What is the treatment for a newborn baby with vomiting and nausea?

Treatment of Vomiting in Newborns

The treatment for a newborn with vomiting and nausea should begin with determining if the vomiting is bilious or non-bilious, as bilious emesis requires urgent evaluation for potential obstruction distal to the ampulla of Vater. 1

Initial Assessment

• Determine if vomiting is bilious or non-bilious, as bilious vomiting suggests intestinal obstruction requiring immediate evaluation 2, 1
• Assess if vomiting is forceful (projectile), which may indicate pyloric stenosis, versus regurgitation, which is more common and benign 1, 3
• Evaluate for red flags: bilious/bloody vomiting, altered mental status, signs of dehydration, abdominal distension, or failure to pass meconium 4, 5
• Consider timing of onset - vomiting within the first 2 days of life raises concern for congenital abnormalities 2

Diagnostic Approach

For Newborns with Red Flag Symptoms:

• Abdominal radiography is usually appropriate as initial imaging for infants vomiting within the first 2 days after birth, especially with poor feeding or no passage of meconium 2
• For suspected proximal bowel obstruction (double bubble sign), an upper GI series may be appropriate 2
• For suspected distal bowel obstruction, a contrast enema is usually appropriate 2
• For bilious vomiting, an upper GI series is usually appropriate to evaluate for malrotation 2

For Newborns with Non-Bilious Vomiting Without Red Flags:

• Diagnostic testing is generally not indicated for uncomplicated reflux 2, 6
• If pyloric stenosis is suspected (projectile vomiting in infants 2-8 weeks), abdominal ultrasound is appropriate 2, 1

Management Strategy

For Physiologic Gastroesophageal Reflux:

• Provide parental reassurance that reflux is common, affecting 70-85% of infants in the first 2 months, and resolves without intervention in 95% by 1 year 3
• Implement feeding modifications:
  • For breastfed infants: continue nursing on demand 2
  • For formula-fed infants: consider smaller, more frequent feedings 2, 1
  • Consider thickened feedings (adding up to 1 tablespoon of dry rice cereal per 1 oz of formula) 2

For Suspected Milk Protein Allergy:

• For breastfed infants: trial of maternal elimination diet restricting milk and eggs for 2-4 weeks 2, 3
• For formula-fed infants: trial of extensively hydrolyzed protein or amino acid-based formula 2, 3

For Dehydration Management:

• For mild vomiting without dehydration: administer small, frequent volumes of fluid (5 mL every minute) 2
• Use oral rehydration solution (ORS) to replace fluid losses 2
• For each episode of emesis, replace with appropriate volume of ORS 2

For Surgical Conditions:

• Immediate surgical consultation for bilious vomiting, suspected malrotation with volvulus, or other obstructive conditions 2, 1
• NPO (nothing by mouth) and nasogastric decompression for suspected obstruction 4

When to Refer for Emergency Evaluation

• Bilious vomiting (requires immediate evaluation) 1, 5
• Projectile vomiting (concerning for pyloric stenosis) 1, 5
• Signs of dehydration not responding to oral rehydration 2, 1
• Abdominal distension or tenderness 1, 4
• Failure to pass meconium within first 24-48 hours 2
• Hematemesis (bloody vomiting) 4, 5

Pharmacologic Treatment

• Pharmacologic treatment is generally not indicated for uncomplicated reflux in newborns 2, 3
• Antiemetics such as ondansetron are not routinely recommended for newborns with vomiting 4
• Acid suppression therapy should be reserved for infants with diagnosed GERD who do not respond to conservative measures 6