Vomiting in the Newborn

1. Vomiting in the Newborn Not uncommon for some vomiting in 1st few hours and days after birth Overfeeding, poor burping DDx: GI: obstruction, reflux, milk allergy, NEC Infection: Sepsis, Meningitis, UTI Endocrine: Adrenal hyperplasia CNS: Increased ICP Drugs Bilious vomiting is a medical emergency!

2. Upper GI problems  vomiting Esophageal: first feed, soon after feed excessive drooling if T-E fistula, risk of aspiration Small bowel atresias Malrotation and volvulus Achalasia Chalasia/GER Pyloric stenosis } Need to r/o

6. Lower GI Obstruction Presents with: Distention Failure to pass meconium Vomiting is a later sign Extrinsic vs intrinsic obstruction DDx: Imperforate anus, Hirschprung, meconium ileus, meconium plug, ileal atresia, colonic atresia

10. Constipation > 90% pass meconium in first 24 h If ‘constipation’ is present from birth: Consider causes of GI obstruction If present after birth: Consider Hirschprungs, hypothyroidism, anal stenosis NB: Some breastfed babies normally stool only once every 5-7 days Premature infants often have delayed meconium passage

11. Jaundice First 24 h or conjugated at ANY time = ALWAYS abN Etiology: Unconjugated 1. RBC destruction/hemolytic : Isoimmune, RBC membrane, enzymes, hgbinopathies Hematoma Sepsis (mixed hemolytic and hepatocellular damage) Hypoxia 2. Conjugation Abnormalities: Breast Milk Jaundice Metabolic/Genetic: Gilbert, Crigler-Najjar, Hypothyroidism 3. Increased Enterohepatic Circulation: GI dysmotility or obstruction Breast feeding jaundice

12. Later onset: Conjugated 1. Hepatocellular damage: Viral Bacterial Metabolic: TPN, CF, tyrosinemia, other 2. Post hepatic: biliary atresia choledochal cyst Jaundice

13. Jaundice - Work-Up History and physical examination Bilirubin - total and direct Blood type and Coomb’s Hemoglobin Reticulocyte count Smear Septic workup +/- Abdominal Ultrasound +/- Metabolic, Viral workup

14. Risk factors for kernicterus Prematurity Hemolysis Asphyxia Acidosis Infection Cold stress Hypoglycemia

15. Treatment of Jaundice Nutrition/hydration Phototherapy Exchange transfusion

16. Anemia Hemorrhage Feto-maternal Feto-placental Feto-fetal Intracranial or extracranial Rupture of internal organs Hemolysis Prematurity Treatment: Transfuse if necessary

17. Endocrine Issues - Hypothyroidism Screen because too late for proper neurodevelopment if wait Signs: Poor feeding Constipation Prolonged jaundice Large fontanelles Umbilical hernia Dry skin

19. Endocrine Issues – Ambiguous Genitalia Congenital adrenal hyperplasia 21-hydroxylase deficiency = most common enzyme abN Signs = vomiting, diarrhea, dehydration, shock, convulsions, clitoris or phallic enlargement Watch for electrolyte imbalances If suspect, send lab tests and treat with steroids

21. Endocrine Issues – Infant of a Mom with Diabetes Increased Risk of: Congenital malformations Increased incidence with poor glycemic control Growth disturbances Metabolic disturbances Hypoglycemia, hypocalcemia Respiratory: RDS, TTN Hematologic: Polycythemia  Hyperbilirubinemia Cardiovascular problems: Hypertrophic cardiomyopathy

23. Hypoglycemia Definition: BS <2.6 prem and bottle fed term BS <2.0 breastfed ** No clear safe cutoff for all Pathophysiology: Lack of supply Lack of reserve (low glycogen): IUGR Inability to use/produce: metabolic Increased utilization: sepsis Increased insulin production

24. Hypoglycemia Treat by supplying glucose needs: Term: supply minimum of 4-6 mg/kg/min Preterm: supply minimum of 6-8 mg/kg/min Look for cause … if severe or persists beyond 48-72h of life ‘Critical Sample’ of blood and urine

25. Neonatal seizures: Etiology

26. Thank you! Questions?