Postgrad Med J: first published as 10.1136/pgmj.23.261.339 on 1 July 1947. Downloaded from 339

INFANTILE VOMITING AND DIARRHOEA By G. H. NEWNS, M.D., M.R.C.P. Physician, Hospital for Sick Children, Great Ormond Street

A classification of the chief causes of diar- interval of from io days onwards, and may rhoea and vomiting in infancy is given below. sometimes be delayed for as long as six-eight Diagnosis of the cause of vomiting in infancy weeks. There is no completely satisfactory can only be arrived at after a careful considera- explanation of the delay in the appearance of tion of the signs and symptoms. symptoms. Pyloric spasm is an important factor in the causation of the obstruction and Vomiting this does not apparently occur immediately after birth. Symptoms disappear at about the IL Obstructive end of the fourth month though the hyper- Congenital hypertrophic pyloric stenosis. trophy persists for many months longer. Congenital atresia or stenosis of the intes- tine. Congenital pyloric stenosis has a much Oesophageal stenosis. greater incidence in males than females- Achalasia of cardia of stomach. about ten to one-and it is much commoner in first-born babies. It occasionally occurs in by copyright. Intussusception. more than one child in a family and it has been II. Non-Obstructive reported in both of identical twins. Overfeeding. The onset of vomiting is generally abrupt Due to aerophagy. and the mother may be able to name the actual Rumination. day of onset. Previous to this time the baby Habit vomiting. has gained weight and thrived. The vomiting Allergic vomiting. rapidly assumes a projectile character, the Vomiting secondary to infection (often vomit sometimes being thrown several feet. http://pmj.bmj.com/ associated with Fluid is often regurgitated through the nose. diarrhoea). The child usually vomits after each feed, Vomiting and Diarrhoea though not all the vomits are projectile. The vomit is copious, contains undigested food, but I. Gastroenteritis. Infection of the bowel no bile. with pathogenic organisms. The infant is usually constipated because II. Due to dyspepsia. very little food is passing into the intestine. In on September 27, 2021 by guest. Protected III. Secondary to parenteral infection. some cases frequent small green stools are passed consisting mostly of bile and intestinal debris (so-called hunger stools). Obstructive Vomiting Loss of- weight may be considerable and varies with the severity of the obstruction. In Congenital hypertrophic pyloric stenosis the more severe cases the infant becomes very This is the commonest of all the congenital dehydrated. forms of obstruction of the gastrointestinal Although this triad of symptoms, projectile tract. vomiting, loss of weight and constipation, is Although the hypertrophy of the muscle of almost pathognomonic of pyloric stenosis, con- the pyloric canal is present at birth, symptoms fir,mation of the diagnosis is essential. This. do not start immediately but appear-after an may be done by observing visible peristalsis. Postgrad Med J: first published as 10.1136/pgmj.23.261.339 on 1 July 1947. Downloaded from 340 POST GRADUATE MEDICAL JOURNAL YulS I1947 and feeling the pyloric tumour. The infant The main lines of medical treatmcnt are: should be examined during a feed. Waves of i. Administration of small frequent feeds. gastric peristalsis can be seen 'passing obliquely from left to right. The pyloric tumour can 2. Daily gastric lavage with normal saline to be felt in all cases but considerable experience reduce the gastritis which is always present. is required to detect it. It is only palpable 3. Administration of an anti spasmodic to when the pylorus is in spasm, and it may be abolish pyloric spasm. Atropine was employed necessary to watch the baby during several until recently but this often caused toxic feeds before it can be felt. It feels like a small. symptoms. Eumydrine (atropine methyl ni- knob, of the consistency of cartilage, usually trate), wA7hich is mtuclh less toxic, is used situated just beyond the edge of the R. rectus nowadays. It is given either in a i in io,ooo but sometimes high up below the edge of the solution, i.S to S cc., or as lamellae (pylostro- liver. The tumour disappears as the spasm pine) in 1/450 or I /750 gm. doses. The passes off. lamellae are placed under the tongue. Both In doubtful cases, where a tumour canlnot preparations are given 20 minutes before each definitely be felt, a barium swallow should be feed. given. This will demonstrate distension of the Medical treatment should be continued until stomach with marked delay in the emptying the age of four months, when the symptoms time. spontaneously disappear. (i) Surgical Treatment Obstruction due to other congenital anomalies This is the method of choice in most cases. Conzgenital intestinal stenosis or atresia may It results in a rapid cure, and the operative cause severe vomiting in the neonatal period mortality in skilled hands is low. It can be and should always be borne in mind when by copyright. performed under a local anaesthetic. In severe severe vomiting starts soon after birth. The cases with much loss of weight and dehydra- site of the obstruction may be in the duodenum tion operation is imperative. Before operation, or in any part of the intestine. The lower dehydration must be treated by means of sub- down the obstruction is, the later the onset of cutaneous or intravenous saline infusions and vomiting. the stomach should be washed out once or In duodenal stenosis or atresia the. vomiting twice with normal saline (not with sodium commences very soon after birth, is persistent bicarbonate, which may precipitate alkalosis). and often projectile. The vomit, unlike that of http://pmj.bmj.com/ There are many different regimes for feeding congenital pyloric stenosis, contains bile. after operation but the principle of all is the Visible peristalsis may be present. It is dis- same, viz., administration of dilute milk feeds tinguished from pyloric stenosis by the earlier in small amounts frequently at first, gradually onset and the presence of bile in the vomit, increasing in strength and amount. Normal and the absence of a pyloric tumour. A barium swallow will show ballooned duo- feeds should be reached two days after the on September 27, 2021 by guest. Protected operation. denum. Occasionally these infants have sur- vived a gastro-enterostomy. (ii) Medical Similar symptoms are met with in intestinal This is not new since it was perforce the atresia, which often extends over a considerable only treatment (short of gastro-enterostomy) length of gut. The actual site is frequently before the introduction of Rammstedt's opera- determined only at autopsy. tion. It was re-introduced on the Continent partly because operation was so often refused. Oesophageal Atresia Medical treatment should be confined to the This is a rare congenital anomaly which cases where operation is refused, where skilled gives rise to regurgitation when the first feeds surgery is not available, and in the milder are given. Choking and cyanosis are fre- cases, which generally have a late onset and do quently associated symptoms. The oeso- not lose much weight. phagus usually ends blindly above, the lower Postgrad Med J: first published as 10.1136/pgmj.23.261.339 on 1 July 1947. Downloaded from Yth1Y I 947 NEWNS Infanitile Vomiting and Diarrhoea 341 end being connected to the trachea by a fistula. a means of getting rid of an excess. Some In one variety the upper end communicates in.fants are verv prone to regurgitate, and the with the trachea. In such cases the infant volume brought u-p may be considerable. rapidly develops a fatal aspiration pneumonia. They generally gain weight nevertheless. Im- Recent advances in thoracic surgery have provement usually results when cereal feeding resulted in cures following end-to-end anas- is introduced. In bad cases the feeds should tomosis. be considerably thickened with a food such as Benger's or Savory and M\oore's. Achalasia of cardia of stomach This is a rare form of obstruction in infancy Overfeeding but possibly commoner than is generally Over distension of the stomach by too fre- thought. Four cases have come under my quent feeding or too large volumes may give observation in the past year. The condition is rise to vomiting in certain babies. It must probably the same as that met with in older not be assumed that babies who habitually children and adults, and is due to a failure of vomit are necessarily overfed. Underfeeding relaxation of the cardiac sphincter. with associated aerophagy is a much commoner The baby regurgitates food forcibly soon cause of vomiting. after it is swallowed and loses weight rapidly. Diagnosis is made by barium swallow. The Vomiting from excessive air swallowing oesophagus is dilated and the bariunm is seen This is the commonest cause of vomiting in to be held up at the lower end of the oeso- early infancy. The vomiting may be occasional phagus. or very frequent; the amounts brought up

Treatment consists in dilatation of the by copyright. oesophagus two or three times a day with a may be small or large. Characteristically the mercury bougie. In the cases observed, baby vomits small quantities at intervals gradual improvement has occurred. between the feeds. Some babies are inveterate wind swallowers Intussusception even when adequately fed. They are restless, irritable, hungry infants as a rule. The In the common form of intussusception, vomiting is usually associated with attacks of vomiting is not as a rule a prominent symptom colic which make thie baby still more restless. in the early stages, though later on vomiting The vomit is never truly projectile though at http://pmj.bmj.com/ may be severe, and faeculent in type. In the times it may be explosive, since it is often rarer enteric type vomiting occurs much brought about by a violent eructation of wind. earlier. If the baby is underfed constipation may be The infant typically has severe attacks of present or there may be green ' hunger ' stools. colicky pain with pallor and sweating. There Loss of weight may also occur for the same is usually bright red blood in the stools. The reason. sausage-shaped intussusception can generally on September 27, 2021 by guest. Protected be easily felt. There may be a superficial resemblance to Occasionally in infancy intestinal obstruc- congenital pyloric stenosis but examination of tion may be due to congenital bands, volvulus, a baby during a feed will reveal neither visible or strangulated inguinal herniae. peristalsis nor a tumour. It must first be determined whether the infant is underfed by a calculation of the Non-obstructive Vomiting correct amount based on the infant's expected Many babies regurgitate a small part of the weight* (2 ozs. per lb. of body weight per feed, especially if the feed is rather large-it is day or 50 calories per pound). If breast-fed,

* The expected weight may be calculated by sub- tracting I o from the age of the infant in days, and adding this figure to the birth weight. This holds good up, to about the age of four months, after which the gain in weight is less than an ounce a day. Postgrad Med J: first published as 10.1136/pgmj.23.261.339 on 1 July 1947. Downloaded from 342 POST GRADUATE MEDICAL JOURNAL YU/.7 I1947 the infant must be test-weighed for 24-48 which may give rise to severe vomiting. In hours. the milder cases gradual introduction of milk An underfed baby will be so hungry that he to the diet will usually desensitize the infant. will gulp down a large quantity of air during In the transition period the baby may be given the first few minutes of feeding. such foods as Benger's, cereals and vegetables, If the baby is underfed the amount of food etc., made up with water instead of milk. must be increased to the required level, calcu- In the more severe cases it may be necessary lations of the amount being made on the ex- to give milks containing no milk protein. The pected, not the actual weight of the baby. In basis of these milks is usually soya bean flour, the case of breast-fed infants, complementary with added fats, sugar and minerals.* feeds must be given, each feed being a test feed. The hole in the teat should be large Vomiting in infancy may be due to meningitis enough to enable the infant to take the feed or cerebral tumour or to toxic states such as easily without straining, in I 0- I 5 minutes. A uraemia secondary to severe congenital renal boat-shaped bottle is often better for this type disease. of infant. A sedative before feeds is very helpful. It Vomiting associated with Diarrhoea makes the baby less restless so that the feed is Diarrhoea with vomiting is due to three main taken more quietly. Chloral, e1-i gr. may be causes. given 20 minutes before each feed. Care should be taken to get up as much wind as (i) Dietetic possible after feeds. Incorrect feeding or persistent overfeeding, excess of fat or carbohydrates will give rise to by copyright. Rumination. Merycism diarrhoea and vomiting. Excess of protein Though not a common form of vomiting it causes vomiting, especially due to excessive may be very persistent and troublesome. It curd formation. Today, with the increase in occurs in breast- and bottle-fed infants alike. knowledge of infant dietetics, severe diarrhoea The rumination has to be watched for carefully and vomiting from this cause is uncommon. as the baby will not usually perform the act If neglected however, dehydration will occur when the mother or nurse is present. and the infant may become as gravely ill as infants in the next group.

About an hour after feeds the infant is http://pmj.bmj.com/ observed to bring up part of the feed, some being swallowed again, some spat out, while (2) Infection of bowel with path'genic organisms some of the food is held in the mouth for some (epidemic gastro-enteritis) time. The regurgitation is preceded by chew- This was the cause of the one-time summer ing movements of the jaws. The weight lost diarrhoea so prevalent in the hot summers in is not as a rule very great, generally it remains this country. In this form it is rarely seen stationary. nowadays. Epidemics of gastro-enteritis still on September 27, 2021 by guest. Protected Treatment is difficult. Thickening of the occur in new-born babies in nurseries. Many feeds with cereals so that it is of a porridge-like cases of diarrhoea arising in hospital wards are consistency is sometimes successful. A re- of this type and are due to cross-infection. straining bandage or cap with tapes tied under Sonne dysentery is also prevalent in young the chin, and kept on for I-2 hours after feeds children and may occur in infants. In hospital may prevent regurgitation. Sedatives may be the disease may spread rapidly. of value. (3) Symptomatic diarrhoea and vomiting due to Allergic vomiting. parenteral infection Occasionally vomiting in infancy is due to Infection outside the bowel is a common allergy to cow's milk, very small amounts of cause of diarrhoea and vomiting in infancy. * There is, at present, no such food made in this country. Postgrad Med J: first published as 10.1136/pgmj.23.261.339 on 1 July 1947. Downloaded from YUIY :1947 NEWNS: Infantile Vomiting and Diarrhoea 343 The mechanism is not properly understood. fact, be regarded as a medical emergency. Pyelitis, otitis media, infections of the throat, Parenteral fluid is essential, the only satis- to name only a few, will give rise to diarrhoea factory route being the intravenous one. All and vomiting, which may in fact be the fluids should be stopped by mouth and intra- presenting symptoms. The primary cauise may venous glucose-saline, or Hartmann's solution only be discovered after careful search. given by drip. This may be continued if The symptoms vary greatly with the severity necessary for several days. Sodium chloride of the infection. The second group com- must only be given in sufficient amounts to prises the worst cases. In these rapid dehydra- replace salt loss, otherwise oedema will occur. tion and prostration occur. The stools are After the vomiting and diarrhoea has watery with very little faecal material, and stopped, weak feeds should be given cautiously, vomiting is persistent, even water not being and gradually increased in strength. Lactic retained. The mortality is high. Severe fatty acid milks are especially useful and are well changes are found in the liver at autopsy. tolerated. Jaundice may occur before death. In most of these cases no pathogenic or- Drug therapy ganism can be isolated from the stools. Treatment in the milder cases consists in Little success has been obtained with withdrawing food for 12-24 hours, giving only sulphonamides and penicillin in straight- glucose and saline in small amounts at frequent forward cases of gastro-enteritis, though sul- intervals. There is often a marked improve- phaguanidine appears to be of value in Sonne ment within a few hours; the diarrhoea dysentery. Appropriate chemotherapy is, of course, indicated when there is a parenteral diminishes and the vomiting stops. Milk feeds by copyright. should then be gradually introduced starting infection. with a weak mixture and gradually increasing Other drugs are of little value. Purging the strength. It is not as a rule necessary to with castor oil has been given up. Astringents give special feeds. such as bismuth and kaolin have little effect. Where dehydration is present more vigorous Opium is a dangerous drug to give to dehy- treatment is required. These cases should, in drated infants and is seldom used nowadays. http://pmj.bmj.com/ on September 27, 2021 by guest. Protected