Vomiting, Newborn, Infants, Infancy, Disposal and Haematcmcsis

Because innumerable conditions cause vomiting in childhood, I have picked out some particularly important features and conditions as a guide to diagnosis. 
Probably all children vomit sooner or later. Features of part­icular importance include the following: 
1.Green, bile-stained vomitus. In the newborn this indicates intestinal obstruction until proved otherwise.
2. Persistent vomiting, as distinct from intermittent vomiting.
3. The child becoming unwell, suckling less well, loss of appetite, ceasing to smile (after five or six weeks of age) and drowsiness.
4. Abdominal distension.
5. Visible peristalsis. 
6. Dehydration.
7. Loss of weight.
8. Fever.
9. Headache associated with vomiting.

Newborn

Obstruction may be caused by a meconium plug (often dealt with simply by inserting the little finger in the rectum), oeso­phageal atresia (in which case there may have been hy-dramnios, and the baby is obviously unable to swallow mucus and saliva), duodenal atresia (in which case there is severe vomiting but without abdominal distension) or obstruction farther down the alimentary tract. In Hirschsprung's disease there is often a story that no stool was passed in the first 24 hours and there is constipation or alternating severe diarrhoea and constipation, with abdominal distension: on rectal exam­ination the rectum is empty.

Intracranial causes include cerebral oedema or hae­morrhage, subdural effusion or meningitis. Fullness of the fontanellc and wide separation of the sutures may point to an intracranial cause, but in meningitis there may be no bulging of the jonianelle or neck stiffness: the child is just ill, and there is no other discoverable cause. E. coli septicaemia is another important cause of vomiting and illness in the newborn: there may or may not be evidence of umbilical infection.
Urethral obstruction in the male is manifested by a poor stream of urine and a palpable bladder. Other causes which are rare but treatable are galactosaemia and adrenocortical hy­perplasia. In the latter there may or may not be notable en­largement of the phallus; biochemical investigation will es­tablish the diagnosis.
Vomiting may be due to obstruction in the alimentary tract, including intussusception and strangulated hernia.
Vomiting may be the side-effect of drugs.
A complaint that the baby is constantly vomiting may be one of the early indications of the child abuse syndrome.
Causes of vomiting after infancy include, in particular, infec­tions (especially otitis media, tonsillitis, urinary tract infection, meningitis, whooping cough and gastroenteritis), migraine and the periodic syndrome, travel sickness, intestinal obstruction, appendicitis and the effect of drugs and excessive or unusual food intake. Do not forget the possibility of a cerebral tumor.
In some cases re-examination after an hour or so may help.
Haematemcsis is a rare symptom in children. The new baby may swallow blood from his mother's cracked nipple. (For the test to determine whether the blood is the mother's or the baby's). Older children may vomit blood after epi-staxis, or in association with acute tonsillitis, or as a result of oesophageal varices or gastric ulceration from aspirins. Other causes arc hiatus hernia and reflux, blood diseases, pyloric stenosis (rarely) and drugs other than aspirins.

Infants after the newborn period

Almost all babies bring a small amount of milk up after a feed: some do it more than others. A major cause of vomiting is excess of wind, which in a bottle-fed baby is almost always due to too small a hole in the teat. Congenital pyloric stenosis presents almost always between three and eight weeks of age with the story of one large vomit immediately after or during a feed. Peristalsis can often be seen, and a pea-sized tumour can almost always be felt. After ten weeks of age it is exceedingly rare. The ruminator is hardly likely to present in a casualty department: the baby arches the back and tries to bring the milk up and he may appear to gargle with the milk in the throat. This may be associated with gastro-oesophageal reflux. When a well baby presents with vomiting after every feed, one must know whether there is blood in the vomitus: it would point to a hiatus hernia or reflux. Numerous infections present as vomiting. The principle ones are otitis media, urinary tract infection, whooping cough, 'winter vomiting disease', menin­gitis and gastroenteritis. It is useful to know whether any other child in the family is poorly with vomiting. With regard to whooping cough, the fact that the vomiting is the result of coughing may only be elicited on careful questioning. The virus infection termed 'winter vomiting' occurs in well babies with no fever or diarrhoea. Vomiting may precede diarrhoea in gastroenteritis. Vomiting may be an early symptom of cocliac disease or adrenocortical hyperplasia.

Vomiting after infancy

Causes of vomiting after infancy include, in particular, infec­tions (especially otitis media, tonsillitis, urinary tract infection, meningitis, whooping cough and gastroenteritis), migraine and the periodic syndrome, travel sickness, intestinal obstruction, appendicitis and the effect of drugs and excessive or unusual food intake. Do not forget the possibility of a cerebral tumour.

Disposal (acute cases) 
When in doubt the child hai 10 be admitted. If he is sent home, the family doctor is spoken 10 on the telephone, and the child must be seen again next day.

Haematcmcsis

Haematemcsis is a rare symptom in children. The new baby may swallow blood from his mother's cracked nipple. Older children may vomit blood after epi-staxis, or in association with acute tonsillitis, or as a result of oesophageal varices or gastric ulceration from aspirins. Other causes arc hiatus hernia and reflux, blood diseases, pyloric stenosis (rarely) and drugs other than aspirins.