“My baby keeps bringing up his feeds!”BMJ 2010; 340 doi: http://dx.doi.org/10.1136/bmj.c2189 (Published 30 April 2010) Cite this as: BMJ 2010;340:c2189
- Jayanta Banerjee, specialist trainee fifth year paediatrics1,
- Mita M Roy, general practitioner2,
- Sheetal Bhojani, specialist trainee fifth year paediatrics1,
- Naina Emcy, consultant paediatrician1
- 1Southend University Hospital NHS Foundation Trust, Southend SS0 0RY
- 2South West Essex Primary Care Trust, Basildon SS14 3HG
- Correspondence to: J Banerjee
- Accepted 7 April 2010
A 6 week old baby boy, first child of young white parents, presents with recurrent episodes of vomiting from age 3 weeks. He was born at term after an uneventful pregnancy.
What issues you should cover
This presentation is common and generally falls into one of three categories:
Those requiring reassurance and parental advice.
Those with minor problems that can be successfully managed in primary care.
Those with serious disorders requiring specialist paediatric attention.
Duration and progression of symptoms—thriving babies who vomit after each feed may simply be overfed. Progressive vomiting with faltering growth suggests gastro-oesophageal reflux or milk intolerance. Acute vomiting in a previously thriving baby might be caused by a serious illness such as sepsis.
Character of vomiting—large volumes of projectile vomit within 30 minutes of feeding suggest pyloric stenosis. Alternatively, effortless vomiting might indicate possetts.
Colour or content of vomit—bilious vomiting, particularly in babies, might indicate bowel obstruction, so clarify the meaning of “bilious” with parents by showing colours to compare, for example milk, yellow, bilious, or blood stained.
Type of feed—ask about volume and frequency. Knowing the different types of formula available and their indications is important (see table 1⇓). Vomiting babies not thriving on formula based on cow’s milk protein might be intolerant to it; this can result in secondary lactose intolerance (http://emedicine.medscape.com/article/187249-overview).
Amount of feed—a term baby should not be fed more than 120-150 ml/kg a day. Lack of appetite and reduced food intake might suggest a developmental disorder and even heart failure secondary to congenital heart disease.
Ask about abdominal discomfort, diarrhoea, constipation, eczema, skin rash, and cough. Babies that cry intensely after meals may have colic.
Discomfort during feeds with back arching might indicate gastro-oesophageal reflux.
Bronchiolitis can present with bouts of cough followed by vomiting.
Irritability, lethargy, poor feeding, and fever suggest sepsis.
Ask if other family members are currently affected by gastroenteritis.
Child neglect and physical abuse may present with growth faltering and vomiting. Ask about possibility of trauma or head injury.
What you should do
Assess the baby’s hydration status. Sunken eyes and fontanelle, reduced skin turgor, tachycardia, central capillary refill time of more than three seconds, lethargy, poor urine output (less than one wet nappy every six hours), and ketonuria indicate dehydration.
Look for signs of sepsis: pyrexia or hypothermia, pallor, lethargy, tachycardia, cold peripheries, and petechial rash. Examine for the septic source (for example, meningism) with a systemic examination, ear, nose and throat examination, and a urine dipstick.
“Test feed” to diagnose pyloric stenosis. A positive test feed in a very hungry baby with vomiting will confirm the diagnosis, but a negative result does not exclude it.
Look for signs of bowel obstruction (abdominal distension and tinkling bowel sounds) and of head injury.
Atopic eczema, rash, perianal redness, and excoriation suggest cow’s milk protein intolerance.
The history and examination provide diagnostic direction. Treatment is tailored to severity of dehydration and seriousness of the underlying cause of vomiting.
Discuss basic bottle feeding techniques—ensure use of appropriate teats (fast, medium, or slow flow) and ensure excessive air is not swallowed.
Plot growth and development parameters that provide useful information about growth faltering and indicate the seriousness of the condition.
Refer urgently to paediatric services for: moderate to severe dehydration or suspected sepsis; severe infection (meningitis, severe pneumonia); bowel obstruction or pyloric stenosis (ask parents not to feed further in interim); severe bronchiolitis; any suspicion of head injury.
Also refer to paediatric services if weight loss has been considerable, for example, a 15% decrease from birth weight, or growth faltering based on weight percentile.
If not referring the child, provide clear guidance to parents about the next step if symptoms get worse or do not improve, and arrange follow-up.
For specific treatment of conditions see table 2⇓.
Important websites for parents
Gastro-oesophageal reflux disease
NHS Clinical Knowledge Summaries (www.cks.library.nhs.uk/patient_information_leaflet/gastro_oesophageal_reflux_disease)—Information from NHS Direct on gastro-oesophageal reflux disease
NHS Lothian Referral Guidelines (www.refhelp.scot.nhs.uk/dmdocuments/gord_pil.doc)—Patient information leaflet for gastro-oesophageal reflux disease
Joint website of Great Ormond Street Hospital for Children NHS Trust and University College London Institute of Child Health (www.ich.ucl.ac.uk/gosh_families/information_sheets/pyloric_stenosis/pyloric_stenosis_families.html)—Information on pyloric stenosis
KidsHealth (kidshealth.org/parent/medical/digestive/pyloric_stenosis.html)—Information on pyloric stenosis and links to other medical disorders of the digestive system
Food reactions (www.foodreactions.org/intolerance/lactose/)—Description and terminology of lactose intolerance
Food Standards Agency (www.eatwell.gov.uk/healthissues/foodintolerance/foodintolerancetypes/milkallergy/)—Advice on milk allergy and intolerance
Useful reading for professionals
Singh J, Kass DA, Sinert RH. Paediatrics, pyloric stenosis. 2009 (emedicine.medscape.com/article/803489-overview)
Chung E. Infantile hypertrophic pyloric stenosis: genes and environment. Arch Dis Child 2008;93:1003-4
Spicer RD. Infantile hypertrophic pyloric stenosis: a review. Br J Surg 1982;69:128-35
Glassman M, George D, Grill B. Gastroesophageal reflux in children: clinical manifestations, diagnosis, and therapy. Gastroenterol Clin North Am 1995;24:71-98
Heyman MB; Committee on Nutrition. Lactose intolerance in infants, children, and adolescents. Pediatrics 2006;118:1279-86
Cite this as: BMJ 2010;340:c2189
This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs
Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare that all authors had: (1) No financial support for the submitted work from anyone other than their employer; (2) No financial relationships with commercial entities that might have an interest in the submitted work; (3) No spouses, partners, or children with relationships with commercial entities that might have an interest in the submitted work; (4) No Non-financial interests that may be relevant to the submitted work.
Provenance and peer review: Not commissioned; externally peer reviewed.