The vomiting baby

Dear Sir,

We read with interest the case report of the vomiting baby published
in your
most recent edition of the BMJ (BMJ 2009;339: b4966). Whilst we
acknowledge
that pyloric stenosis does occur in children shortly after birth, this is
unusual.
Typically babies present at several weeks of age, although the median age
of
presentation is earlier than previously described due probably to the
increased
use of ultrasound in diagnosing this condition (1). Vomiting form birth is
a
much more sinister complaint, and we would contend that malrotation with
intermittent volvulus is the most important diagnosis to exclude - this
can occur
in the absence of bile-stained vomiting. To miss this condition is an
avoidable
tragedy. We also note with some sadness that the authors do not mention
the
'test feed' as an appropriate investigation as it remains the most
important
component of the physical examination in making the diagnosis of pyloric
stenosis.

1. Macdesi J, Oates RK. Clinical diagnosis of pyloric stenosis : a
dying art. BMJ
1993;306: 553-555.

Competing interests:
None declared