Evidence-Based Management November 2014

Volume 11, Number 11

Of Neonatal Vomiting In The Authors

Kristin Ratnayake, MD

Emergency Department
Fellow, Division of Pediatric Emergency Medicine, Department of
Emergency Medicine, Loma Linda University Medical Center and
Childrens Hospital, Loma Linda, CA
Tommy Y. Kim, MD
Abstract Assistant Professor of Emergency Medicine and Pediatrics, Loma
Linda University Medical Center and Childrens Hospital, Loma
Linda, CA; California Emergency Physicians, Riverside, CA
Vomiting accounts for up to 36% of neonatal visits to the emergency Peer Reviewers
department. The causes of vomiting can range from benign to life- Steven J. Choi, MD
threatening. Evidence to guide the diagnosis and management of Medical Director of Quality, Director of Pediatric Cardiac Inpatient
Services, The Childrens Hospital at Montefiore; Assistant
neonatal vomiting in the emergency department is limited. History Professor of Pediatrics, Albert Einstein College of Medicine,
and physical examination are extremely important in these cases, Bronx, NY
especially in identifying red flags such as bilious or projectile emesis. Landon A. Jones, MD
Assistant Professor of Pediatric Emergency Medicine, University
A thorough review is presented, discussing various imaging modali- of Kentucky, Lexington, KY
ties, including plain abdominal radiography, upper gastrointestinal CME Objectives
studies, ultrasonography, and contrast enema. A systematic approach
in the emergency department, as outlined in this review, is required to Upon completion of this article, you should be able to:
1. Recognize the significance of bilious emesis in the neonate.
identify the serious causes of vomiting in the neonate. 2. Differentiate the most appropriate diagnostic tests to order
in the vomiting neonate based upon history and physical
examination.
3. Develop a treatment plan for the vomiting neonate with
suspected GERD.
Prior to beginning this activity, see Physician CME Information
on the back page.

Editor-in-Chief
Adam E. Vella, MD, FAAP
Associate Professor of Emergency
Medicine, Pediatrics, and Medical
Education, Director Of Pediatric
Emergency Medicine, Icahn
School of Medicine at Mount Sinai, Chief of Pediatric Emergency
New York, NY
Associate Editor-in-Chief
Vincent J. Wang, MD, MHA
Associate Professor of Pediatrics, Marianne Gausche-Hill, MD,
Keck School of Medicine of the
University of Southern California;
Associate Division Head,
Division of Emergency Medicine,
Children's Hospital Los Angeles,
Los Angeles, CA
Editorial Board
Jeffrey R. Avner, MD, FAAP
Professor of Clinical Pediatrics
and Chief of Pediatric Emergency
Medicine, Albert Einstein College
of Medicine, Childrens Hospital at
Montefiore, Bronx, NY
Steven Bin, MD
Associate Clinical Professor,
Division of Pediatric Emergency
Medicine, UCSF Benioff Childrens Sandip Godambe, MD, PhD
Hospital, University of California, Vice President, Quality & Patient
San Francisco, CA
Richard M. Cantor, MD, FAAP,
FACEP
Professor of Emergency Medicine
and Pediatrics, Director, Pediatric
Emergency Department, Medical
Director, Central New York
Poison Control Center, Golisano
Children's Hospital, Syracuse, NY
Ilene Claudius, MD
Associate Professor of Emergency
Medicine, Keck School of Medicine
of the University of Southern
California, Los Angeles, CA
Alson S. Inaba, MD, FAAP
Ari Cohen, MD
Medicine Services, Massachusetts
General Hospital; Instructor in
Pediatrics, Harvard Medical
School, Boston, MA
FACEP, FAAP
Professor of Clinical Medicine,
David Geffen School of Medicine
at the University of California at
Los Angeles; Vice Chair and Chief,
Division of Pediatric Emergency
Medicine, Harbor-UCLA Medical
Center, Los Angeles, CA
Michael J. Gerardi, MD, FAAP,
FACEP, President-Elect
Associate Professor of Emergency
Medicine, Icahn School of
Medicine at Mount Sinai; Director,
Pediatric Emergency Medicine,
Goryeb Children's Hospital,
Morristown Medical Center,
Morristown, NJ
Safety, Professor of Pediatrics and Assistant Professor of Emergency
Emergency Medicine, Attending
Physician, Children's Hospital
of the King's Daughters Health
System, Norfolk, VA
Ran D. Goldman, MD
Professor, Department of Pediatrics,
University of British Columbia;
Co-Lead, Division of Translational
Therapeutics; Research Director,
Pediatric Emergency Medicine, BC
Children's Hospital, Vancouver, BC,
Canada
Associate Professor of Pediatrics,
University of Hawaii at Mnoa
John A. Burns School of Medicine,
Division Head of Pediatric
Emergency Medicine, Kapiolani
Medical Center for Women and
Children, Honolulu, HI
Madeline Matar Joseph, MD, FAAP,
FACEP University of British Columbia;
Professor of Emergency Medicine
and Pediatrics, Chief and Medical
Director, Pediatric Emergency
Medicine Division, University
of Florida Medical School-
Jacksonville, Jacksonville, FL
Stephanie Kennebeck, MD
Associate Professor, University
of Cincinnati Department of
Pediatrics, Cincinnati, OH
Anupam Kharbanda, MD, MS
Research Director, Associate
Fellowship Director, Department
of Pediatric Emergency Medicine,
Children's Hospitals and Clinics of
Minnesota, Minneapolis, MN
Tommy Y. Kim, MD, FAAP, FACEP
Medicine and Pediatrics, Loma
Linda University Medical Center and
Childrens Hospital, Loma Linda, CA;
California Emergency Physicians,
Riverside, CA
Melissa Langhan, MD, MHS
Associate Professor of Pediatrics,
Fellowship Director, Pediatric
Emergency Medicine, Director of
Education, Pediatric Emergency
Medicine, Yale School of Medicine,
New Haven, CT
Robert Luten, MD
Professor, Pediatrics and
Emergency Medicine, University of Professor of Pediatrics, Attending
Florida, Jacksonville, FL
Garth Meckler, MD, MSHS
Associate Professor of Pediatrics,
Division Head, Pediatric
Emergency Medicine, BC
Children's Hospital, Vancouver,
BC, Canada
Joshua Nagler, MD
Assistant Professor of Pediatrics,
Harvard Medical School;
Fellowship Director, Division of
Emergency Medicine, Boston
Childrens Hospital, Boston, MA James Damilini, PharmD, MS,
James Naprawa, MD
Associate Clinical Professor
of Pediatrics, The Ohio State
University College of Medicine;
Attending Physician, Emergency
Department, Nationwide Childrens Quality Editor
Hospital, Columbus, OH
Steven Rogers, MD
Assistant Professor, University of
Connecticut School of Medicine,
Attending Emergency Medicine
Physician, Connecticut Children's
Medical Center, Hartford, CT
Christopher Strother, MD
Assistant Professor, Director,
Undergraduate and Emergency
Simulation, Icahn School of
Medicine at Mount Sinai, New
York, NY
AAP Sponsor
Martin I. Herman, MD, FAAP, FACEP
Physician, Emergency Medicine
Department, Sacred Heart
Childrens Hospital, Pensacola, FL
International Editor
Lara Zibners, MD, FAAP
Honorary Consultant, Paediatric
Emergency Medicine, St Mary's
Hospital, Imperial College Trust;
EM representative, Steering Group
ATLS-UK, Royal College of
Surgeons, London, England
Pharmacology Editor
BCPS
Clinical Pharmacy Specialist,
Emergency Medicine, St.
Joseph's Hospital and Medical
Center, Phoenix, AZ
Steven Choi, MD
Medical Director of Quality,
Director of Pediatric Cardiac
Inpatient Services, The Childrens
Hospital at Montefiore; Assistant
Professor of Pediatrics, Albert
Einstein College of Medicine,
Bronx, NY
Case Presentations
A 3-week-old boy with emesis is brought to the ED by his
parents. He has had persistent nonbilious vomiting occur-
ring after nearly every feed for the past 2 weeks. The par-
ents have changed his formula 3 times, but there has been
no change in symptoms. Although the baby has gained
weight, he has not gained as expected. No fever has been
noted. The remainder of the review of systems is negative.
On physical examination, the patient is well-appearing
and is not dehydrated. His abdomen is soft, nontender,
and nondistended. You observe a brief episode where he
arches his back, grimaces, and seems to tighten up
while lying supine. Considering all the possible diagnoses,
you debate what your workup should be... involve multiple imaging modalities as well as con-
A 2-day-old girl is then brought to the ED by her par-
ents. The infant has had 5 episodes of vomiting that day.
The mother reports that the vomit has changed from the
color of colostrum to a green color. The mother and baby
had an uncomplicated delivery and were discharged from
the hospital earlier that day. The infant passed meconium
on day 1 of life and has had 5 wet diapers since birth. The
mother has noted that the infant has not been as vigorous
when attempting breastfeeding since that morning. The
remainder of the review of systems is negative. The physi-
cal examination reveals a lethargic neonate who reacts
minimally to examination. Her abdomen is distended with
quiet bowel sounds, and a slight whimper is elicited with
palpation. The patient appears dehydrated, and there is a
light green stain on the mothers shoulder from the em-
esis. You tell the patients mother that you have concerns
and that you need to work fast to uncover the cause of her
vomiting. What can be the cause of vomiting in this neo-
nate? All bilious emesis is bad, right? Should you call the
surgeon right away, or wait until you have the diagnosis?
Should you get an x-ray, an ultrasound, or a UGI study?
A 4-week-old boy is sent to the ED after being seen in
his pediatricians office for vomiting and weight loss. He
is noted to have lost 8 ounces since his last office visit 1
week prior. His mother reports that, for the past 2 weeks,
he has been spitting up, it has become progressively more
frequent, and is now forceful. She states that the color of
the emesis is the formula she has been feeding him, and
the vomiting occurs after every feed. He still has 4 to 5
wet diapers per day and no diarrhea. The remainder of the
review of systems is negative. On physical examination,
you find a sleeping neonate who reacts to the examination
by crying. You notice that he does not produce many tears
and his diaper is dry. On abdominal examination, you
palpate a possible small mass in the right upper quadrant,
but the baby moves frequently, and the examination is
difficult to reproduce. The remainder of the examination is
noncontributory. As you think about the orders you want
to place, you wonder if a set of electrolytes would be help-
ful. Should you attempt a bedside ultrasound? Which test
is first-line an ultrasound or a UGI study?
Copyright 2014 EB Medicine. All rights reserved. 2
Introduction
Vomiting in the neonate is a common presenting
complaint in the emergency department (ED), with
etiologies ranging from benign to life-threatening.
Vomiting and feeding difficulties have been reported
in 11% to 36% of neonates who visit the ED.1,2 Vomit-
ing (particularly bilious emesis) must be considered
a surgical emergency until proven otherwise. The
incidence of bilious emesis indicative of a surgi-
cal obstruction is reported to be between 20% and
38%.3-7 A timely and accurate diagnosis is the key to
successful management.8 Determining the etiology
of vomiting in the neonate can be difficult and may
sultation with subspecialists. This review will focus
on the evaluation and treatment of neonates with
gastrointestinal causes of vomiting, particularly the
life-threatening etiologies.
Critical Appraisal Of The Literature
A literature search was performed in PubMed and
Ovid MEDLINE, using the search terms vomiting,
neonate, bilious, emesis, gastroesophageal reflux disease,
GERD, malrotation, midgut volvulus, Hirschsprung
disease, hypertrophic pyloric stenosis, necrotizing
enterocolitis, and incarcerated inguinal hernia. Signifi-
cant, well-designed, randomized controlled trials
and meta-analyses were included as well as older
publications that have been frequently referenced in
the medical community. A search of the Cochrane
Database of Systematic Reviews yielded 1 pertinent
publication related to the treatment of neonatal
vomiting.9 One relevant review was not included in
this issue, as it had been withdrawn from the Co-
chrane Library because the authors were unable to
update the review.10 Guidelines released through the
National Guideline Clearinghouse by the American
College of Radiology in 201111 and guidelines from
the North American Society for Pediatric Gastroen-
terology, Hepatology, and Nutrition (NASPGHAN)
in conjunction with the European Society for Pe-
diatric Gastroenterology, Hepatology, and Nutri-
tion (ESPGHAN) in 200912 were reviewed. Both of
these guidelines are consensus statements and not
systematic, evidence-based guidelines. A search of
the American Academy of Pediatrics website did
not reveal any clinical practice guidelines on this
topic. There is a wide range in the quality of clinical
evidence available for the diagnosis and manage-
ment of neonatal vomiting, with most falling into
the moderately strong category. There are limited
prospective studies focused on ED management.
www.ebmedicine.net November 2014
Etiology And Pathophysiology
Vomiting is the forceful expulsion of gastric contents
and may not be normal in the neonate. Vomiting
may represent a complete or partial obstruction of
the gastrointestinal tract, and, when bilious, should
be regarded as a surgical emergency until proven
otherwise.8 Differentiating between vomiting and
regurgitation can often be difficult. Regurgitation is
often normal in the first 3 months of life and, classi-
cally, resolves with time.11
In broad terms, the causes of neonatal vomiting
can be divided into obstructive and nonobstructive
pathologies. Obstructive lesions in neonates can be
life-threatening, and understanding the anatomy of
the gastrointestinal system helps differentiate be-
tween obstructive pathologies of neonatal vomiting.
Lesions that are superior to the sphincter of Oddi
(such as pyloric stenosis) generally present with
nonbilious vomiting. Lesions that are inferior to the
sphincter of Oddi (such as malrotation with midgut
volvulus) are often associated with bilious vomiting.
Of the nonobstructive etiologies, gastroesophageal
reflux is most common in the neonatal period. The
lower esophageal sphincter is located at the junc-
tion between the esophagus and the stomach, and
it is under tonic smooth muscle control. Transient
lower esophageal sphincter relaxations are believed
to be the major mechanism involved in regurgitation
resulting in gastroesophageal reflux. Most episodes
of reflux resolve by 12 to 14 months of age.13-16
Differential Diagnosis
The differential diagnosis for neonatal vomiting is
expansive. Due to its broad differential, emergency
clinicians need to approach the vomiting neonate is
a systematic fashion. Certain elements of the history
and physical examination can aid the clinician in
distinguishing different etiologies. Table 1 presents
differential diagnoses based on obstructive or non-
obstructive processes. It is important for the emer-
gency clinician to keep in mind the similarities and
differences seen among the wide variety of diagno-
ses in obstructive and nonobstructive pathologies. A
thorough history and careful physical examination
will guide the emergency clinician toward elucidat-
ing the cause of vomiting in the neonate.
Obstructive Pathologies
Bilious Etiologies
Obstructive lesions that cause vomiting in the neo-
nate are often considered surgical emergencies and
may present with bilious vomiting. Malrotation is
a developmental anomaly in which the mesenteric
attachment and fixation for the midgut has not
developed, leaving the midgut to rotate around the
mesenteric vessels. Volvulus occurs when perito-
November 2014 www.ebmedicine.net
neal bands (Ladd bands) tighten and occlude the
duodenal lumen.17 This typically presents with
bilious emesis in the first week of life. Infants may
present in critical condition, but more often, they
will appear normal.18 Radiologic evaluation is
required to make this diagnosis. The most serious
complication is intestinal infarction, and the pres-
ence of necrotic bowel is associated with increased
mortality.19 Surgical consultation for correction is
the mainstay of treatment.
Intestinal atresias can present with either
bilious or nonbilious vomiting, depending on the
location, and can occur anywhere along the small
bowel. Characteristically, duodenal atresia has a
double bubble sign on plain abdominal radio-
graphs. (See Figure 1, page 4.) The cause of atresia
is not well-understood, but theories have hypoth-
esized that it may be due to intrauterine vascular
compromise.20 Therapy for atresia of the small
bowel is surgical correction.
Nonbilious Etiologies
Hypertrophic pyloric stenosis (HPS) is one of the
nonbilious obstructive causes of vomiting. HPS
causes gastric outlet obstruction, which is usually
diagnosed between 2 and 12 weeks of life.21 It is
caused by hypertrophy and hyperplasia of the layers
of the pylorus, and it typically presents with projectile
nonbilious emesis, although bilious emesis has been
reported as well.22 The incidence of HPS is estimated
to be 1 to 8 out of 1000 live births, with a 4:1 male
predominance.23 A history of macrolide use in infants
during the first 2 weeks of life has been noted as a risk
factor for the development of HPS.24-26 A recent study
of 880 infants with HPS found a risk ratio of 29.8
Table 1. Differential Diagnosis Of Vomiting In
The Neonate
Obstructive Pathologies
Malrotation with midgut volvulus
Intestinal atresias
Hypertrophic pyloric stenosis
Incarcerated inguinal hernia
Hirschsprung disease
Congenital anomalies (meconium ileus and meconium plug syn-
drome)
Intussusception
Nonobstructive Pathologies
Gastroesophageal reflux, gastroesophageal reflux disease
Overfeeding
Feeding intolerance (cows milk protein allergy, formula intolerance)
Necrotizing enterocolitis
Sepsis/infection/gastroenteritis/gastritis
Kernicterus
Inborn errors of metabolism/congenital adrenal hyperplasia
Increased intracranial pressure
Toxin exposure
Nonaccidental trauma
3 Reprints: www.ebmedicine.net/pempissues
(95% confidence interval [CI], 16.4-54.1) for macro-
lide use.27 Interestingly, the authors of the study also
found maternal macrolide use during breastfeeding
also had a small increased risk ratio of 3.49 (95%
CI, 1.92-6.34). In 50% to 83% of cases, a palpable
olive-sized mass may be found in the right upper
quadrant on physical examination.23,28,29 Ultrasound
is the diagnostic study of choice, and surgical correc-
tion is the most common management. HPS should
be considered in infants with progression of symp-
toms or persistent vomiting.
Inguinal hernias are a common problem encoun-
tered in EDs. Most hernias are easily reducible with
mild manipulation. Incarcerated inguinal hernias
should be suspected in the presence of a tender,
swollen inguinal region that can extend into the
scrotum in males. Incarceration occurs in up to 24%
of infants.30 There is a bimodal age distribution of
occurrence of inguinal hernia with the first peak oc-
curring between 1 and 2 months of age, and the sec-
ond peak occurring around 1 year of age.21 Prompt
attempts at reduction are required, and surgical
management is indicated, if irreducible, to preserve
the bowel segments involved.
Hirschsprung disease is associated with
congenital aganglionic megacolon, and it can be
difficult to diagnose in the newborn. The most com-
mon presenting symptoms are delayed passage of
Figure 1. Radiographic Double Bubble Sign
Associated With Duodenal Atresia
Arrows point to "double bubble" sign.
Used with permission from Loma Linda University, Loma Linda, CA.
Copyright 2014 EB Medicine. All rights reserved. 4
meconium (> 48 h), vomiting, feeding intolerance,
distended abdomen, and apathy.31 Barium enema,
rectal suction biopsy, and anorectal manometry are
all methods of diagnosis, but these do not typically
occur in the ED setting. Diagnosis after the first
week of life is associated with more severe presen-
tation.32 Surgical consultation is required.
Other causes of delayed passage of meconium
include meconium ileus and meconium plug syn-
drome. In the case of meconium ileus, the patient
will fail to pass meconium 24 to 48 hours after birth
and will develop a distended abdomen and possi-
bly bilious emesis. This is caused by obstruction of
meconium in the distal small bowel due to pancre-
atic insufficiency in altering the content of meco-
nium. Contrast enema is usually both diagnostic and
therapeutic, revealing a small-caliber colon. Patients
should be evaluated for cystic fibrosis, as meconium
ileus can be an early sign of cystic fibrosis.33 Infants
with meconium plug syndrome have a similar pre-
sentation as infants with meconium ileus; however,
the plug may be passed with digital rectal stimula-
tion, and contrast enema usually reveals a normal
colon. Most of these infants are otherwise healthy.34
Intussusception is rare in pediatric patients
aged < 3 months, with only 1.5% of cases described
during this age.21 Case reports and case series have
demonstrated that this condition is often misdiag-
nosed as necrotizing enterocolitis in neonates.35-37
Ultrasound, with or without plain film x-ray stud-
ies, is needed for diagnosis, and management is
preferably pneumatic (air) over hydrostatic (con-
trast) enema reduction.38
Nonobstructive Pathologies
Gastroesophageal Reflux And Gastroesophageal
Reflux Disease
Of the nonobstructive lesions, gastroesophageal
reflux is the one of the most common causes of neo-
natal vomiting. Gastroesophageal reflux is a normal
physiologic process, occurring in up to 50% of all
infants.39,40 Gastroesophageal reflux can be seen as a
continuum of symptoms, ranging from mild spit-up
to forceful vomiting. In contrast, gastroesophageal
reflux disease (GERD) is classified by associated
conditions, such as poor weight gain, refusal to feed,
irritability, sleep disturbance, or esophagitis. Extra-
esophageal conditions may include respiratory
symptoms (such as cough, laryngitis, or wheezing).41
Often, a clinical diagnosis is made, but supporting
studies (such as esophageal pH monitoring, upper
gastrointestinal [UGI] contrast studies, scintigra-
phy, and ultrasound) can be of benefit when there
is no clear-cut diagnosis. Controversy surrounds
therapeutic modalities for GERD, which range from
conservative nonpharmacologic measures to phar-
macologic measures and, potentially, surgery.
www.ebmedicine.net November 2014
Overfeeding Inborn Errors Of Metabolism
An important entity to distinguish from GERD is
overfeeding. Overfeeding of the neonate results
in vomiting simply because the stomach cannot
accommodate the amount the caretaker is feeding
the infant. An infant can be fed too frequently, not al-
lowing previous feedings to be completely digested,
or an infant can be fed too large a quantity at each
feeding. This can be determined by questioning the
caretaker about the infants feeding regimen. It is
commonly accepted that the neonate should be fed
approximately 2 to 3 ounces every 3 to 4 hours.
Feeding Intolerance
Feeding intolerances should also be considered as a
cause of vomiting. Both cows milk protein allergy
and formula intolerance can also present with diar-
rhea, occasionally with streaks of blood, abdominal
distention, and discomfort. Often, the infant has
been trialed on multiple formulas by the time of the
ED visit, making pinpointing the offending agent
difficult. This diagnosis may involve trial and error
on the part of the infants pediatrician. While not un-
common, feeding intolerances should be considered
a diagnosis of exclusion in the ED setting.
Necrotizing Enterocolitis
Necrotizing enterocolitis is commonly seen in pre-
mature infants in the neonatal intensive care setting,
but it can also be seen in term newborns. This condi-
tion may present with bloody diarrhea, abdominal
distention, and vomiting. Radiographs are the gold
standard for diagnosis. Management may be medical
or surgical, but should involve a surgical consultation
for definitive management, based upon Bell staging.42
Sepsis And Infection
Sepsis and infection in the neonate can lead to vomit-
ing. Evaluating the septic neonate involves a system-
atic approach that is well-established by the litera-
ture and for which there is an American College of
Emergency Physicians policy statement.43 All infants
aged < 28 days with a fever of 38C should receive
parenteral antibiotics and be admitted to the hospi-
tal. Typically, blood, urine, and cerebrospinal fluid
samples are obtained and analyzed.43 Urinary tract
infection should be considered in the neonate (even
in the absence of fever), as vomiting is reported as a
presenting symptom of urinary tract infection.44,45 An
infant may also have a viral illness (such as gastritis
or gastroenteritis) that can cause neonatal vomiting.
Kernicterus
Kernicterus is another nonobstructive cause of
neonatal vomiting. It is a progressive encephalopa-
thy caused by severely elevated levels of bilirubin,
which is neurotoxic. A jaundiced neonate should be
evaluated early in the course to prevent the develop-
ment of kernicterus.
November 2014 www.ebmedicine.net
Other metabolic conditions that may present with
vomiting are inborn errors of metabolism. Most
states employ newborn screening for certain meta-
bolic conditions, but the results may not be known
immediately. Congenital adrenal hyperplasia is a
metabolic disease affecting the production of cor-
tisol from cholesterol. It can be detected by labora-
tory results and is often brought to the pediatri-
cians attention because of an abnormal newborn
screen. These patients may initially present to the
ED with vomiting and can appear seriously ill
and dehydrated. A key to diagnosis is electrolyte
abnormalities, including hyperkalemia, hypona-
tremia, and hypoglycemia.
Increased Intracranial Pressure
A less common cause of neonatal vomiting (but a
potentially deadly one) is increased intracranial
pressure. This may be due to hydrocephalus, cen-
tral nervous system tumor, head trauma, meningi-
tis, or hemorrhage. A careful history and physical
examination may lead to consideration of one of
these causes.
Other Nonobstructive Etiologies
Every emergency clinician should include exposure
to toxins and nonaccidental trauma in the differ-
ential when evaluating neonates with vomiting.
Often, a high degree of suspicion is necessary to
make these diagnoses.
Prehospital Care
Vomiting in the neonate is often a frightening experi-
ence for the caregiver and may prompt a call to local
emergency medical services (EMS) for evaluation.
As there are life-threatening conditions that may
need to be addressed, prehospital care should be
aimed at efficient stabilization and safe transport.
The severely dehydrated neonate may benefit from
placement of an intravenous line and initiation of
fluid replacement therapy. If there is altered mental
status and concern for hypoglycemia, this should be
assessed and remedied quickly. The most important
aspect of the EMS system in this case is transporting
the patient to the closest and most appropriate facil-
ity capable of caring for the neonate.
Emergency Department Evaluation
The main goals of the ED evaluation are to cor-
rectly identify patients with causes of vomiting
that should be managed surgically and patients
with causes of vomiting that can be appropriately
managed nonsurgically. A thorough history and a
focused physical examination are the key compo-
nents to this assessment.
5 Reprints: www.ebmedicine.net/pempissues
History
Quality Of Emesis
In the stable neonate, the emergency clinician should
proceed with evaluation of the chief complaint with
specific questions focused on the duration and
details of the vomiting. Of utmost importance is the
determination of the quality of the emesis. This is
best done by asking the caregiver the color of the
emesis and not prompting them with the term bil-
ious, as one study demonstrated that most parents
equated bile with the color yellow.46 The identifica-
tion of bilious vomiting is critical, as the chance of
surgical obstruction is higher. Several studies have
evaluated outcomes of neonates with bilious vom-
iting. Godbole and Stringer prospectively evalu-
ated 63 consecutive neonates admitted for bilious
vomiting and identified a surgical cause in 24 of
the patients (38%).7 In another retrospective review
by Malhotra et al, 61 infants with bilious vomiting
were admitted, and 14 patients (23%) had causes of
vomiting that required surgery.3 Lilien et al studied
neonates with bilious vomiting in the first 72 hours
of life and found that 20% had a lesion requiring
surgical intervention.5
Determining whether the emesis is projectile
or progressively worsening may guide the clini-
cian toward an evaluation for pyloric stenosis. Of
patients diagnosed with HPS, several studies have
shown projectile vomiting to be present in 66% to
84% of cases.22,23,47
Feeding Patterns
Details regarding the patients feeding patterns, both
the amount per feeding and the intervals between
feeds, are pertinent to the history. This can aid in
determining whether a patient may have vomiting
due to overfeeding.
Growth
Reviewing the patients birth weight as compared
to the current weight on a growth curve may help to
establish a pattern of insufficient growth. This may
be due to lack of caloric intake related to vomiting
(as in the case of patients with GERD).
Gastroesophageal Reflux Disease
Obtaining further history of feeding refusal, irrita-
bility, back arching, sleep disturbance, and respira-
tory symptoms could aid in the clinical diagnosis
of GERD. One complication of GERD is Sandifer
syndrome, in which infants can have episodes of
torticollis, head-eye version, and dystonic posturing
often confused with seizure disorder. This occurs in
< 1% of patients with GERD, and usually resolves
when GERD is treated.48
Hydration Status, Urine Output, And Stooling
Caregivers should be questioned regarding the
Copyright 2014 EB Medicine. All rights reserved. 6
patients hydration status, particularly the urine
output. The presence of fever or similar symptoms
in other family members may indicate an infec-
tious etiology. The patient's stooling habits should
be discussed with the caregivers: Has meconium
passed in the newborn? Is there blood in the stool?
Is constipation a problem? Green, yellow, and brown
stools can be considered normal in newborns, and
formula-fed babies may have fewer and more-solid
stools compared to breastfed infants who may have
more frequent and looser stools.
Physical Examination
Vital signs (heart rate, respiratory rate, blood pres-
sure, temperature, and oxygen saturation) should be
obtained on all patients with vomiting. The patient
should be weighed without clothes to obtain an ac-
curate measurement. The neonate should be evalu-
ated for signs of toxicity, such as overall appearance,
work of breathing, and perfusion, and abnormalities
should be attended to with urgency. Jaundiced skin
should prompt emergency clinicians to evaluate
for causes of hyperbilirubinemia. A full or bulging
fontanelle may be the only subtle sign of elevated
intracranial pressure, as a comprehensive neurologi-
cal examination on a neonate is often limited by
the inability of the patient to cooperate and follow
commands. Careful examination for signs of dehy-
dration, such as a sunken fontanelle, absence of tears
with crying, poor capillary refill, and decreased skin
turgor, should be performed.
The abdominal examination is essential in all
neonates with vomiting. A distended abdomen is
more likely to be present in patients with a surgical
cause of vomiting. Chen et al found that 61.8% of
full-term newborns with abdominal distension had
a congenital malformation (including congenital
megacolon, anal atresia, malrotation, and intestinal
atresia).49 Emergency clinicians should assess for
hepatomegaly on abdominal examination, as this
can be associated with some inborn errors of metab-
olism. In patients with HPS, a palpable olive-sized
mass in the right upper quadrant is reported in 50%
to 83% of cases.23,28,29
A complete physical examination includes eval-
uation of the groin and genitalia. An incarcerated
inguinal hernia can be seen as a hard mass overlying
the inguinal canal. It may be erythematous, and it is
usually tender to palpation. In female infants with
congenital adrenal hyperplasia, the genitalia may be
ambiguous. In the case of reported constipation or
bloody stool, the emergency clinician can perform
a rectal examination to assess rectal tone and the
presence or absence of stool in the vault and perform
a visual inspection for blood, as may be the case in
necrotizing enterocolitis or intussusception. In the
case of Hirschsprung disease, a classic rectal exami-
nation reveals no stool in the rectum, with explosive
www.ebmedicine.net November 2014
discharge of foul-smelling gas upon removal of the
examiners digit.50
Serial examinations and observation of a feed-
ing may help identify diagnoses such as overfeed-
ing. Emergency clinicians should also examine the
patient for subtle signs of nonaccidental trauma
possibly related to head or abdominal trauma.
Diagnostic Studies
There are multiple diagnostic modalities used in the
evaluation of a neonate with vomiting. Choosing the
most appropriate study based upon basic histori-
cal and physical examination features will facilitate
management of the patient.
Bedside Tests
If the vomiting neonate is difficult to arouse, a point-
of-care glucose is warranted; appropriate interven-
tions depend on the results. A urine dipstick test can
aid in assessing for signs of infection and dehydra-
tion. If the emergency clinician has access to bedside
point-of-care arterial blood gas and electrolyte test-
ing, this can be helpful in assessing infants who are
toxic or ill-appearing.
Laboratory Studies
There is no single laboratory test that will elucidate
the etiology of vomiting. It is generally recognized
that certain patterns of electrolytes may accompany
particular diagnoses. The most well-known is the
hypokalemic, hypochloremic, metabolic alkalosis of
HPS.51 However, 2 studies have demonstrated that
the majority of patients presenting with HPS have
normal electrolytes.52,53 This may be attributed to
earlier age at diagnosis, as Tutay et al confirmed that
patients who were diagnosed later in life were more
likely to have electrolyte abnormalities.53 In an effort
to distinguish severe GERD from HPS, one study
examined serum electrolytes and determined that a
serum bicarbonate level > 29 mmol/L and a chlo-
ride level < 98 mmol/L had high positive predictive
values (0.96 and 0.97, respectively) and specificity
(0.99 for both), but low sensitivity (0.36 and 0.50,
respectively).54 Patients who are significantly dehy-
drated may only show abnormalities of metabolic
acidosis or may have an elevated blood urea nitro-
gen (BUN)/creatinine ratio, typically > 20. Another
pattern of electrolytes to consider is hyperkalemia,
hyponatremia, and hypoglycemia in patients with
congenital adrenal hyperplasia. This diagnosis is
typically made with newborn screening, but this
should be considered in an infant presenting with
vomiting and this pattern of electrolytes. For the
patient who is well-appearing and well-hydrated,
electrolytes are expected to be normal, and these
tests are not usually necessary.
November 2014 www.ebmedicine.net
Radiographic Imaging Studies
Bilious Emesis
Unlike laboratory studies, radiographic studies are
the key to determining the etiology of vomiting in
the neonate. Bilious vomiting in the neonate should
be regarded as a surgical emergency, and it requires
further radiographic evaluation for diagnosis con-
firmation. However, surgical consultation should
not be delayed for diagnostic studies in an unstable
neonate with bilious vomiting.
The American College of Radiology guidelines for
evaluation of neonatal bilious emesis suggest obtain-
ing abdominal radiographs in all patients, but, even
if they are negative, pursuing a UGI contrast study is
warranted.11 The sensitivity and specificity of plain
abdominal radiographs for obstruction in the presence
of bilious emesis have been reported to be 44% to 50%
and 80% to 97%, respectively, indicating that > 50% of
cases would be missed based on radiographs alone.3,5
When an obstructive pattern is present, radiographs
are most helpful, but they cannot provide a definitive
diagnosis, and other studies will be needed.17 In the
case of necrotizing enterocolitis, the gold standard for
diagnosis is abdominal radiographs. Bell staging of
the disease is based on radiographic results that will
dictate therapeutic decisions.42
The UGI contrast study is likely to be the most
conclusive study in the case of bilious emesis. It is
the gold standard for diagnosis of malrotation with
midgut volvulus as for intestinal atresias, and it
can suggest the diagnosis of meconium ileus. The
findings seen on a UGI study for malrotation with
midgut volvulus are: (1) obstruction seen high in the
gut; (2) abnormal duodenojejunal junction; and (3)
abnormal position of the proximal jejunal loops to
the right of midline.55 (See Figure 2.) The UGI study
Figure 2. Malrotation On Upper
Gastrointestinal Study
Dilated duodenum
Bands
Jejunum
A B
A. Graphic representation of anatomic abnormality encountered in
malrotation. B. Appearance of A on upper gastrointestinal study.
Reprinted from Journal of Pediatric Surgery, Volume 7(2), Alan J.
Simpson, John C. Leonidas, Irwin H. Krasna, Jerrold M. Becker, Keith
M. Schneider, Roentgen diagnosis of midgut malrotation: value of
upper gastrointestinal radiographic study, pages 243-252, Copyright
1972, with permission from Elsevier.
7 Reprints: www.ebmedicine.net/pempissues
is not without flaws, however, as both false-positive
(15%)56,57 and false-negative (3%-6%)56,58,59 rates
have been reported. The most common reason for an
inaccurate reading is an abnormal jejunal position.60
In one trial, 41% of patients with a preoperative
diagnosis of malrotation had discrepant findings at
diagnostic laparoscopy.61
Although the UGI has been well established as
the gold standard for evaluation of bilious emesis,
it does have its disadvantages, including exposure
to ionizing radiation and contrast administration,
which may require nasogastric tube placement.55 De-
spite its inadequacies, UGI studies are still superior
to barium enema, which often has false-positive
results in infants due to a mobile cecum (which can
be a normal finding in infants).55
Another modality for evaluation of bilious em-
esis is the contrast enema. For detection of malrota-
tion, the contrast enema is inferior to UGI. In one
study, 17% of patients with malrotation underwent
contrast enema that was reported as inconclu-
sive, and a confirmatory UGI was necessary.62 The
contrast enema can be used as a screening tool for
Hirschsprung disease, however. The presence of
a transition zone in the rectosigmoid colon and
delayed evacuation of barium are considered highly
suggestive of Hirschsprung disease. The sensitiv-
ity for barium enema in Hirschsprung disease is
reported to be 70% to 80% with specificity ranging
from 64% to 76%.63-65 Bilious emesis and the absence
of a transition zone are risk factors for false-positive
results of contrast enema.66 In the case of inconclu-
sive enema, anorectal manometry and rectal suction
biopsy are regarded as the most accurate tests for
Hirschsprung disease,65,67 but these are not usually
undertaken in the ED setting.
preventing unnecessary surgery.72 A drawback is
that ultrasonography is heavily operator-dependent.
Since the advent of ultrasonography for diagnosing
HPS, the number of patients with a clinical find-
ing of a palpable olive-sized mass has fallen from
previous reports of 78% to 83% to only 50%.23,28,29
This may be due to earlier diagnosis when the mass
is smaller, or due to diminishing clinical skills of
clinicians.
The American College of Radiology offers a
guideline for imaging choices when evaluating
projectile, nonbilious emesis.11 Projectile vomiting
should be concerning for HPS, and an ultrasound
of the pylorus is recommended. If ultrasound is
negative, but clinical suspicion is high, a UGI series
should be performed.
Gastroesophageal Reflux Disease
For nonprojectile, nonbilious vomiting, the most
common cause is likely related to gastroesophageal
reflux. The diagnosis of gastroesophageal reflux dis-
ease is usually made clinically, based on a thorough
history and physical examination. Deal et al devel-
oped age-specific questionnaires to determine symp-
Figure 3. Ultrasound Of Hypertrophic Pyloric
Stenosis

Nonbilious Emesis
Hypertrophic Pyloric Stenosis
The major gastrointestinal causes of nonbilious
emesis are HPS and GERD. It can be difficult to
differentiate an infant with early HPS from an
infant with gastroesophageal reflux. Consideration
should be given to the diagnosis of HPS in infants
with progressively worsening episodes of vomiting.
Ultrasonography is currently regarded as the gold
standard for diagnosis of HPS, and it was first de-
scribed in 1977 by Teele.68 During an ultrasound for
HPS, measurements are taken of the pyloric channel
length and thickness. (See Figure 3.) In general, py-
loric measurements of 15 mm (length) and 3 mm
(wall thickness) are considered positive for HPS.69
Sensitivity of ultrasonography for HPS is reported to A. Muscle wall thickness; B. Channel length.
be 97% to 100%, with a specificity of 100%.70-72 It has
been suggested that the measurement criteria should Reprinted from Evaluation of Hypertrophic Pyloric Stenosis by
be altered for patients aged < 21 days, as, initial sono- Pediatric Emergency Physician Sonography, Adam B. Sivitz, Cena
graphic evaluation of these patients is often normal Tejani, Stephanie G. Cohen, Academic Emergency Medicine, pages
or borderline.73 An advantage of ultrasonography 646-651. Copyright 2013 by the Society for Academic Emergency
is that it is easily repeated and is cost-effective for Medicine; with permission from John Wiley & Sons.

Copyright 2014 EB Medicine. All rights reserved. 8 www.ebmedicine.net November 2014

tom scores in the clinical diagnosis of GERD.74 They
used back arching, choking, gagging, episodes of
hiccups, irritability/fussiness, refusal to feed, vomit-
ing, and regurgitation as symptoms. They found that
infants with GERD had more severe symptoms than
the controls for all symptoms except refusal to feed
and irritability/fussiness.
For the workup of potential GERD, a number of
imaging modalities exist, but a good clinical history
and physical examination are most useful. The stud-
ies are nonurgent and not expected to be performed
in the ED, but rather in conjunction with the pedia-
trician on an outpatient basis. The emergency clini-
cian should be aware of the diagnostic options to
enable proper discussion with the caregivers. There
is no consensus on the diagnostic study of choice for
the diagnosis of GERD. Diagnostic options include
esophageal pH monitoring, UGI study, multichannel
intraluminal impedance monitoring, gastroesopha-
geal scintigraphy, ultrasonography, and endoscopy.
The most common diagnostic methods are UGI
study, pH monitoring, and endoscopy. The Ameri-
can College of Radiology guidelines for evaluation
of the vomiting neonate recommend that the gold
standard for diagnosing GERD is the esophageal pH
probe.11 Again, these diagnostic tests are not typi-
cally performed in the ED, but may be part of an
inpatient or outpatient workup for GERD, depend-
ing on the patients needs.
Treatment
Initial treatment of the vomiting neonate in the ED
is focused on stabilization of airway, breathing, and
circulation. Placement of an intravenous line to
deliver fluid for restoration of fluid balance may be
indicated. If a peripheral intravenous line cannot
be placed quickly, the emergency clinician should
consider placement of an intraosseous or umbilical
line. The criteria for placing an umbilical line include
a patient aged < 2 weeks and no signs of infection
around the umbilical stump.75 Prompt diagnosis and
treatment of hypoglycemia is warranted. There is
controversy over what is considered hypoglycemia
in the neonate, and levels have been established
based on the patients number of hours of life. A
meta-analysis by Alkalay et al demonstrated that,
after 48 hours, the cutoff for the fifth percentile of
neonatal blood glucose was 48 mg/dL.76 It is recom-
mended that infants should be given 2 mL/kg of
10% dextrose in water (D10W) as a bolus, with glu-
cose measurements repeated every 10 to 15 minutes
until normalized. This is a smaller dose of glucose
than is typically given, in an attempt to avoid hyper-
glycemia. Electrolyte abnormalities may be recog-
nized from basic blood work and should also be
remedied, particularly before the patient undergoes
any surgical procedures.
November 2014 www.ebmedicine.net
The particular diagnosis reached after thorough in-
vestigation will mandate what therapies are necessary.
This review will approach treatment in 2 broad catego-
ries: (1) obstructive management and (2) nonobstruc-
tive management.
Management Of Obstructive Etiologies
Malrotation With Midgut Volvulus
When the emergency clinician suspects the diagnosis
of malrotation with midgut volvulus, the most im-
portant next step is to consult the pediatric surgeon,
since bowel necrosis is correlated with increased
mortality. A nasogastric tube should be placed to
decompress the proximal bowel obstruction created
by the malrotation. Intravenous fluid resuscitation
and maintenance are critical, and the patient should
be placed on NPO (nothing by mouth) status. Surgi-
cal correction of the gut anomaly is undertaken
through the Ladd procedure. This procedure was
first reported in 1936, and involves reduction of vol-
vulus, division of mesenteric bands, replacement of
the small bowel on the right and the large bowel on
the left side of the abdomen, and appendectomy.77
Recent retrospective studies have looked at open
versus laparoscopic Ladd procedure and concluded
that the laparoscopic procedure is the therapy of
choice, as it has no increase in complications or op-
erative time, and the time to return to full feeds and
length of hospital stay are shorter.78,79
Hypertrophic Pyloric Stenosis
The initial treatment of HPS is correction of any
electrolyte abnormality prior to surgical procedure,
in order to minimize risks associated with anesthe-
sia.80 Once the patient is stabilized, pyloromyotomy
is performed by a surgeon, during which an incision
is made through the layers of the pylorus, effectively
relieving obstruction. Multiple meta-analyses have
been performed comparing laparoscopic versus
open techniques for pyloromyotomy. For time-relat-
ed outcomes, a laparoscopic approach is preferred,
but there are, otherwise, no significant differences
in results.81-84 Interestingly, a study was completed
looking at postoperative outcomes in patients who
had a nasogastric tube placed preoperatively. Pa-
tients with nasogastric tube placement had a signifi-
cantly higher number of postoperative episodes of
vomiting and a longer length of stay.85
Incarcerated Inguinal Hernia
Incarcerated inguinal hernia is a diagnosis requiring
prompt recognition and the involvement of pediat-
ric surgeons to optimize bowel salvage. Typically,
history and physical examination are all the emer-
gency clinician needs to diagnose this entity. Manual
reduction should be attempted in the ED with or
without the pediatric surgeon present. One study
found that manual reduction is successful in 96% of
patients.86 One technique of reduction is to apply
9 Reprints: www.ebmedicine.net/pempissues
 Clinical Pathway For Management Of Neonatal Vomiting
In The Emergency Department

Neonate presents with Stabilize airway, breathing,

vomiting and circulation

Projectile vomiting or Obtain ultrasound

YES Bilious emesis? NO YES
suspicion of HPS? (Class I)

NO

Ultrasound positive for

YES NO Well-appearing?
Stable patient? HPS?

YES NO YES
NO

Symptoms consistent Consult pediatric surgeon,

Obtain plain abdominal
with GERD? who will obtain additional
films (Class II) and/or UGI
diagnostic studies as
contrast study (Class I)
needed
YES NO

YES Obstruction? Persistent vomiting?

NO YES NO

Consult pediatric surgeon, Consider nonsurgical Counsel caregivers Discharge home

who will obtain additional causes of vomiting and on nonpharmacologic Ensure close follow-
diagnostic studies as admission for observation treatment up with primary care
needed Consider H2 blocker physician
Ensure close follow- Counsel caregivers on
up with primary care symptoms warranting
physician return to ED

Abbreviations: ED, emergency department; GERD, gastroesophageal reflux disease; HPS, hypertrophic pyloric stenosis.

Class Of Evidence Definitions

Each action in the clinical pathways section of Emergency Medicine Practice receives a score based on the following definitions.
Class I Class II Class III Indeterminate
Always acceptable, safe Safe, acceptable May be acceptable Continuing area of research
Definitely useful Probably useful Possibly useful No recommendations until further
Proven in both efficacy and effectiveness Considered optional or alternative treat- research
Level of Evidence: ments
Level of Evidence: Generally higher levels of evidence Level of Evidence:
One or more large prospective studies Nonrandomized or retrospective studies: Level of Evidence: Evidence not available
are present (with rare exceptions) historic, cohort, or case control studies Generally lower or intermediate levels of Higher studies in progress
High-quality meta-analyses Less robust randomized controlled trials evidence Results inconsistent, contradictory
Study results consistently positive and Results consistently positive Case series, animal studies, Results not compelling
compelling consensus panels
Occasionally positive results

This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patients individual needs. Failure
to comply with this pathway does not represent a breach of the standard of care.
Copyright 2014 EB Medicine. 1-800-249-5770. No part of this publication may be reproduced in any format without written consent of EB Medicine.

Copyright 2014 EB Medicine. All rights reserved. 10 www.ebmedicine.net November 2014

pressure with one hand along the proximal ingui-
nal canal and use the other hand to push the gas or
contents back with gentle pressure. Pressure should
be increased over the distal aspect of the hernia to
reduce the bowel.87 Some emergency clinicians will
provide analgesia and/or sedation for this proce-
dure. No guidelines exist for medication choices.88,89
Previously, after manual reduction, there was a wait-
ing period of 24 to 48 hours prior to open hernior-
rhaphy to allow time for edema to subside. Now,
authors are advocating for laparoscopic hernior-
rhaphy sooner after manual reduction. Nonetheless,
outcome measures have indicated that the laparo-
scopic technique requires more operating room time
and patients have more postoperative pain. Open
herniorrhaphy remains the mainstay of therapy if
surgical correction is warranted.86,90
Intestinal Atresias
Intestinal atresias, once recognized, need to be surgi-
cally corrected. The emergency clinician should refer
the patient for surgical consultation. Traditionally,
the lesion is repaired with transverse supraumbilical
laparotomy with exteriorization of the bowel and
excision of atretic ends, followed by anastomosis of
the remaining bowel. As with a number of surgi-
cal lesions, trials of laparoscopic management have
been undertaken. Small, early case series have dem-
onstrated comparable postoperative courses (when
compared to open surgery) and improved satisfac-
tion with cosmetic results.91-93
Hirschsprung Disease
Once the diagnosis of Hirschsprung disease is
made and the patient is referred to the surgeon,
the surgical management varies widely, depending
upon the capabilities of the surgeon and the treat-
ing facility. The procedures all accomplish a similar
goal of resecting the aganglionic segment of colon
and reuniting the remaining bowel. This can occur
by creating a diverting colostomy with delayed
definitive repair until the child is of larger size, or
by a single-stage pull-through with anastomosis. A
2009 meta-analysis found no operative technique to
be superior with respect to perioperative outcomes,
including mortality, morbidity, rate of enterocolitis,
and functional outcome.94
Intussusception
Intussusception, while rare in the neonatal period,
is managed in the same fashion as in older children.
A recent meta-analysis of 5559 patients determined
that pneumatic enema reduction of intussusception
is preferred to contrast enema, as there were sig-
nificantly fewer failed attempts in patients without
operative indications.38 Studies of older patients
have demonstrated that there is no need to admit
patients after reduction and that a short observa-
November 2014 www.ebmedicine.net
tion period in the ED for toleration of oral trials
and pain control is adequate.95,96 No studies have
been completed on postreduction management of
neonates with intussusception. For more informa-
tion on pediatric intussusception, see the January
2012 issue of Pediatric Emergency Medicine Practice
titled "The Young Child With Lower Gastrointes-
tinal Bleeding Or Intussusception," available at:
www.ebmedicine.net/intussusception.
Management Of Nonobstructive Etiologies
Gastroesophageal Reflux Disease
The emergency clinician is likely to encounter
patients with GERD, and, therefore, understand-
ing its management is pertinent. Numerous efforts
have been made to attempt to control the symptoms
of GERD, but few, if any, have proven effective.
Interventions for GERD can range from conserva-
tive to pharmacological to surgical. Patients with
the suspected diagnosis of gastroesophageal reflux
are managed with reassurance and recommenda-
tions for close follow-up of symptoms of GERD. The
emergency clinician should keep in mind that this
is a normal occurrence in most neonates. Neonates
with GERD may need to be started on pharmaco-
therapy or be admitted for further evaluation.
Nonpharmacologic Treatment
The emergency clinician can counsel caregivers on
some of the more conservative approaches to man-
aging GERD. The most frequently studied interven-
tion for GERD is that of thickening the infants feeds,
if the infant is aged > 4 weeks. A meta-analysis
reports that this is moderately effective at reducing
symptoms.97 Caregivers can thicken feedings by
adding dry rice cereal or changing to commercially
thickened formulas. Unfortunately, this does not
decrease the index measures of reflux, but it does
decrease clinical regurgitation. Studies have shown
that thickening feeds results in a decrease in the total
number of reflux episodes, slows gastric emptying
times, and decreases the amount of time infants
spend crying.98-100 Other thickening agents added
to formulas and proven to decrease symptoms are
cornstarch and locust bean gum.101-104
Another nonpharmacologic strategy for GERD
treatment is adjusting the positioning of the patient
during the postprandial period. One study by Sha-
laby et al found GERD symptoms to improve in 24%
of infants after 2 weeks of avoiding overfeeding and
avoiding seated or supine positions.105 Positions that
may benefit the infant with GERD include sitting
completely upright and prone. Flat prone position-
ing is better than flat supine.106-109 The amount of
reflux seen in the supine position with the head ele-
vated is equal to that of the supine and flat position.
Interestingly, the infant car seat position appears to
exacerbate reflux symptoms.110,111 Prone position-
11 Reprints: www.ebmedicine.net/pempissues
ing in the postprandial period is recommended for
patients with reflux, if the infant is awake and being
observed.
There is a small subset of children with GERD
occurring as a result of a cows milk protein allergy.
Vomiting decreased significantly in infants with the
elimination of cows milk protein from the diet, and
reintroduction was shown to cause recurrence of
symptoms.112 The presentations of GERD and cows
milk protein allergy are very similar, making this di-
agnosis difficult. The clinician may have heightened
suspicion for cows milk protein allergy if the patient
has frequent diarrhea with mucus and/or blood
streaks, or if there are other signs of atopy in the
infant. Definitive diagnosis in the ED is not possible
with this entity, but, if it is suspected, the patient
may need referral to a gastroenterologist and/or al-
lergist for further testing.112,113
Pharmacologic Treatment
When nonpharmacologic treatment fails, pharma-
cologic management can be considered. The emer-
gency clinician can discuss these options with the
caregivers; however, generally, prescription of these
medications will be from the patients primary care
physician. The 2 major classes of pharmacologic
agents are acid suppressants and prokinetic agents.
Acid Suppressants
Acid suppressants include histamine-2 (H2) receptor
antagonists and proton pump inhibitors (PPIs), both
of which function as antacids.
First-line pharmacologic therapy for GERD is
the use of H2receptor-blocker medications, such
as cimetidine, ranitidine (Zantac), and famotidine
(Pepcid). In one study, infants given once-daily
dosing of ranitidine reduced time of gastric pH
< 4 by 44%, and twice-daily dosing reduced time
by 90%.114 A similar study of famotidine showed
0.5 mg/kg/day decreased the frequency of reflux,
and doubling the dose also improved crying time and
volume of reflux.115 One randomized trial of infants
and children with erosive esophagitis compared
cimetidine to placebo and showed significant improve-
ment in clinical and histopathologic scores.116 Research
demonstrates that H2receptor-blocker therapy results
in clinically significant improvement in GERD symp-
toms, and a trial is recommended in the neonate with
vomiting attributed to this cause when conservative
measures have failed.
Another acid suppression medication is the
PPI. One study in infants with symptoms sugges-
tive of GERD who were treated empirically with
a PPI showed no efficacy over placebo.117 A sys-
tematic review in 2011 concluded that PPIs should
not be prescribed for infants with GERD, as they
have not been shown to be efficacious in reducing
GERD symptoms when compared to placebo, and
Copyright 2014 EB Medicine. All rights reserved. 12
evidence supporting their safety is lacking.118 This
recommendation is surprising in light of the success
reported with PPIs in adults, but this may be at-
tributed to symptoms in adults being more distinct
and better expressed than in infants. The studies
included in the review were largely subjective, with
measurements of GERD based upon questionnaires
answered by the caregivers. More trials in infants are
necessary in order to change this recommendation.
Acid blockers are not without side effects, which
can be a reason to stop their use or to avoid initiation
of this therapy. There are documented risks associ-
ated with acid suppression, and multiple authors
have demonstrated statistically significant evidence
of increases in the risk of community-acquired
pneumonia (odds ratio [OR] 6.39; 95% CI, 1.38-
29.7), gastroenteritis (OR, 3.58; 95% CI, 1.87-6.86),
candidemia (OR, 1.76; 95% CI, 1.16-2.66), and even
necrotizing enterocolitis (OR, 1.71; 95% CI, 1.34-2.19)
in infants.119-122
Prokinetic Agents
Prokinetic agents, such as metoclopramide
(Reglan), facilitate gastric emptying. In 2008, a
systematic review of metoclopramide concluded
that there is a poor level of evidence to recom-
mend its use, and there are inconclusive safety
and efficacy profiles.123 Twelve studies were
included in the review, and, of those, only 5 were
blinded randomized controlled trials. Within those
5 studies, one found no difference in scintigraphy
during metoclopramide use compared to placebo,
and 2 others found no improvement in pH mea-
surements compared to placebo. The remaining 2
studies did demonstrate improvement in gastric
emptying rate compared to placebo. A number
of studies reported adverse events due to the
medication, but incidence could not be calculated
due to small study size, frequency of nonblinded
study designs, and lack of systematic criteria to
define an adverse event. The described side effects
included lethargy, irritability, galactorrhea, extra-
pyramidal reactions, and tardive dyskinesia.
Surgical Management
When medical management fails, the last option for
treatment of GERD is surgical management; how-
ever, referral will likely be made by the patients
primary care physician. The most common surgical
procedure performed is Nissen fundoplication. The
procedure consists of repair of the esophageal hiatus
with plication of the fundus around the esophagus
in a 360-fashion. This can be performed open or
laparoscopically without significant differences in
complications.124 One of the most common com-
plications is recurrence of reflux in up to 14% of
patients undergoing fundoplication.125
www.ebmedicine.net November 2014
Necrotizing Enterocolitis
Necrotizing enterocolitis can present with distended
abdomen, bilious or nonbilious emesis, and occa-
sionally bloody stools. Initial assessment and stabi-
lization are key to management. Diagnosis is con-
firmed with the abdominal radiograph. Treatment is
based upon staging indicated by the Bell classifica-
tion.42 Medical management consists of intravenous
hydration, bowel rest, antibiotics, and serial abdomi-
nal radiographs. Surgical management may involve
exploratory laparotomy or placement of a perito-
neal drain. Typically, pneumoperitoneum is cause
for surgical management, but a recent prospective
trial concluded that early surgical therapy may be
warranted to reduce morbidity and mortality from
necrotizing enterocolitis.126 A Cochrane review and
another randomized controlled trial have demon-
strated that there is no harm or benefit to choosing
peritoneal drain over exploratory laparotomy.9,127
There has been a decrease in mortality shown in
patients treated with probiotics.128
Management Of Other Nonobstructive Causes Of
Neonatal Vomiting
The management of the other etiologies of nonob-
structive vomiting (such as inborn errors of metabo-
lism, infections, and increased intracranial pressure)
are beyond the scope of this article. When surgical
causes of neonatal vomiting are ruled out, consider-
ation should be given to the multiple other medical
causes of vomiting and treated accordingly.
Special Populations
Premature infants can represent a very fragile por-
tion of the population that an emergency clinician
might encounter after a patient has been discharged
home from the neonatal intensive care unit (NICU).
While most instances of necrotizing enterocolitis are
diagnosed in the NICU, it is important to recognize
that it can still occur in patients who are discharged
home, as well as in full-term infants.
Premature infants are also at a higher risk of
having inguinal hernias that may become incarcer-
ated. The risk in full-term newborns is 3.5% to 5%,
but in preterm infants, the risk is 9% to 11%. In very
lowbirth-weight and preterm (< 28 weeks gesta-
tion) infants, risk of incarcerated inguinal hernias
can approach 30%.129 There is controversy surround-
ing when to electively repair these hernias, and,
thus, a number of patients are discharged home
from the NICU prior to repair and may present with
an incarceration.130
Controversies And Cutting Edge
Cutting edge improvements in the care of neonatal
vomiting are abundant, and most involve the use of
November 2014 www.ebmedicine.net
ultrasound. The benefits of ultrasound include the
absence of harmful effects of radiation, and the fact
that it is readily available, noninvasive, and quick.
One small prospective study demonstrated that
ultrasound had a 100% positive predictive value in
detecting surgical candidates with bilious emesis,
but when ultrasound was inconclusive, follow-up
radiologic contrast studies were necessary.131 Ul-
trasound is capable of diagnosing malrotation with
midgut volvulus by identifying the whirlpool pat-
tern of the superior mesenteric vein and mesentery
around the superior mesenteric artery. This twisting
of the mesenteric vascular structures is best seen on
color Doppler imaging.132 The whirlpool sign has an
88% sensitivity, but it is not considered pathogno-
monic.133 A 2011 systematic review concluded that
ultrasound is a good screening tool for malrotation,
but its false-negative rate (between 15% and 30%) is
too high to be conclusive.134 There are no published
studies on the use of bedside ultrasound by emer-
gency clinicians for suspected malrotation.
Ultrasound has also been shown to be diagnos-
tic in cases of necrotizing enterocolitis. Free gas and
focal fluid collections have been correlated with
cases of necrotizing enterocolitis requiring surgi-
cal intervention.135 Ultrasound has even demon-
strated abnormalities in the bowel wall prior to the
appearance of these findings on plain abdominal
radiography.136,137 It can be argued that monitoring
the bowel with ultrasonography might help guide
management of patients with necrotizing enterocoli-
tis. However, despite these advances, it is still agreed
that plain radiographs are the gold standard for
evaluation of necrotizing enterocolitis.
Bedside ultrasound techniques performed in
the ED are gaining popularity. Sivitz et al demon-
strated that pediatric emergency clinicians could
identify HPS on bedside ultrasound with 100%
sensitivity and 100% specificity.138 There are cur-
rently no studies comparing ultrasound skills of
technologists/radiologists to emergency clinicians
in diagnosing HPS on ultrasound. Because it is
less invasive and without the harmful effects of
ionizing radiation, ultrasonography appears to be
becoming more useful as a diagnostic modality for
evaluating neonatal vomiting.
Disposition
The disposition of a neonate with vomiting depends
upon the suspected diagnosis. Identifying emergent
surgical causes of vomiting is extremely important.
When a surgical cause is found, patients should
be admitted to the hospital with pediatric surgery
consultation. An infant who is well-appearing, gain-
ing weight appropriately, and tolerating feeds in the
ED is safe for outpatient referral. For nonemergent
causes of neonatal vomiting (such as reflux), families
13 Reprints: www.ebmedicine.net/pempissues
 Risk Management Pitfalls For Neonatal Vomiting
1. The infant had bilious vomiting and did not
look well, but I decided to wait until comple-
tion of the diagnostic study before calling the
surgeon.
In a toxic-appearing neonate with bilious
vomiting, the diagnosis of a malrotation with
midgut volvulus must be considered. Evaluation
by a pediatric surgeon as soon as this diagnosis
is suspected is warranted, as bowel necrosis is
correlated with increased mortality.
2. I evaluated a well-appearing infant with a
history of vomiting. When asked, the mother
confirmed the emesis was bile. The patient
appeared well and had a completely normal ex-
amination, but because of the history of bilious
vomiting, I proceeded to place an NG tube, call
a surgeon, and order a UGI study.
Most caregivers (71%) equate bile with the
color yellow. Asking the caregiver to describe
the color of the emesis and not prompting them
with the term bile could avoid an unnecessary
workup in a well-appearing infant.
3. I admitted an infant with abdominal disten-
sion, irritability, and vomiting, but did not
consider a surgical abdomen, as the vomiting
was nonbilious and nonprojectile.
Surgical etiologies for neonates with vomiting
should still be considered with nonbilious
vomiting in the presence of other concerning
signs and symptoms, such as abdominal
distention and irritability.
4. For this infant with bilious vomiting, the
initial abdominal radiograph did not show air
fluid levels, so I determined that further imag-
ing was not necessary.
The sensitivity and specificity of abdominal
plain radiographs for obstruction in the presence
of bilious emesis have been reported to be 44%
to 50% and 80% to 97%, respectively, indicating
that > 50% of cases would be missed if the
diagnosis is based on radiographs alone.
5. The infant had been spitting up since birth,
so I didnt think of considering a surgical is-
sue, although the vomiting had become more
frequent and more forceful.
In a study of return ED visits, patients
diagnosed with reflux and/or vomiting at the
first visit had a high frequency of admission
(55%) and diagnosis of pyloric stenosis at the
second visit (26%).
Copyright 2014 EB Medicine. All rights reserved. 14
6. I made the clinical diagnosis of GERD in a
well-appearing infant and started treatment
with metoclopramide.
The recommendations for treatment of GERD in
well-appearing infants include nonpharmacologic
treatments and consideration of pharmacologic
treatment. Considerations include avoidance of
cows milk protein and postprandial position
changes. When nonpharmacologic treatment
fails, H2-receptor blockers can be considered. Due
to significant side effects and lack of evidence of
effectiveness in the treatment of GERD, prokinetic
agents (such as metoclopramide) are no longer
recommended for the treatment of GERD in infants.
7. I discharged a 3-week-old baby with vomit-
ing with a diagnosis of GERD because the
infant was too young to consider HPS and the
laboratory studies did not show hypokalemia,
hypochloremia, or metabolic alkalosis.
Several authors have demonstrated that the
majority of patients with HPS have normal
electrolytes. Up to 88% of patients have no
electrolyte abnormalities on admission. If the
diagnosis of HPS is suspected, ultrasound
should be ordered.
8. I always recommend mothers with infants
with suspected GERD to thicken formula and
sit the infant in a car seat after feeds.
Although this was traditionally thought to
decrease reflux symptoms, sitting upright in
car seats after feeds has been shown to increase
reflux symptoms in infants.
9. I did not feel a palpable olive-sized mass in
the abdomen, so I discharged the vomiting
infant home with diagnosis of reflux.
Since the advent of ultrasonography for
diagnosing HPS, the portion of patients with a
clinical finding of a palpable olive-sized mass has
fallen from previous reports of 78% to 83% to only
50%. This may be due to earlier diagnosis, which
renders the mass smaller and not as palpable.
10. I suspected the diagnosis of an incarcerated
hernia in an infant with a painful inguinal mass
and abdominal distension and ordered an ab-
dominal ultrasound to confirm the diagnosis.
Incarcerated inguinal hernia is a diagnosis
requiring prompt recognition and involvement
of pediatric surgeons to optimize bowel salvage.
Typically, history and physical examination are
all the clinician needs to diagnose this entity and
manual reduction should be attempted in the ED.
www.ebmedicine.net November 2014
should be educated about conservative antireflux
therapies, including feeding smaller volumes more
frequently and postprandial position recommenda-
tions. Neonates who do not look well (even those
in whom the emergency clinician suspects GERD)
may need admission for further workup, especially
if they are failing to thrive. Choosing to start phar-
macotherapy from the ED is at the discretion of the
emergency clinician, and discussing this with the
patients primary care provider is preferred, but not
required. Before discharge, it is important to advise
the family on reasons to return to the ED. In a study
of return ED visits, patients diagnosed with reflux
and/or vomiting at the first visit had high frequency
of admission (55%) and diagnosis of pyloric stenosis
at the second visit (26%). 139
Summary
Vomiting in the neonate has a broad differential
diagnosis, and its workup can range from simple
observation in the ED to multiple radiological stud-
Time- And Cost-Effective
Strategies
Do not perform unnecessary tests on neonates
with vomiting while in the ED. In the well-
appearing and well-hydrated infant without
concerning signs or symptoms, history and
physical examination should be sufficient to
manage the patient.
Risk Management Caveat: Ensure that the
caregivers have close follow-up with the
primary care physician. The infant may not
have lost weight, but it could be early in
the course of GERD (if this is the suspected
diagnosis), and close follow-up can prevent the
patient from presenting to the ED with failure
to thrive. Secondly, if suspicion for pyloric
stenosis is too low to obtain an ultrasound
for this visit, educate the caregivers about the
signs and symptoms and advise them to return
appropriately if they develop.
Do not perform screening electrolytes on all
neonates with vomiting, as even those with
surgical causes will most likely have normal
electrolytes.
Risk Management Caveat: It is important to
recognize that there are entities in which electro-
lytes being abnormal may help the emergency
clinician make the diagnosis (such as congenital
adrenal hyperplasia). These infants tend to pres-
ent as ill-appearing and/or dehydrated. Surgi-
cal cases may need electrolytes drawn to follow
trends or for preoperative purposes.
November 2014 www.ebmedicine.net
ies and surgical consultation. It is important for
the emergency clinician to appreciate the variety
of presentations and to be able to recognize the red
flags indicating serious underlying pathology. These
patients should be assessed quickly for potentially
life-threatening conditions. Diagnostic imaging
modalities will vary, depending on the differential
diagnosis, but pediatric surgical consultation should
not be delayed in ill-appearing children. A thorough
history is extremely important in differentiating the
many possible causes of neonatal vomiting. The
well-appearing infant who is gaining weight appro-
priately and does not have a surgical condition on
evaluation in the ED will likely be safe for discharge
home. As always, it is suggested that the caregivers
have close follow-up with the primary care physi-
cian for reassessment.
Case Conclusions
After reviewing the history of the 3-week-old boy, you
determined that he presented with symptoms consistent
with reflux. His poor weight gain made him a more likely
candidate for GERD. The episode that you observed was
most likely a component of Sandifer syndrome, which
is often related to severe GERD. Intravenous hydration
and stabilization were not necessary. You counseled the
parents on the condition and recommended close follow-
up and discussion with his pediatrician as well as a trial
of H2-blocker therapy.
The 2-day-old girl had a very concerning presenta-
tion. She was ill-appearing and showed signs of toxicity.
Her bilious emesis was a red flag, and you promptly noti-
fied the pediatric surgeon of her presence in the ED. The
patient required intravenous fluid resuscitation and place-
ment of an NG tube for decompression of the abdomen.
After appropriate resuscitation, the child was evaluated
by the pediatric surgeon and taken to the operating room
emergently for surgical correction with a laparoscopic
Ladd procedure.
After examination, you determined that the 6-week-
old boy had HPS. Because the patient was dehydrated,
you ordered electrolyte studies. You obtained an ultra-
sound of his abdomen and palpated a very small olive-
sized mass. The laboratory studies revealed that the
patient was hypokalemic, hypochloremic, and in a state of
metabolic alkalosis. He was referred for consultation by a
pediatric surgeon and admitted for pyloromyotomy.
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15 Reprints: www.ebmedicine.net/pempissues
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84. Oomen MW, Hoekstra LT, Bakx R, et al. Open versus laparo-
Copyright 2014 EB Medicine. All rights reserved. 18
scopic pyloromyotomy for hypertrophic pyloric stenosis: a
systematic review and meta-analysis focusing on major com-
plications. Surg Endosc. 2012;26(8):2104-2110. (Meta-analysis;
4 studies, 502 patients)
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cohort study. J Pediatr Surg. 2010;45(5):1020-1023. (Retrospec-
tive chart review; 109 patients)
86. Koivusalo A, Pakarinen MP, Rintala RJ. Laparoscopic her-
niorrhaphy after manual reduction of incarcerated inguinal
hernia. Surg Endosc. 2007;21(12):2147-2149. (Retrospective
chart review; 40 patients)
87. Puri P, Guiney EJ, ODonnell B. Inguinal hernia in infants:
the fate of the testis following incarceration. J Pediatr Surg.
1984;19(1):44-46. (Retrospective chart review; 158 patients)
88. Goldman RD, Balasubramanian S, Wales P, et al. Pediatric
surgeons and pediatric emergency physicians attitudes
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hernia reduction. J Pain. 2005;6(10):650-655. (Questionnaire;
245 respondents)
89. Al-Ansari K, Sulowski C, Ratnapalan S. Analgesia and seda-
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Clin Pediatr (Phila). 2008;47(8):766-769. (Retrospective chart
review; 99 patients)
90. Koivusalo AI, Korpela R, Wirtavuori K, et al. A single-
blinded, randomized comparison of laparoscopic versus
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(Randomized controlled trial; 89 patients)
91. Li B, Chen WB, Wang SQ, et al. [Transumbilical laparoen-
doscopic single-site surgery in the treatment of neonatal
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92. Li B, Chen WB, Wang SQ, et al. Laparoscopy-assisted sur-
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35 cases. Pediatr Surg Int. 2012;28(12):1225-1228. (Prospective
study; 35 patients)
93. Abhyankar A, Mukhtar Z. Laparoscopy-assisted surgery for
neonatal intestinal atresia: single-center experience. Asian J
Endosc Surg. 2011;4(2):90-93. (Prospective study; 3 patients)
94. Marquez TT, Acton RD, Hess DJ, et al. Comprehensive
review of procedures for total colonic aganglionosis. J Pediatr
Surg. 2009;44(1):257-265. (Meta-analysis; 19 studies, 161
patients)
95. Whitehouse JS, Gourlay DM, Winthrop AL, et al. Is it safe to
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115. Orenstein SR, Shalaby TM, Devandry SN, et al. Famotidine
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November 2014 www.ebmedicine.net
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118. van der Pol RJ, Smits MJ, van Wijk MP, et al. Efficacy of pro-
ton-pump inhibitors in children with gastroesophageal re-
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121. Saiman L, Ludington E, Dawson JD, et al. Risk factors for
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tive study; 2157 patients)
122. Chung EY, Yardley J. Are there risks associated with empiric
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2013;3(1):16-23. (Systematic review; 14 studies)
123. Hibbs AM, Lorch SA. Metoclopramide for the treatment
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124. Siddiqui MR, Abdulaal Y, Nisar A, et al. A meta-analysis of
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134. Quail MA. Question 2. Is Doppler ultrasound superior to
19 Reprints: www.ebmedicine.net/pempissues
 upper gastrointestinal contrast study for the diagnosis of 4. Which of the following conditions is classi-
malrotation? Arch Dis Child. 2011;96(3):317-318. (Systematic cally associated with nonbilious vomiting?
review; 4 studies, 1025 patients)
a. Pyloric stenosis
135. Silva CT, Daneman A, Navarro OM, et al. Correlation of
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b. Malrotation with midgut volvulus
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ence of bilious emesis is approximately:
137. Kim WY, Kim WS, Kim IO, et al. Sonographic evaluation of
a. 5% to 10% b. 23% to 30%
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Radiol. 2005;35(11):1056-1061. (Prospective cohort study; 40 c. 44% to 50% d. 65% to 70%
patients)
138. Sivitz AB, Tejani C, Cohen SG. Evaluation of hypertrophic 6. The diagnostic study of choice for pyloric ste-
pyloric stenosis by pediatric emergency physician sonogra- nosis is:
phy. Acad Emerg Med. 2013;20(7):646-651. (Prospective study; a. UGI study
67 patients)
b. Ultrasound
139. Perry AM, Caviness AC, Allen JY. Characteristics and diag-
c. Computed tomography scan
noses of neonates who revisit a pediatric emergency center.
Pediatr Emerg Care. 2013;29(1):58-62. (Retrospective chart d. pH probe
review; 147 patients)
7. The gold standard examination for evaluating
for GERD is:
CME Questions a. Esophageal manometry
b. Ultrasound
Take This Test Online! c. UGI
d. Esophageal pH probe
Current subscribers receive CME credit absolutely
free by completing the following test. Each issue 8. Which of the following nonpharmacologic
includes 4 AMA PRA Category 1 CreditsTM, 4 ACEP treatment options for GERD in infants has not
Category I credits, 4 AAP Prescribed credits, and 4 been shown to provide clinical improvement
Take This Test Online!
AOA Category 2A or 2B credits. Monthly online in reflux symptoms?
testing is now available for current and archived a. Thickening formula with locust bean gum
issues. To receive your free CME credits for this b. Sitting upright in a car seat
issue, scan the QR code below with your smart- c. Lying prone after feeds
phone or visit www.ebmedicine.net/P1114. d. Thickening formula with rice cereal

9. Which of the statements in regard to treatment

with a PPI for infants with GERD is TRUE?
a. Treatment with a PPI is indicated after H2
receptor-blocker medication failure.
b. Treatment with a PPI has been shown to
cause liver failure in infants.
1. The incidence of neonatal bilious emesis c. Treatment with a PPI is associated with an
indicating an obstruction requiring surgery is increased risk of pyloric stenosis in infants.
approximately: d. When compared to placebo, treatment with
a. < 5% b. 20% to 38% a PPI has not been shown to be efficacious in
c. 60% to 74% d. 100% reducing symptoms.

2. Most episodes of reflux in infants resolve by 10. Risk factors associated with acid suppression
the age of: in the treatment of GERD include all the fol-
a. 1 month b. 6 to 9 months lowing EXCEPT:
c. 12 to 14 months d. 18 months a. Increased rates of community-acquired
pneumonia
3. Current literature reports that a palpable olive- b. Gastroenteritis
sized abdominal mass in a patient with HPS is c. Candidemia
found in what percentage of cases? d. Sudden infant death
a. < 10% b. 32% to 40%
c. 50% to 83% d. > 90%

Copyright 2014 EB Medicine. All rights reserved. 20 www.ebmedicine.net November 2014

 Coming Soon In
Pediatric Emergency Medicine Practice
Management Of Upper
Gastrointestinal Bleeding In
Pediatric Patients In The Emergency
Department
AUTHORS: Nicole Schacherer, MD; Kelli Patronis, MD;
and Jill Miller, MD
Upper gastrointestinal (GI) bleeding (defined as
bleeding that originates in the gastrointestinal tract,
superior to the ligament of Treitz) is an uncommon
problem that accounts for 0.2% of presenting
complaints in children visiting the emergency
department. Managing pediatric patients suspected of
having an upper GI bleed can be anxiety-provoking, as
the differential diagnosis of an upper GI bleed ranges
from benign to life-threatening conditions and carries
the potential for significant morbidity and mortality
if management is delayed. This issue of Pediatric
Emergency Medicine Practice reviews the common
differential diagnosis of upper GI bleeding and focuses
on the clinical evaluation and management of children
with a suspected upper GI bleed.
Time- And Cost- Effective Strategies
Prompt intravenous access is essential in
managing pediatric patients with suspected GI
bleeding.
Screening laboratory studies for patients with
suspected upper GI bleed include: complete
blood count, comprehensive metabolic panel,
prothrombin time, partial thromboplastin time,
international normalized ratio.
Blood type and screen should be ordered if there
are worrisome findings on history or physical
examination. Nasogastric tube lavage should
be performed in the presence of worrisome
symptoms and signs.
November 2014 www.ebmedicine.net
Kawasaki Disease And Pediatric
Patients: Evidence-Based
Management In The Emergency
Department
AUTHORS: Kara Seaton, MD; and Anupam
Kharbanda, MD
Kawasaki disease, also known as mucocutaneous lymph
node syndrome, was first described in Japan in 1967. It
is currently the leading cause of acquired heart disease
in children in the United States. Untreated disease may
lead to the formation of coronary artery aneurysms
and sudden cardiac death in children. This vasculitis
presents with fever for 5 days and a combination
of key criteria. Because each of the symptoms is
commonly seen in children, the disease can be difficult
to diagnose, especially in children who present with
the incomplete form of the disease. At this time, the
etiology of the disease remains unknown, and there
is no single diagnostic test to confirm the diagnosis.
This issue reviews the presentation, diagnostic criteria,
and management of Kawasaki disease. Physicians
and healthcare providers need to consider Kawasaki
disease as a diagnosis in pediatric patients presenting
with prolonged fever, as prompt evaluation and proper
management can significantly decrease the risk of
serious cardiac sequelae.
Time- And Cost-Effective Strategies
Children with fever < 5 days or symptoms that
are inconsistent with Kawasaki disease can be
discharged from the emergency department if they
are well-appearing and if close follow-up with a
primary care provider can be arranged.
Children who have symptoms consistent with
incomplete Kawasaki disease but whose laboratory
testing is not definitive should be referred for
echocardiography. The presence of coronary artery
ectasia or perivascular echocardiogram brightness
can aid in finalizing the diagnosis, ensuring that the
child can be treated in a timely manner.
21 Reprints: www.ebmedicine.net/pempissues
 The Pediatric Emergency Medicine
Practice Audio Series Vol. II
In addition to presenting a summary of 4 issues of Pediatric Emergency Medicine Practice, Vol. II of the Pediatric Emergency
Medicine Practice Audio Series focuses on supplemental information to augment the issues. As an added bonus, you can also
earn up to 1.25 AMA PRA Category 1 CreditsTM at no extra charge. You only need to spend 17 to 31 minutes listening to each
topic, and the entire collection contains over an hour-and-a-half of evidence-based audio content, with recommendations that
you can immediately begin applying to your practice. The Pediatric Emergency Medicine Practice Audio Series Vol. II includes an
MP3 download (available as soon as you complete your purchase).

PRODUCT DETAILS:
Speaker: Dr. Andrew Sloas
Recording date: August 1, 2014
Length: 86 minutes (individual topics run from 17-31 minutes)
CME: 1.25 AMA PRA Category 1 CreditsTM
CME expiration date: August 1, 2017
Price: $59

Topic #1: Management Of Headache In The Pediatric Emergency Department

This issue is designed to serve as a refresher on the basics of diagnosing and treating pediatric headache for the academic and
community-based emergency clinician. With so little understood about the causes of adult and pediatric headache, this audio
review aims to take the practitioner one step further into the most cutting-edge theory behind the etiology and treatment
options available. An accurate differential is the cornerstone to implementing the most effective treatments for primary and
secondary headaches. The treatment of pediatric patients who present with acute headaches is generally the same as in
adult patients, with minor exceptions. Those exceptions are presented in detail to aid the emergency clinician in successful
management of pediatric headaches and effective treatment strategies unique to the pediatric population are explored.

Topic #2: Management Of Acute Asthma In The Pediatric Patient: An Evidence-Based Review
The emergency clinician must know how to evaluate and treat patients who present with all degrees of asthma severity. While
asthma is not limited to children, the differential diagnosis may be broader in the pediatric patient population because they
are sometimes unable to provide an adequate history. This audio resource serves as a reminder that not all that wheezes is
asthma, but most patients with known asthma do wheeze. A thorough review of the most current literature on this subject
is presented, and the subtle differences between diagnosing and treating pediatric patients, as opposed to adults, are also
covered. In extreme asthma situations, treatment for pediatric patients is not usually the same as treatment for adult patients.
When managed correctly, asthma is a disease process in which the need to intubate a crashing patient can be avoided.

Topic #3: Evidence-Based Emergency Management Of The Pediatric Airway

There is nothing in emergency medicine that is more stress-provoking or carries more serious consequences than intubating
a pediatric patient. Whether you work 5 days a week or 5 days a month, the difficult pediatric airway is going to find you.
Will you be ready? The subtle differences between effectively intubating pediatric and adult patients are minimal, but never
is it more important to understand those nuances than when you have a pediatric patient in respiratory arrest. Emergency
clinicians often flounder in this situation because of lack of experience and understanding of the differences between adult
and pediatric airways. This audio resource explores those differences in a manner that allows the emergency clinician to
command control from the most routine to the most difficult pediatric airway. This audio review not only serves as a survey of
the basics, but also lays out memory tools, mnemonics, and treatment strategies that build on the adult/general emergency
clinicians well-founded knowledge of the adult airway.

Topic #4: Capnography In The Pediatric Emergency Department: Clinical Applications

By the very definition of the specialty, every emergency clinician preforms sedation, resuscitation, and intubation. Emergency
clinicians who still rely on pulse oximetry to guide these types of interventions and procedures may quickly find themselves
behind the times. The advent of waveform capnography has provided the safest possible approach to patients with
potential ventilation issues. Such a device provides a potential early warning system that can alert clinicians far in advance
of impending respiratory arrest and of return of spontaneous circulation before a pulse check. This audio review provides a
detailed explanation of the current and future uses of capnography by exploration of the most current literature. The most
validated levels of end-tidal CO2 with waveform capnography and its physiologic interpretation are presented for immediate
application into practice.

Purchase your copy today at www.ebmedicine.net/PEMPAUD14!

Copyright 2014 EB Medicine. All rights reserved. 22 www.ebmedicine.net November 2014

 EB Medicine Enhancements
Are Headed Your Way!
EB Medicine is in the process of making several improvements, enhancements, and changes to its
product line and services:

In Fall 2014, a redesigned website for EB Medicine will go live, with improved navigation and search, a
cleaner look, and additional content features (including blog pages and discussions). We look forward
to your feedback and participation all you have to do is register on the EB Medicine site, if you have
not already done so, and join the discussion!

With greater focus on online content, EM Critical Care will no longer be published as a separate journal,
and its critical care content will be merged into Emergency Medicine Practice. William Knight, MD, the
Editor-in-Chief of EM Critical Care, is joining the EMP Editorial Board as the Critical Care Section Editor.
EM Practice Guidelines Update will be discontinued in its current form, but it will be published quarterly
on the website. Sigrid Hahn, MD, continuing in her role as Guidelines Editor, will lead online discussions
on important topics in practice guidelines.

Another new feature will be a twice-monthly Editors Choice newsletter to provide you with
information on all EB Medicine publications, bringing to the forefront both current issues and archived
topics that are trending in the medical community.

Visual Diagnosis is a featured blog on the new website that provides you with a case synopsis and a
picture, allowing you to answer the question: Whats the diagnosis? You will be provided with Clinical
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 Physician CME Information
Date of Original Release: November 1, 2014. Date of most recent review: October 15,
2014. Termination date: November 1, 2017.
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing
Medical Education (ACCME) to provide continuing medical education for physicians. This
activity has been planned and implemented in accordance with the Essential Areas and
Policies of the ACCME.
Credit Designation: EB Medicine designates this enduring material for a maximum of 4
AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate
with the extent of their participation in the activity.
ACEP Accreditation: Pediatric Emergency Medicine Practice is also approved by the
American College of Emergency Physicians for 48 hours of ACEP Category I credit per
annual subscription.
AAP Accreditation: This continuing medical education activity has been reviewed by the
American Academy of Pediatrics and is acceptable for a maximum of 48 AAP credits per
year. These credits can be applied toward the AAP CME/CPD Award available to Fellows
and Candidate Fellows of the American Academy of Pediatrics.
AOA Accreditation: Pediatric Emergency Medicine Practice is eligible for up to 48
American Osteopathic Association Category 2A or 2B credit hours per year.
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Pediatric Emergency for emergency physicians.

Target Audience: This enduring material is designed for emergency medicine physicians,
physician assistants, nurse practitioners, and residents.
Medicine Practice Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical
decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose

Has Gone Mobile! and treat the most critical ED presentations; and (3) describe the most common
medicolegal pitfalls for each topic covered.
Discussion of Investigational Information: As part of the newsletter, faculty may be
presenting investigational information about pharmaceutical products that is outside
You can now view all Pediatric Emergency Food and Drug Administration approved labeling. Information presented as part of this
activity is intended solely as continuing medical education and is not intended to promote
Medicine Practice content on your iPhone off-label use of any pharmaceutical product.
Faculty Disclosure: It is the policy of EB Medicine to ensure objectivity, balance,
or Android smartphone. Simply visit independence, transparency, and scientific rigor in all CME-sponsored educational
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Presenters must also make a meaningful disclosure to the audience of their discussions
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Standards, and Guidelines, all faculty for this CME activity were asked to complete a full
disclosure statement. The information received is as follows: Dr. Ratnayake, Dr. Kim, Dr.
On our mobile site, you can: Choi, Dr. Jones, Dr. Vella, Dr. Wang, Dr. Damilini, and their related parties report no
significant financial interest or other relationship with the manufacturer(s) of any
commercial product(s) discussed in this educational presentation.
View all issues of Pediatric Emergency Medicine
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Method of Participation:
Take CME tests for all Pediatric Emergency Print Semester Program: Paid subscribers who read all CME articles during each
Medicine Practice issues published within the last Pediatric Emergency Medicine Practice 6-month testing period, complete the CME
3 years thats over 100 AMA Category 1 CreditsTM! Answer And Evaluation Form distributed with the June and December issues, and
return it according to the published instructions are eligible for up to 4 hours of CME
credit for each issue.
View your CME records, including scores, dates of
Online Single-Issue Program: Current, paid subscribers who read this Pediatric
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And more! Hints will be provided for each missed question, and participants must score 100%
to receive credit.
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Copyright 2014 EB Medicine. All rights reserved. 24 www.ebmedicine.net November 2014