastroesophageal reflux. A history of poor development or neurologic manifestations suggests a CNS disorder.
Physical examination:
Examination focuses on overall appearance, signs of dehydration (eg, dry mucosa, tachycardia, lethargy), growth parameters, signs of developmental progress, and abdominal findings. Findings of poor weight gain or weight loss demand an intense search for a diagnosis. An epigastric mass or “olive” suggests pyloric stenosis. Abdominal distention or masses may represent obstructive lesions or tumors. An infant who is not showing appropriate developmental progress may have a CNS disorder. Abdominal tenderness suggests an inflammatory process.
Testing:
No diagnostic testing is needed for an infant who is growing well and has no signs of disease. Tests should be ordered if history and examination suggest an underlying disorder and may include x-rays, CT scans, and MRI for lesions or tumors obstructing the GI tract; upper GI x-rays and pH probe for reflux; brain imaging for CNS disorders; cultures for infection; and specific blood chemistries for metabolic defects.
Treatment
Spitting up does not require treatment. When too-rapid feeding is a cause, treatment is use of bottles with firmer nipples and smaller holes, combined with more frequent burping.
Nonspecific treatment of vomiting involves ensuring adequate hydration (see Dehydration and Fluid Therapy: Oral Rehydration); those willing to take oral liquids may be given small, frequent amounts of electrolyte-containing fluids. IVs are rarely required. Antiemetics are not given to infants and young children because of concern about adverse effects. Specific treatment of vomiting is directed at the cause; gastroesophageal reflux responds to positioning of the head higher than the feet, thickened feedings, and sometimes acid-blocking and promotility drugs. Pyloric stenosis and other obstructive lesions require surgery.
Last full review/revision November 2005
Content last modified November 2005
| |
