Evaluation and Management of Neonatal Vomiting
Immediate Priority: Distinguish Bilious from Non-Bilious Emesis
Bilious vomiting in any neonate is a surgical emergency until proven otherwise and mandates immediate imaging to exclude midgut volvulus, which can cause intestinal necrosis within hours. 1
Critical First Steps
Red Flag Assessment
Immediately evaluate for:
- Bilious (green) vomitus – indicates obstruction distal to the ampulla of Vater and requires urgent surgical evaluation 1, 2
- Bloody vomitus or "currant jelly" stools – suggests mucosal ischemia from intussusception or volvulus 3, 2
- Toxic appearance with fever – may indicate sepsis, meningitis, or urinary tract infection requiring immediate treatment 2
- Severe dehydration (≥10% fluid deficit): prolonged skin tenting >2 seconds, cool extremities, decreased capillary refill, lethargy – mandates IV resuscitation 2
- Absent meconium passage or poor feeding – suggests congenital intestinal obstruction 2
Algorithmic Approach Based on Vomitus Character
BILIOUS VOMITING (Green Emesis)
This is the most critical presentation requiring urgent action:
Within First 2 Days of Life
Obtain abdominal radiograph immediately as first imaging study 4, 2
Interpret radiograph pattern:
- "Double bubble" sign with no distal gas → Duodenal atresia (most common proximal obstruction) 4, 2
- "Triple bubble" with absent distal gas → Jejunoileal atresia 4, 2
- Multiple distended loops with absent/decreased distal gas → Distal obstruction; proceed to fluoroscopic contrast enema to differentiate meconium plug, meconium ileus, Hirschsprung disease, or ileal atresia 4
- Non-classic double bubble, few distended loops, OR normal gas pattern → Critical: proceed immediately to upper GI series to exclude malrotation with midgut volvulus 4, 1
Upper GI contrast series is the definitive study with 96% sensitivity for malrotation, identifying abnormal position of the duodenojejunal junction (ligament of Treitz) 4, 1
Critical Pitfall to Avoid
Normal abdominal radiographs do NOT exclude malrotation or volvulus – clinical suspicion based on bilious vomiting alone mandates proceeding to upper GI study regardless of radiograph findings, as plain films miss up to 7% of malrotation cases 1, 2
Why This Matters
Midgut volvulus accounts for 20% of bilious vomiting cases in the first 72 hours and causes twisting around the superior mesenteric artery, leading to venous congestion, arterial compromise, transmural intestinal ischemia, and potentially necrosis requiring massive bowel resection or death within hours 1, 2
Immediate Management
- Stop all oral intake immediately 5
- Place nasogastric tube for gastric decompression 5
- Establish IV access and begin fluid resuscitation if dehydrated 2
- Urgent pediatric surgical consultation upon confirmation of malrotation/volvulus 3
NON-BILIOUS VOMITING
The approach differs significantly based on age and vomiting pattern:
Age 3-6 Weeks: Projectile Non-Bilious Vomiting
Suspect hypertrophic pyloric stenosis (HPS):
- Abdominal ultrasound is the initial imaging modality of choice to confirm diagnosis 2
- Upper GI series should NOT be performed if ultrasound confirms HPS; reserve upper GI for atypical presentations or when bilious vomiting develops 2
- Differentiate from gastroesophageal reflux (GER): GER presents with intermittent regurgitation from birth with normal weight gain, whereas HPS shows progressive forceful projectile vomiting beginning at 3-6 weeks 2
Intermittent Regurgitation with Normal Weight Gain
Likely benign gastroesophageal reflux:
- Imaging is NOT indicated when infant demonstrates normal weight gain and lacks progressive projectile vomiting 2
- GER typically resolves with age 2
Age 6-18 Months: Intermittent Crampy Pain with Vomiting
Suspect intussusception:
- Ultrasound is the initial imaging modality when clinical features include intermittent crampy pain, "currant jelly" stools, lethargy, or palpable abdominal mass 3, 2
- Bilious vomiting indicates progression and worsening obstruction 3
Hydration Assessment and Management
Clinical Stratification
- Mild dehydration (3-5% deficit): increased thirst, slightly dry mucous membranes 2
- Moderate dehydration (6-9% deficit): loss of skin turgor, dry mucous membranes 2
- Severe dehydration (≥10% deficit): lethargy, prolonged skin tenting >2 seconds, cool extremities, reduced capillary refill – requires immediate IV resuscitation 2
Treatment Approach
- Oral rehydration therapy (ORT) is the cornerstone for viral gastroenteritis with early refeeding once rehydrated 2
- IV rehydration for severe dehydration with electrolyte monitoring 2
- Ondansetron (0.2 mg/kg oral; 0.15 mg/kg IV; maximum 4 mg) may be used for children unable to take oral fluids due to persistent vomiting, but should not replace proper fluid management 2, 5
Laboratory and Additional Workup
When to Obtain Labs
Investigations are required in any child with:
- Dehydration or red flag signs 5
- Bilious vomiting (to assess for metabolic derangements and surgical planning) 5
- Bloody diarrhea, recent antibiotic use, daycare exposure, recent travel, or immunodeficiency (obtain stool cultures) 2
What NOT to Do
- Antimicrobials are NOT indicated for watery diarrhea and vomiting in children <2 years, as the condition is most often viral 2
- Antidiarrheal agents (loperamide, kaolin-pectin) are contraindicated – they do not reduce stool volume or duration and can cause severe abdominal distention, ileus, and death 2
Non-Gastrointestinal Causes to Consider
Fever, vomiting, and loose stools may signal:
- Meningitis, bacterial sepsis 2, 5
- Pneumonia, otitis media, urinary tract infection 2
- Metabolic disorders, congenital adrenal hypoplasia 2, 5
- Increased intracranial pressure, hydrocephalus 2, 5
- Toxic ingestions, trauma (shaken baby syndrome) 5
These must be actively excluded through history, physical examination, and targeted workup 2
Summary Algorithm
- Bilious vomiting? → Immediate abdominal radiograph → Upper GI series (regardless of radiograph findings) → Surgical consultation 4, 1, 2
- Projectile non-bilious vomiting at 3-6 weeks? → Ultrasound for pyloric stenosis 2
- Intermittent crampy pain with vomiting at 6-18 months? → Ultrasound for intussusception 3, 2
- Intermittent regurgitation with normal weight gain? → Likely benign GER; no imaging needed 2
- Watery diarrhea with vomiting in child <2 years? → Likely viral gastroenteritis; oral rehydration therapy, no antibiotics or antidiarrheals 2
Never dismiss bilious vomiting as "just gastroenteritis" – it is a surgical emergency until proven otherwise 1, 2