Having a new baby is a joyful yet stressful experience. Your great love for your new child will drive you to do everything possible to keep your precious cargo safe. In this month’s blog series I have attempted to explain the most important things you need to know to give your newborn the best chance at a healthy and happy start in life. This includes the importance of breastfeeding, preventing SIDS, and awareness of dangers of serious infection. Today’s blog is about the perils of intestinal obstruction.
Feeding volumes gradually increase over the first several days of life; therefore, your infant’s intestine system is largely unchallenged before you leave the hospital. Unfortunately, 1 in 1500 children will experience a bowel obstruction. Bowel obstruction is when the intestine is kinked or blocked, preventing the contents from moving through, which can be very dangerous. Some of these are detected before birth or in the hospital but many are not. Of those babies that make it to surgery an estimated 16 % will die. Early detection and prompt treatment of bowel obstruction is essential to improve outcome. Whenever the intestines are obstructed there is a chance of compromised blood supply which causes the intestines to die or produces serious infection (sepsis) which I discussed last week.
The challenge in detecting bowel obstruction early is distinguishing abnormal vomiting from normal regurgitation of infancy. Most babies regurgitate or spit up to some degree. Some newborns spit-up frequently and occasionally large amounts. Most infants spit-up infrequently and small amounts. Vomiting should not be considered normal and may be a sign of bowel obstruction while routine spitting, or regurgitation, is a normal phenomenon associated with gastroesophageal reflux. Reflux itself can very rarely lead to complications such as esophagitis, feeding problems, and difficulty gaining weight. These problems can be serious but are not imminently life threatening like a bowel obstruction. For a discussion of reflux please see http://www.gikids.org/content/22/en/refulx-gerd/infants
Normal reflux is effortless and not bothersome to the infant. The volumes may intermittently be large but they are not expelled under pressure with fire hydrant force spewing across the room. Normal spit-ups exit the mouth effortlessly and cascade down the front of the child splattering onto floors, furniture, and parents. The child is calm and content before he throws up and remains pleasant afterward. Parents of course many not find it too pleasant.
Signs that your infant is having problematic vomiting and not just reflux include the following: green stomach contents, acting sick while vomiting, looking pale or seeming distressed, projecting large vomits that shoot or spray a distance out of the mouth, repeated waves of expelling stomach contents, or looking miserable after vomiting.
Green vomit is an emergency symptom in an infant indicating possible bowel obstruction and requiring immediate attention. One must assume the intestines are obstructed and that the blood supply may be compromised until proven otherwise. Any child vomiting green should be seen by a physician immediately.
Yellow stomach content is a more difficult dilemma. Early breastfeeding colostrum has a light yellow tinge and, if associated with normal appearing spit up, can be normal. Some children with recurrent vomiting from an intestinal virus will have yellow vomits after several milk color vomits. They should still be evaluated urgently but the risk of intestinal obstruction is low. Infants who randomly vomit bright yellow, or whose initial vomit of a series is bright yellow, should be considered at high risk of obstruction and be seen emergently.
Any newborn with fever over 100.4 rectally or other symptoms of serious infection with vomiting should be seen emergently. See the last blog post about sepsis.
Normal reflux is often scary to parents because babies gag, choke, cough, and sputter to protect their airway. This is not a sign of disease or bowel obstruction. See previous blog post on SIDS. The best treatment for reflux is to place the infant over your shoulder, tummy down, upright, or at a 45 degree angle while they clear their airway. The head should be in neutral position. This should only be done while infants are awake, right after feeding, or during a reflux episode. Babies should still be put to sleep flat on their backs. They will protect their airway in the case of a reflux episode.
Hopefully things go smoothly with your newborn and there are no complications. My hope is that this information will help you to stress less by knowing what signs to watch for that might indicate a serious illness. Please let us know if there are any problems and bring any questions you have to your child’s first checkup two to three days after leaving the hospital and at two weeks of age. Canyon View Pediatrics has evening and weekend hours and after hour phone services if you have questions or problems.
John Bennett M.D. FAAP
Malrotation of the intestines in children: The effect of age on presentation and therapy
J Pediatr Surg. 1990 Nov;25 (11):1139-42.
Neonatal Intestinal Obstruction: A 15 Year Experience in a Tertiary Care Hospital
Journal of Clinical and Diagnostic Research. 2016 Feb, Vol-10(2): SC10-SC13