Vomiting in the First Week of Life – Comprehensive Bullet-Point Notes

Case-Based Differential Diagnoses

• Case 1 – 33-day-old female
• Presentation: clear, non-projectile vomiting + watery diarrhea in last 2424 h
• Birth & nursery course: term 3939 w, BW 3.5 kg3.5\,\text{kg}, uneventful, passed meconium <2424 h
• Exam: sleepy, afebrile 37.5∘C37.5^\circ\text{C}, weight 3.3 kg3.3\,\text{kg} (↓15%15\% BW), sunken fontanel, dry mucosa
• Working Dx:
• Gastroenteritis
• Dehydration
• Supporting Hx points: clear non-bilious emesis, watery non-bloody stool, mild dehydration signs, no distress
• Further Hx to seek: sick contacts, maternal mastitis/meds, feeding technique/volume, urine output, travel, stool frequency & colour, fever spikes, prenatal GBS/ROM history, immunisation status, family GI disorders

• Case 2 – 66-day-old male
• Presentation: bilious vomiting day 55
• Birth: 3737 w, BW 3 kg3\,\text{kg}, normal course
• Exam: well, afebrile, weight 2.8 kg2.8\,\text{kg} (↓13%13\%)
• Working Dx: upper bowel obstruction – esp. duodenal atresia
• Key Hx feature: bilious (green) emesis
• Additional Hx to obtain: maternal polyhydramnios, delayed meconium, abdominal distention, perinatal U/S, antenatal Down syndrome screen, family hx of malrotation/atresia, emesis frequency & projectile nature

• Case 3 – 77-day-old male
• Presentation: bilious emesis day 55 → fecaloid vomiting + bloody stools day 77, progressive distension, respiratory distress
• Birth: 3838 w, BW 3.3 kg3.3\,\text{kg}
• Exam: dehydrated, hypothermic, distended tender abdomen, blood per rectum
• Working Dx: bowel obstruction ± intussusception
• Supporting Hx: transition from bilious to fecaloid vomit, hematochezia
• Need more Hx: stool frequency/colour change timeline, colicky pain, currant-jelly stool pattern, maternal polyhydramnios, feeding intolerance, sepsis risk factors

• Case 4 – 22-day-old male
• Presentation: drooling, choking, coughing, cyanosis with feeds
• Antenatal U/S: polyhydramnios + absent stomach bubble
• Working Dx: tracheoesophageal fistula (TEF) / esophageal atresia
• Supporting Hx: immediate post-natal symptoms, excessive salivation, respiratory distress on first feed, antenatal findings
• Additional Hx: inability to pass OG/NG tube, maternal diabetes, associated VACTERL anomalies, prenatal scans, family hx of foregut defects

• Case 5 – extremely preterm 2727 w, 800 g800\,\text{g} male
• Course: initial stability → day 22 sepsis-like deterioration, distended painful abdomen, non-bilious → bilious emesis, bloody mucus stools, ↑ ventilatory needs
• Differential: sepsis, infectious enteritis, intussusception, NEC, perforation, malrotation/volvulus
• NEC supporting features: extreme prematurity, enteral feeds, abdominal distension & tenderness, bilious emesis, bloody stools, systemic instability
• Extra Hx desired: antenatal steroids, maternal antibiotics, feed volumes/advancement, gastric residuals, abdominal girth trends, blood cultures, ventilation days, medication exposure (indomethacin)

Comprehensive History Framework for Neonatal Vomiting

Presenting Symptom Analysis

• Age at onset categorisation:
• Newborn (<77 d) vs infancy <2 y vs childhood >3 y
• Vomit attributes (ask parents to describe/retain linen):
• Onset time after birth
• Frequency & quantity
• Quality/colour/consistency:
• Bilious = obstruction distal to ampulla of Vater
• Bloody = mucosal damage/ulcer/ingestion of maternal blood
• Projectile vs effortless regurgitation vs rumination
• Relationship to feeding & positioning
• Aggravating/relieving factors (burping, prone, upright)

Associated Symptoms & Systems Review

• General: poor sucking, feed refusal, weight loss, fever/ hypothermia, skin rash
• GI: distension, tenderness, delayed meconium, diarrhea/ constipation, bloody stools, drooling
• Respiratory: cough, choke, tachypnea, apnea
• CVS: tachy/bradycardia, hypotension
• Neuro: irritability, lethargy, seizures, coma

Prenatal History

• Maternal age (teenage, advanced), marital status, chronic illness
• Adequacy of antenatal care & screening
• Maternal conditions: bleeding disorders, epilepsy (anticonvulsants ⇢ ↓Vit K), recurrent UTIs/STIs, colonisation (GBS)
• Drugs affecting fetus: anticoagulants, anticonvulsants
• Complications detected by imaging/genetics:
• Polyhydramnios ⇢ TEF/atresia
• Proximal obstruction (duodenal atresia, pyloric stenosis)
• Distal obstruction (jejuno-ileal atresia, Hirschsprung)
• CNS anomalies, Down syndrome → ↑ duodenal atresia risk

Perinatal History

• PROM & duration, chorioamnionitis risk
• Fetal distress/meconium, aspiration
• Birth injuries (cephalo-hematoma), stress ulcer risk

Neonatal Course (First Week)

• Delivery room status: BW, length, OFC, Apgars 1 / 5 / 10 min1\,/\,5\,/\,10\,\text{min}
• Resuscitation: ET-tube, NG-tube
• Respiratory support requirement
• Feeding details:
• Breast vs formula, dilution, frequency, hygiene
• Inexperienced technique, overfeeding
• GI issues: regurgitation, projectile vomiting, bile/blood content
• Output: weight curve, stool & urine pattern, delayed meconium, haem-positive stool
• Sleep-wake cycle abnormalities

Family History

• Three-generation pedigree: consanguinity, genetic disorders, bleeding diathesis, CAH, GI malformations
• Specific system clustering (respiratory, CVS, GI, GU, metabolic, CNS)

Physical Examination Strategy & Key Findings

General & Vital Signs

• Appearance, grimace, cry intensity
• BP (for sick / murmur), HR 120–160 bpm120–160\,\text{bpm}, RR 30–60 min−130–60\,\text{min}^{-1}, rectal T 36.5–37.5∘C36.5–37.5^\circ\text{C}
• Peripheral pulses upper vs lower (coarctation)
• Capillary refill ≤22 s normal

Anthropometry

• Daily weights: >10%10\% loss of BW = red flag
• Length & OFC plotted on WHO charts
• Dysmorphic survey

Hydration Status (compare to Table of severity)

• Fontanel (depressed vs bulging)
• Oral mucosa moisture
• Eye sunkenness
• Skin turgor recoil <2 s vs >2 s
• CRT, tears, extremity temp/colour, urine output
• Mental status gradient: alert → lethargic → unconscious

Head & Neck

• Red reflex (absent → cataract/retinoblastoma/ICP)
• Bulging fontanel → ↑ICP
• Drooling → TEF/EA
• Palate integrity, tongue mobility, torticollis

Thorax

• Breath sounds, respiratory effort, cough/choke with feeds
• CV: heart sounds, murmurs, cyanosis, femoral pulses (CoA), pulse-ox screen

Abdomen

• Shape, wall defects (omphalocele, omphalitis)
• Bowel sounds (absent → obstruction)
• Visible peristalsis R→L → pyloric stenosis
• Distension, tenderness, masses, organomegaly
• Rectal exam: explosive stool (Hirschsprung), blood (intussusception)

GU & MSK

• Genital anomalies, hip dysplasia (Barlow/Ortolani), anal patency
• Spine lesions (dysraphism)
• Limb symmetry, tone

Neurologic & Primitive Reflexes

• Posture, tone (hypo/hyper), asymmetric movements
• Primitive reflex table:
• Moro (disappears 5–65–6 mo)
• ATNR, Galant, Palmar/Plantar grasp, Rooting, Parachute (persists)
• Abnormal if absent, asymmetric, or persistent beyond window (↦ cortical dysfunction)

Investigations

Baseline Panels for Vomiting ± Dehydration

• CMP: Na+\text{Na}^+, K+\text{K}^+, Cl−\text{Cl}^-, Ca2+\text{Ca}^{2+}, Mg2+\text{Mg}^{2+}, HCO3−\text{HCO}_3^-, glucose, BUN, creatinine
• Urinalysis & culture
• LFTs: total/direct/indirect bili, ALT, AST, GGT, ALP, albumin, PT/INR, PTT, ammonia

Vomitus Contains Blood

• Apt test (HbF vs HbA)
• CBC: Hb, Hct, RBC indices (MCV, MCH, MCHC, RDW), WBC diff, platelets, retic count
• Peripheral smear
• Iron studies: serum iron, ferritin, TIBC, transferrin sat, FEPP

Suspicion of Obstruction

• Abdominal USS preferred > X-ray
• Dilated loops, fluid levels, “olive” sign (hypertrophic pylorus)
• Contrast radiographs or CT abdomen for localisation

Additional Targeted Tests

• Blood/urine/CSF cultures for sepsis
• Esophageal pH probe → GER
• CXR → aspiration pneumonia
• Rectal biopsy → Hirschsprung
• Gastroscopy if hematemesis
• CT head if ↑ICP suspected

Management Principles

• Always treat underlying cause, gauge severity & modifiers

Supportive & Preventive Measures

• Parental education: hygiene, correct latch, formula dilution, bottle technique
• Dietary: hydrolysed casein formula for CMPA, thickened feeds for GER
• Correct fluids & electrolytes:
• Oral rehydration for mild
• IV isotonic NaCl\text{NaCl} + dextrose for moderate/severe
• Iron supplementation when deficient

Indications for Hospitalisation

• Need for further diagnostics
• IV antibiotics for proven/suspected sepsis
• Management of severe dehydration, hypoglycaemia, metabolic acidosis
• Airway protection for aspiration / recurrent choking

Surgical / Procedural Interventions

• TEF / esophageal atresia repair
• Pyloromyotomy for pyloric stenosis
• Duodenal atresia or malrotation ± volvulus correction
• Resection & anastomosis for intestinal atresia
• NEC with perforation → laparotomy, drain
• Hirschsprung pull-through
• Imperforate anus repair