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Clinical update: vomiting in infants.

Introduction

Vomiting is a common symptom which almost all children will experience. Vomiting is an organised autonomic response resulting in the forceful ejection of gastric contents through the mouth. There are a number of reasons why vomiting is more common in infants than in older children:

* Infants have an immature gastro-oesophageal sphincter that is 'incompetent'

* Infants spend a large amount of time lying flat rather than upright

* Liquid feed is easier to regurgitate than solids.

Parents may misinterpret other conditions for vomiting; for example, posseting, which is a normal phenomenon where small amounts of feed dribble through the lips, as well as regurgitation, the non-forceful ejection of feed, most commonly associated with gastro-oesophageal reflux in infants.

Although vomiting is distressing for parents, most cases are not clinically significant and reassuring parents is extremely important. It is important that community practitioners are aware of potentially serious causes of vomiting so that underlying conditions can be suspected and early referrals made. The most common and serious causes of vomiting in infants will be discussed, including their presentations, aetiologies and management in the community.

Red flags

Community practitioners should always promptly assess the infant for 'red flag' signs, some of which are listed below (Allen, 2007). The presence or suspicion of any of these warrant urgent referral for assessment to exclude serious and potentially life-threatening causes of vomiting. Red flag signs are:

* Bile-stained vomit (green)

* Blood in the vomit

* Bulging fontanelle

* Failure to thrive

* High fever

* Inconsolability

* Infant smells abnormal

* Lethargy and listlessness

* Neck stiffness and photophobia

* Persistent vomiting

* Projectile vomiting

* Severe abdominal pain or distension.

Non-surgical causes

This section discusses conditions that can cause vomiting and may require medical intervention. Most are benign conditions, which can be managed effectively in the community; however, some require referral for further assessment.

Overfeeding

UNICEF (2010) recommends a total daily feed volume of 150-200 ml/kg for a formula-fed, normal, thriving infant. Excess volumes of feed are known to cause vomiting and are often called overfeeding. It is most common in infants who are bottle-fed, or breastfed with formula supplementation. A few common reasons why babies are overfed include (Heinig et al, 2006):

* Babies who cry or wake frequently often are fed at night every time they wake

* Parents can feel pressurised by family and friends to feed their child as much as possible

* Parents often believe that babies will stay full for longer if they are fed more

* Parents may be misinformed by healthcare professionals.

An infant who is being overfed may present with vomiting but will be healthy and thriving, with their weight in the upper centiles. It is important to ensure that the child is growing well, with regular reviews and weight monitoring in the community. Parents will need reassurance and education about normal infant behaviour with regard to crying and waking.

Limiting feeds to 150-200 ml/kg each day should reduce vomiting (UNICEF, 2010). For those who are exclusively breastfeeding their infant, feeding on demand has been found to provide appropriate volumes of feed for the child (Kent et al, 2006). Parents require reassurance and an explanation that their child does not need the excess feed. If parents are still worried or the infant continues to vomit, referral may be required.

Gastro-oesophageal reflux disease

Gastro-oesophageal reflux is a normal, physiological process that occurs occasionally in any healthy child; however, 60-70% of infants aged 3^ months experience reflux more regularly (Schwartz, 2012). If reflux is coupled with failure to thrive or other complications, this is termed gastro-oesophageal reflux disease (GORD). Reflux is caused by involuntary passage of gastric contents into the oesophagus. It is thought to be caused by functional immaturity of the lower oesophageal sphincter, which allows stomach contents to pass into the oesophagus (Vandenplas and Hassall, 2002).

GORD presents with non-forceful regurgitation of feed into the oesophagus. Occasionally, symptoms of aspiration (choking, wheezing, coughing) occur, especially in children with neuromuscular problems such as cerebral palsy or spino-muscular atrophy. Infants may appear unsettled around feeding time and present with failure to thrive. Apnoea (short periods without breathing) can occur with symptoms such as choking or gagging. Infants appear unsettled around feeding: they become stiff, red in the face, cry a lot and push the feed away.

Diagnosis is based on history and clinical findings. Parents need to be told that there is no cure for reflux; however, measures can be taken to ensure that their child is comfortable until reflux is outgrown. Parents can be reassured that the majority of cases resolve themselves spontaneously by the age of 12 months.

Simple, non-medical steps can be taken to reduce reflux symptoms in infants, including providing smaller feeds more often, raising the head end of the infant's cot and encouraging the early introduction of solid foods. If these measures do not reduce symptoms, referral may allow for symptomatic reflux to be treated pharmacologically. It is important to emphasise that these measures will make the infant feel better but might not stop the vomiting itself.

Cow's milk protein allergy

Cow's milk protein allergy (CMPA) results from an immune reaction to one or more of the proteins in cow's milk as these are different in quantity and antigenicity from those in human milk (Crittenden and Bennett, 2005). The prevalence is thought to be between 2% and 7.5% of infants (Vandenplas et al, 2007). A breakdown of moderate and severe symptoms are listed in Box 1. Rarely, if CMPA is severe it can lead to failure to thrive (Vandenplas et al, 2007). Infants with suspected CMPA should be seen by a medical professional and dietician before a change in formula is initiated. Usually, extensively hydrolysed milk formula or amino acid-based formula will be trialled for six weeks as a replacement for cow's milk formula (Kemp et al, 2008). Lactose-free and goat's milk are not effective replacements as lactose-free milk contains cow's milk protein and the proteins in goat's milk may react like cow's milk protein (Kemp et al, 2008). For the same reason, changing between over-thecounter formula milks is not recommended as all these contain cow's milk protein. Breastfeeding should always be encouraged as this reduces the chance of infants developing CMPA initially and is also the ideal hypoallergenic formula (Crittenden and Bennett, 2005).
Box 1. Symptoms of cow's milk
protein allergy (adapted from Vandenplas
et al, 2007)

Moderate symptoms

* Frequent vomiting, diarrhoea or
constipation

* Blood in stool

* Iron deficient anaemia

* Atopic dermatitis

* Persistent distress or colic

Severe symptoms

* Failure to thrive

* Refusal to feed

* Large amounts of blood in stool

* Protein losing enteropathy

* Severe atopic dermatitis


Gastroenteritis

In developed countries the most common cause of gastroenteritis is rotavirus, accounting for around 60% of cases in children younger than two years old (Lillitos et al, 2011). Commonly, presentation is with vomiting or diarrhoea in combination with mild pyrexia lasting a few days. Usually, gastroenteritis requires minimal intervention but parents should be told to provide lots of fluid to maintain hydration and electrolyte balance (Scorza et al, 2007). Carbonated drinks and fruit juices should be avoided but water and milk feeds are suitable (NICE, 2009). It is not advisable to dilute milk feeds.

Infants are at higher risk of dehydration and it is the main danger for those with gastroenteritis. The signs and symptoms of dehydration are listed in Box 2. If any of these signs are present, the family should seek medical help immediately. Oral rehydration solutions such as Dioralyte[R] should be given to replace fluid loss: 50 ml/kg given gradually over four hours is recommended (NICE, 2009).
Box 2. Signs of dehydration
(Lissauer and Clayden, 2007)

Moderate dehydration

* Fast breathing

* Poor perfusion (central capillary refill is
prolonged)

* Reduced skin elasticity

* 5-10% reduction in body weight

* Thirsty and drowsy

* Dry mouth and eyes

* Reduced urine output

Severe dehydration

* Sunken eyes

* Absent tears

* More than 10% weight loss (compare with
the recent weight in the Red Book)

* Severely reduced or no urine output (liquid
faeces may be confused with urine)


Medical advice should be sought if there is blood in the vomit or stool, if the infection is thought to have been caught on holiday abroad, if vomiting persists for more than two days or if the infant is becoming increasingly dehydrated.

To prevent spread of the causative organism parents should be reminded to wash their hands after changing nappies and before food preparation. Parents should be advised to keep their child out of childcare facilities until more than 48 hours after the last bout of vomiting or diarrhoea. The rotavirus vaccine was introduced in July 2013 and community practitioners should encourage parents to get their child immunised (Paul and Basude, 2013).

Urinary tract infections

In infants urinary tract infections (UTIs) have similar incidences in males and females and often present with non-specific symptoms (Shaik, 2010). Vomiting may be the sole symptom or may appear in association with pyrexia, collapse, colic, failure to thrive or poor feeding.

A clean catch urine sample should be obtained from infants presenting in this manner and should be sent for urgent microscopy and culture to confirm a UTI (NICE, 2007). Around 40% of infants with UTI have an underlying genitourinary anomaly. An example of this is a posterior urethral valve anomaly in boys, which can present with poor urinary stream. Referral to a paediatrician for ultrasound scan and other investigations is usually indicated. Treatment of UTI is with oral/intravenous antibiotics and if a urine dipstix is suggestive of a UTI, referral to a paediatrician is necessary for assessment and treatment is needed to avoid renal damage.

Meningitis

Vomiting is one of many potential presentations of an infant with meningitis. Other symptoms can include fever, bulging fontanelle, drowsiness, fast breathing, shivering, rash, irritability and cold peripheries. All these signs and symptoms may present in isolation or in combination with one another. A child with suspected meningitis should be urgently transferred to hospital.

After a case of meningitis, community practitioners need to ensure that the child receives regular follow-up and meets all of their milestones as meningitis can have a lasting impact on the child's health, especially hearing and development. Checking that the rest of the family has received meningitis vaccination is also important. Identifying immigrant children for vaccination and providing information about vaccine programmes to new parents need to be emphasised for meningitis prophylaxis to be effective.

Metabolic disorders

Vomiting can be a striking presentation of inborn errors of metabolism. Although they are more likely to present this way in older children, in those who do present with vomiting during infancy, the underlying condition is likely to be significant (Burton, 1998). Urea cycle disorders are one example and usually present in babies who are a few days old, once they are established on milk feeds. The milk's rich source of protein triggers the illness: vomiting, poor feeding and lethargy are just some of the possible symptoms (Gardeitchik et al, 2012). Metabolic errors are unlikely to be the primary differential for an infant presenting in this way, but should always be considered.

Metabolic disorders, for example MCADD (medium chain acyl-coA dehydrogenase deficiency) or phenylketonuria (PKU), may become more apparent when a child is ill so a high level of suspicion should be held in immigrant children and others who may have missed the Day five neonatal screening. As early diagnosis can prevent sudden death or long-term disability (Carroll et al, 2009), the importance of newborn screening tests should be emphasised to parents and encouraged by community practitioners.

Surgical causes

Surgical causes of vomiting are rarer than other causes but can cause serious morbidity. Often, community practitioners can identify these conditions early, which is essential for prompt diagnosis and intervention. Signs that should raise concern of a surgical cause include bilious (dark green) vomiting, blood in the stool or vomit and asymmetrical pain or distension of the abdomen. A few of the more common surgical causes of vomiting will be discussed.

'Bile is bad'

Any green colour in the vomitus is a serious sign and intestinal obstruction should be considered until proven otherwise. Parents will often describe vomiting as containing 'bile' and it is important to elicit the colour of the vomitus from them. Colostrum is often yellow and this can be what parents describe as bile. Any green colour, however, is a sign of bile, suggesting that the vomit originated distal to the stomach. Bile-stained vomiting can be associated with surgical conditions, such as intestinal malrotation and Hirschprung's disease. Bile-stained vomitus should always trigger referral immediately as these conditions require rapid diagnosis and surgical treatment may be required (Walker et al, 2006).

Pyloric stenosis

Pyloric stenosis occurs in around one in 1,000 births. It is five times more common in males than females and tends to present within the first 12 weeks of life (Wyllie and Hyams, 1999). Evidence suggests that infants who are exclusively breastfed are less likely to develop pyloric stenosis than those who are bottle-fed (Krough et al, 2012). This emphasises another benefit of breastfeeding.

Thickening of the pylorus (the muscle between the end of the stomach and the intestines) causes gastric outflow obstruction; this results in non-bilious, projectile vomiting immediately or soon after feeding as the food cannot leave the stomach. Infants are constantly hungry and irritable, despite being given multiple feeds. Occasionally, waves of contraction can be seen through the left upper part of the abdominal wall (gastric peristalsis) as the stomach tries to empty (Aspalund and Langer, 2007).

If this condition is suspected, referral to hospital for thorough history and examination is required. Often, the diagnosis will be confirmed with an ultrasound scan. Surgical correction (pyloromyotomy) is required.

Intussusception

In intussusception the bowel telescopes, as if it were swallowing itself. It is the most common cause of intestinal obstruction in infants after the neonatal period and usually occurs in children aged between two months and two years of age.

The classic triad of vomiting, abdominal pain and red currant jelly stool is seen in only 10-15% of infants with intussusceptions (Paul et al, 2010). Other symptoms can include listlessness, decreased feeding, pale appearance and drawing up of the legs. Symptoms often present in short but intense bursts with severe pain.

Infants presenting with these symptoms need urgent referral as the diagnosis needs ultrasound confirmation. Intussusceptions can be corrected with air enema, although some cases require surgical treatment. In most cases, infants recover well following treatment.

Inguinal hernias

Swelling in the groin should raise suspicion of an inguinal hernia. The bulge may only appear occasionally; for instance, during crying. If the lump cannot be pushed in, the hernia may be strangulated and this is a surgical emergency needing immediate referral for assessment and management (Paul and Henning, 2010).

Multiple aetiology may be present

Vomiting may not always have only one cause. If an infant has vomited previously as a result of gastro-oesophageal reflux, one should not assume that it is the same cause when he presents subsequently. As vomiting is so common in infants, they are likely to encounter more than one cause of vomiting before reaching adulthood. This is illustrated by the case of a young boy who initially suffered with reflux from three weeks of age. At six weeks of age he presented with vomiting shortly after feeding, he was described as continuously hungry and his growth had begun to falter. As ultrasound scan revealed hypertrophy of the pylorus and he was referred for surgical correction. Subsequently, he continued to vomit although his mother described it as being less dramatic, vomiting was accompanied by diarrhoea and he developed atopic eczema. He was trialled on Neocate[R] formula, which improved his symptoms suggesting a diagnosis of cow's milk protein allergy. This case illustrates how multiple conditions can co-exist and should be considered by professionals at each presentation.

Conclusion

Vomiting is common in infants and the more common aetiologies have been discussed above. Benign conditions underlie the majority of vomiting; however, some serious pathologies can present with vomiting, sometimes in isolation, and these always need to be considered. The surgical causes of vomiting are rare, but require early recognition and intervention; therefore, knowledge of their presentation is essential. Recognition of all these pathologies by community practitioners can facilitate early referrals to paediatricians, allowing for more efficient diagnosis and effective management.

The community practitioner role

* Early recognition of serious conditions, which should be referred promptly

* Always look for the red flag signs in vomiting infants

* Consider surgical causes of vomiting, especially if blood or bile is present in vomitus or stool

* If meningitis is suspected refer immediately

* Check immunisation status of patient and other children in family following meningitis

* Advise parents on appropriate volume of feed

* Reassure parents whose children have common, benign conditions such as gastro-oesophageal reflux

* Educate parents to continue normal feed in children with gastroenteritis and to give oral rehydration solution, if needed

* Educate parents about the signs of dehydration and when to seek medical help

* Encourage newborn screening uptake and ensure adequate action is being taken if results are abnormal

* Check the immunisation and screening status of immigrant children.

No conflict of interest declared.

References

Allen K. (2007) The vomiting child: what to do and when to consult. AustFam Physician 36(9): 684-7.

Aspalund G, Langer JC. (2007) Current management of hypertrophic pyloric stenosis. Semin Paediatr Surg 16(1): 27-33.

Burton BK. (1998) Inborn errors of metabolism in infancy: a guide to diagnosis. Pediatrics 102(6): 69-78.

Carroll JC, Gibbons CA, Blaine SM et al. (2009) Genetics: newborn screening for MCAD deficiency. Can Fam Physician 55(5): 487.

Gardeitchik T, Humphrey M, Nation J, Boneh A. (2012) Early clinical manifestations and eating patterns in patients with urea cycle disorders. J Paediatr 161(2): 328-32.

Heinig MJ, Follett JR, Ishii KD, Kavanagh-Prochaska K, Cohen R, Panchula J. (2006) Barriers to compliance with infant-feeding recommendations among low-income women. J Hum Lact 22(1): 27-38.

Crittenden RG, Bennett LE. (2005) Cow1 s milk allergy: a complex disorder. J Am Coll Nutr 24(6 Suppl): S582-91.

Kemp AS, Hill DJ, Allen KJ et al. (2008) Guidelines for the use of infant formulas to treat cows milk protein allergy: an Australian consensus panel opinion. Med J Aust 188(2): 109-12.

Kent JC, Mitoulas LR, Cregan MD, Ramsay DT, Doherty DA, Hartmann PE. (2006) Volume and frequency of breastfeeding and fat content of breast milk throughout the day. Pediatrics 117(3): 387-95.

Krogh C, Biggar RJ, Fischer TK, Lindholm M, Wohlfahrt J, Melbye M. (2012) Bottle-feeding and the risk of pyloric stenosis. Pediatrics 130(4): 943-9.

Lillitos P, Michie C, Apps J, Bentley D. (2011) Advances in the management of gastroenteritis. West London Med J 3(4): 15-22.

Lissauer T, Clayden G. (2007) Illustrated Textbook of Paediatrics, 3rd Edn. Edinburgh: Mosby Elsevier.

National Institute for Health and Care Excellence (NICE). (2007) CG54: UTI in Children. London: NICE.

NICE. (2009) CG84: Diarrhoea and Vomiting in Children. London: NICE.

Paul SP, Henning S. (2010) Swelling of the groin in children. Practice Nursing21(12): 641-3.

Paul SP, Candy DCA, Pandya N. (2010) A case series on intussusceptions in infants presenting with listlessness. Infant 6(5): 174-7.

Paul SP, Basude D. (2013) Introducing the rotavirus vaccine in the UK. Nurs Times 109(25): 12-3.

Schwarz SM. (2012) Pediatric Gastroesophageal Reflux. Available from: http://emedicine.medscape.com/ article/930029-overview#showall [Accessed October 2012J.

Scorza K, Williams A, Phillips JD, Shaw J. (2007) Evaluation of nausea and vomiting. Am Fam Physician 76(1): 76-84.

Shaik N. (2010) Acute urinary tract infection in infants and young children. CMAJ 182(2): 800-1.

UNICEF. (2010) The health professional's guide to: 'A guide to infant formula for parents who are bottle feeding7. Available from: www.unicef.org.uk/Documents/Baby_Friendly/ Leaflets/health_professionals_guide_infant_formula.pdf [Accesse d August 2013].

Vandenplas Y, Hassall E. (2002) Mechanisms of gastroesophageal reflux and gastroesophageal reflux disease. JPediatr Gastroenterol Nutr 35(2): 119-36.

Vandenplas Y, Koletzko S, Isolauri E et al. (2007) Guidelines for the diagnosis and management of cow's milk protein allergy in infants. Arch Dis Child 92(10): 902-8.

Walker GM, Neilson A, Young D, Raine PA. (2006) Colour of bile vomiting in intestinal obstruction in the newborn: questionnaire study. BMJ 332(7554): 1363.

Wyllie R, Hyams JS (eds). (1999) Pediatric Gastrointestinal Disease, Pathophysiology: Diagnosis and Management. Philadelphia, PA: WB Saunders Company.

CPD questions (please visit www.communitypractitioner.com/CPD to submit your answers)

1. Overfeeding is a common cause of vomiting in infants. Which of the following statements are true?

A. It usually resolves on its own

B. Parents often believe that if infants are fed more they will stay full longer and sleep better

C. It is important to make sure that community practitioners adequately explain and provide reassurance to parents and advise that feed volume be given between 120-150 (or around 150) ml/ kg/day

D. All of the above

2. Surgical presentation of vomiting in infants is:

A. Common and serious

B. Uncommon but serious

C. The same as in adults

D. All of the above

3. Which of the following are true about cow's milk protein allergy?

A. It is more commonly seen in atopic infants

B. Suspicion should lead to referral to a medical professional and specialist dietician

C. Breastfeeding should be encouraged although adjustment to maternal diet may be necessary

D. All of the above

4. Bile is a commonly reported symptom when infants vomit. What is the colour of bile?

A. Yellow

B. Green

C. White and frothy

D. None of the above

5. A two-month-old infant has had a bout of gastroenteritis previously and his parents ask you about the rotavirus vaccine. What would you advise?

A. The infant should still be vaccinated with the oral rotavirus vaccine

B. It is important to ensure that the infant does not have immune suppression

C. It can be given with the other childhood vaccines

D. All of the above

6. 'Red-currant' jelly stool, a classic sign of intussusception in infants, is:

A. Always present in a child with intussusception

B. A late sign (bleeding and mucus occurs due to venous congestion)

C. An early sign of intussusception

D. None of the above

7. Which of the following statements about gastro-oesophageal reflux are true?

A. It is uncommon for infants to have gastro-oesophageal reflux

B. Weaning on to solid food late may be helpful

C. All infants with gastro-oesophageal reflux need treatment with drugs

D. None of the above

8. Which of the following statements are true about inguinal hernia in children?

A. More commonly seen in premature babies

B. When there is a suspicion of obstruction, it should be immediately referred to secondary care (paediatricians/surgeons)

C. Discolouration of skin over hernia site, poor feeding, vomiting, looking listless, crying a lot may be all signs of an obstructed inguinal hernia

D. All of the above

9. Which of the following statements about meningitis are true?

A. It is a medical emergency

B. Vomiting can be a sign of meningitis in infants

C. Vaccination has decreased the incidence of meningitis in infants

D. All of the above

10. Which of the following are true about urinary tract infections?

A. Girls suffer more than boys in infancy

B. Posterior urethral valve does not increase the risk for UTIs

C. Vomiting and fever are always present in an infant with UTIs

D. None of the above

Jennifer Whinney

Medical Student, University of Bristol

Siba Prosad Paul

ST6 in Paediatric Gastroenterology, Bristol Royal Hospital for Children, Bristol

David CA Candy

Professor and Consultant Paediatric Gastroenterologist, St Richard's Hospital, Chichester
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Title Annotation:PRACTICE: CPD
Author:Whinney, Jennifer; Paul, Siba Prosad; Candy, David C.A.
Publication:Community Practitioner
Article Type:Report
Geographic Code:4EUUK
Date:Sep 1, 2013
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