Approach to vomiting in the neonates nicu

Approach to vo.iting in neonates

1. Approach to vomiting By dr hamza khan jadoon

2. Vomiting Vomiting, also known as emesis, is defined as the forceful expulsion of gastrointestinal contents, and is a common symptom caused by a wide variety of underlying conditions .Vomiting should be differentiated from regurgitation, Regurgitation is the involuntary and effortless expulsion of small amounts of gastric contents that is not accompanied by nausea. Regurgitation is a relatively frequent symptom during the newborn period. In most cases this is unimportant and rarely persists.

3. Vomiting is a common and non-specific symptom, not a diagnosis
Infection is the most common cause of acute vomiting
Bilious vomiting occurs when there is a gastrointestinal obstruction. Bile is dark green rather than yellow. Using a visual aid to clarify vomitus colour with families is helpful
Early morning vomiting and headache may be due to raised intracranial pressure

4. Many babies vomit at some time and in most cases this is unimportant. Vomiting in the neonate covers different types of vomiting, and links to specific causes of vomiting requiring management.
Vomiting or more often, regurgitation is a relatively frequent symptom during the newborn period. In most cases this is unimportant and rarely persists beyond the first few feeds. However, there are circumstances when the type of vomiting is important.

5. When vomiting may be significant Vomiting may be clinically significant if:
vomit contains blood (red or black, the colour of the blood will depend upon how long the blood has been in the stomach)
the vomit is bile (green, not yellow) The baby is projectile vomiting

6. the baby is unwell
the baby is failing to thrive
the baby has gastroesophageal reflux and could be aspirating
the baby also has diarrhoea the abdomen is distended
delay in passage of meconium
the baby is dehydrated (dry mouth, decreased wet nappies, hypotonic)

7. Now, if a newborn or infant presents with vomiting, perform an ABCDE assessment to determine if the patient is unstable or stable. If unstable, stabilize their airway, breathing, and circulation; obtain IV access, and if needed, provide IV fluids. Next, put your patient on continuous vital sign monitoring, including heart rate, blood pressure, and pulse oximetry, and if needed, provide supplemental oxygen..

8. History taking History Taking: pertinent information that should be sought includes
Clarification of the vomit colour (ideally with direct visualisation ) and any prior episodes Feeding assessment
Stooling habits- time to first passage of meconium, frequency, colour Antenatal imaging- specifically any morphologic abnormalities or presence of polyhydramnios Risk factors for early onset sepsis Risk factors for NEC

9. Clinical examination Clinical Examination:
Examine for evidence of respiratory compromise
Assessment of fluid status and perfusion Thorough abdominal examination- distension, whether tense, quality of bowel sounds Inspection of groin to exclude an inguinal hernia Confirm patent anus In general, a profoundly distended abdomen suggests more distal obstruction. Both distension and tenderness are predictors of surgical pathology.Neonates can initially present deceptively well with intestinal obstruction- a normalexamination does not exclude evolving ischaemi a

10. Characterizing emesis what does it look like Colour Clear Yellow White Brown Bloody Green or bilous Amount Consistency Mucosy Watery Crdeled milk

11. . Vomiting may be clinically significant in following situations – 1) If the vomit contains blood (red or black, the color of the blood will depend upon how long the blood has been in the stomach)or is bile stained 2) In case of projectile vomiting 3) Sick neonate 4) Associated with failure to thrive 5) Associated with diarrhea 6) Associated signs of abdominal distension,organomegaly , absent bowel sounds, tenderness, guarding 7) History of delayed passage of meconium8) associated with dehydration .

12. Approach based on history Age of onset: Symptoms within 48 hours after birth are likely due to congenital intestinal malformations. Bilious or Nonbilious vomiting: Bilious vomit has a greenish appearance due to the presence of bile and is indicative of obstruction distal to the ampulla of Vater , the opening of the common bile duct into the duodenum .It helps in anatomical localization of intestinal obstruction or pathology Well baby or sick baby : Well baby with pathological vomiting is likely due to underlying surgical abdomen – noncomplicated

13. Does the vomitus contain blood? Blood in the vomit indicates inflammation or damage to the GI mucosa and may indicate need for endoscopy to rule out acute upper GI bleed. Blood stained vomitus after birth – rule out maternal blood by Apt test. Projectile or non-projectile or projectile vomiting : Points towards specific diagnosis – namely, pyloric stenosis. True expulsive vomiting should be distinguished from regurgitation, which is not associated with retching or prodromal features like nausea

14. Approach based on examination: Well or sick baby? – Sick baby sepsis or NEC or complicated surgical abdomen
Abdominal mass if any palpable? Surgical abdomen
Abdominal tenderness? Peritonitis or perforation
Bowel sound present or absent? Ominous signsuggests ileus

15. Approach based on investigations Septic screen –To rule out infectious causes Xray abdomen – USG abdomen Neurosonography-neurolgical causes Gastroscopy- In Upper GI bleed
Barium enema- dilated proximal segment and the transition zone Hirschsprung disease • EsophagealPH monitoring –GER

16. Management The objectives are to stabilise the neonate and arrange urgent transfer to a surgical centre for further assessment. Initial Measures If the baby is on the postnatal ward, admit to NICU/HDU. These babies cannot be admitted to the Special Care Nursery Monitor with continuous cardiorespiratory monitoring Evaluate for features of hypovolaemia or shock and treat accordingly
Early notification of the on call fellow/consultant

17. Investigations Insert a peripheral cannula and send blood for culture, venous gas, FBC and electrolytes
Urgent abdominal x-ray Bowel rest Cease enteral feeds
Gastric decompression with a large bore 8F orogastric tube
Monitor gastric output. Consider replacing losses >20ml/kg/day

18. Fluids Consider intravenous fluid resuscitation with crystalloid therapy if hypovolaemia suggested by haemodynamic status, perfusion or raised lactate Commence maintenance intravenous fluids- 10% dextrose if less than 24 hours of age, otherwise 0.225% NaCl + 10% dextrose if over 24 hours
Correct electrolyte imbalances. Biochemical disturbance is more likely in more proximal bowel obstruction Monitor urine output. Consider urinary catheterisation if hypovolaemic or shocked Intravenous Antibiotics Consider commencing broad-spectrum empiric antibiotics with anaerobic coverage to cover for the possibility of sepsis

19. Gastroesoohageal reflux Gastroesophageal reflux (GER) is defined as the involuntary retrograde passage of gastric contents into the esophagus with or without regurgitation or vomiting. It is a frequently experienced physiologic condition occurring several times a day, mostly postprandial and causes no symptoms. These infants are also called ‘happy spitters ’.

20. GER disease (GERD) occurs when reflux of the gastric contents causes symptoms that affect the quality of life or pathologic complications, such as failure to thrive, feeding or sleeping problems, chronic respiratory disorders, esophagitis, hematemesis, apnea, and apparent life-threatening events. About 70-85 % of infants have regurgitation within the first 2 months of life, and this resolves without intervention in 95 % of infants by 1 year of age.

21. Home Remedies for Vomiting in neonates First, try feeding your baby smaller amounts more frequently. Overfeeding is one of the main reasons newborns vomit, so regulating their feeding schedule is important. You can also burp your baby after every ounce or two of milk to release any trapped air. You can prevent vomiting by keeping your child upright for at least 30 minutes after feeding. If your baby is lying flat, it can put pressure on their stomach and increase the likelihood of vomiting.