Chapter 26

Unique Considerations in the

Neonate and Infant: Bile-Stained

Vomiting in the Neonate

Robert T. Peters and Sean S. Marven

Key Points

››Bile in vomit or gastric aspirate is green.

››Any child with bilious vomiting/bile-stained aspirates should be referred to a pediatric surgeon urgently.

››Malrotation with midgut volvulus is a life-threatening emergency

26.1  Introduction

It is normal for babies in the first few months of life to bring up small amounts of milk during or following feeds (possetting).As long as they are otherwise well and continue to grow then nothing further need be done.

This chapter concerns bile-stained, i.e., green vomiting in the first month of life. Any neonate with bilious vomiting or bile-stained aspirates should be referred urgently to a pediatric surgeon to rule out an obstructive cause of the vomiting. Over one third of neonates admitted to a pediatric surgical unit with bilious vomiting may have a surgical cause.1 Bile enters the gut in the second part of the duodenum and obstruction at any point below this level can result in bilious

P.P. Godbole et al. (eds.), Guide to Pediatric Urology and

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Surgery in Clinical Practice, DOI: 10.1007/978-1-84996-366-4_26,

© Springer-Verlag London Limited 2011

240 R.T. Peters and S.S. Marven

FIGURE 26.1.  Neonate with bilious aspirate.

vomiting. It is possible that yellow vomit/aspirate may be seen early in intestinal obstruction but it would normally become green. Obstruction proximal to the second part of the duodenum, e.g., esophageal atresia or pyloric atresia (rare) will therefore not cause bilious vomiting.

Amongst parents and healthcare professionals there is little agreement about the color of bile in the newborn. When shown four shades of yellow and four shades of green as part of a questionnaire study, 56% of parents, 25% of GPs and 10% of midwives did not choose any of the shades of green as a possible match for bile.2 It is therefore paramount when referred or seeing a neonate with reported vomiting that a clear history is taken from the parents or referring clinician about the actual color of the vomit/aspirate (Fig. 26.1).

26.2  Assessment of the Neonate

With Bilious Vomiting

Assessment of the neonate includes a detailed maternal, pregnancy and labor history with a search for clues that may

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give the cause for the vomiting. Points from the history include:

History

Maternal			Labor
•	Medical conditions		•	Mode of delivery
•	Medications		• Risk factors for sepsis
•	Family history		•	Condition at birth
•	Consanguinity		•	meconium-stained liquor
Pregnancy			• green liquor (fetal vomiting)
•	Antenatal scans		Early neonatal period
	–	Timing	•	Vitamin K given?
	–	Bright or dilated	•	Any feeds given/tolerated?
		Bowel
			•	Delayed/failure to pass
				meconium
			•	onset of vomiting/color

The examination of the neonate includes an assessment of its general condition with a search for co-existing abnormalities and it may provide an estimate of the level of obstruction if present and a search for co-existing abnormalities:

Examination

Respiratory condition	External appearance of
Hydration/perfusion	perineum/anus
Jaundice	Sacrum/spine normal?
Dysmorphic features	Hernia?
Degree of abdominal distension

Initial investigations will be guided by your assessment of the child so far and the clinical setting you are in. The

242 R.T. Peters and S.S. Marven

following should be considered but are by no means a prescriptive list nor exhaustive:

Investigations

Bedside	Radiological
• Urine dipstix	• Supine plain abdominal
	x-ray

•Capillary blood gas

•Bilirubin Laboratory

•Contrast studies (usually in tertiary pediatric centre

–Upper or lower GI contrast

•	Full blood count	– (Ultrasound)
	(¯ platelets NEC/sepsis)
•	Lactate
	( NEC/ischemia)
•	Biochemistry (note
	renal function is
	maternal in first 24 h)

The purpose of the assessment is to determine the cause of the vomiting and guide initial management. The key features in neonatal bowel obstruction are:

1.Bile-stained vomiting

2.Abdominal distension

3.Failure to pass or delayed passage of meconium

The level of obstruction determines the degree of abdominal distension.A neonate with a high obstruction may have no or a small degree of abdominal distension. They may also pass meconium initially and are likely to have onset of vomiting early. Conversely, a neonate with more distal obstruction will usually not pass meconium and may tolerate feeds initially. Over the first 24 h of life the abdomen will become progressively distended and they will then begin to vomit. At birth there is no air in the gastrointestinal tract but in a normal child it can take as little as 6 h for swallowed air to reach the rectum.