What is the management of a 13-day-old infant with vomiting?

Management of Vomiting in a 13-Day-Old Infant

In a 13-day-old infant with vomiting, initial management should focus on assessing for serious underlying causes, providing small frequent oral rehydration, and maintaining adequate nutrition while monitoring for red flag symptoms requiring urgent evaluation.

Initial Assessment

• Determine if vomiting is bilious or non-bilious, as bilious emesis suggests obstruction distal to the ampulla of Vater and requires urgent evaluation 1
• Assess for forceful (projectile) vomiting which may indicate obstruction versus regurgitation which is more common and benign 1
• Evaluate weight gain and other symptoms, as infants with normal weight gain and no other symptoms are less likely to have obstruction 1
• Check for red flag signs: bilious/bloody vomiting, altered mental status, toxic appearance, severe dehydration, inconsolable crying, or excessive irritability 2

Differential Diagnosis

• Gastroesophageal reflux (GER) - most common cause in first weeks of life, often related to overfeeding 1, 3
• Congenital GI tract abnormalities - consider in neonates with persistent vomiting 1
  • Malrotation with or without volvulus
  • Atresia of antropyloric region
  • Annular pancreas
  • Atresia/stenosis of small bowel or colon
• Formula intolerance or lactose intolerance 1
• Gastroenteritis 2, 4
• Other causes: sepsis, meningitis, metabolic disorders, increased intracranial pressure 1

Management Approach

Hydration Management

• For mild vomiting without dehydration:

  • Administer small, frequent volumes of fluid (5 mL every minute) 1
  • Use a spoon or syringe with close supervision to ensure gradual progression 1
  • Oral rehydration solution (ORS) should be used to replace fluid losses 1

• For moderate dehydration:

  • Oral rehydration therapy remains first-line treatment 4
  • Consider ondansetron (0.2 mg/kg orally; maximum 4 mg) if vomiting persists and prevents adequate oral intake 2, 5

• For severe dehydration or intractable vomiting:

  • Hospitalization and intravenous fluids are recommended 4

Nutritional Management

• Breastfed infants should continue nursing on demand 1
• For formula-fed infants:
  • Continue with full-strength formula if tolerated 1
  • If formula intolerance is suspected, consider lactose-free or lactose-reduced formulas 1
  • True lactose intolerance will present with worsening diarrhea when lactose-containing formula is introduced 1

Home Management Instructions

• Educate parents on:
  • Offering small, frequent feeds 1
  • Recognizing signs of dehydration 1
  • When to seek medical attention: irritability, lethargy, decreased urine output, intractable vomiting, or persistent diarrhea 1

When to Refer for Emergency Evaluation

• Bilious vomiting (requires immediate evaluation for malrotation with volvulus) 1
• Projectile vomiting (concerning for pyloric stenosis) 1
• Signs of dehydration not responding to oral rehydration 1
• Lethargy, altered mental status, or toxic appearance 2
• Bloody vomiting 2
• Abdominal distension or tenderness 1

Imaging Considerations

• Imaging is not routinely needed for simple regurgitation or gastroesophageal reflux 1
• Consider imaging when there is:
  • Bilious vomiting
  • Forceful/projectile vomiting
  • Signs of obstruction
  • Failure to respond to conservative management 1

Common Pitfalls and Caveats

• Don't dismiss persistent vomiting in a neonate as simple reflux without thorough evaluation, as it could indicate serious underlying conditions 1, 3
• Avoid routine use of antiemetics in young infants except in specific circumstances under medical supervision 2, 5
• Remember that gastroesophageal reflux is normal in infants and usually resolves with time without specific treatment 1, 3
• Don't delay evaluation of bilious vomiting, as it could indicate life-threatening conditions like malrotation with volvulus 1