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Digestive Problems

Feeding intolerance

Spitting up

Vomiting and projectile vomiting

Digestive system abnormalities

Feeding intolerance

Feeding intolerance is when a newborn baby has trouble either keeping milk or formula down, or emptying the stomach. Minor episodes of feeding intolerance are common during the first few days of life and usually disappear without any special treatment. For some newborn babies, feeding intolerance is a sign of an important medical problem. There may be an infection of the bloodstream or elsewhere, or the may be a congenital malformation affecting the stomach or intestines. Persistent or severe feeding intolerance and bile-stained vomiting demand prompt investigation and treatment.

Spitting up

Many newborn babies and young infants are prone to spitting up some of their breast milk or formula during or shortly after a feeding. Some newborn babies spit-up only occasionally, and others spit-up with every feeding. Spit-up effortlessly rolls out of the baby’s mouth, sometimes with a burp.

Spitting up, also called gastroesophageal reflux, occurs when the ring of muscle at the top end of the stomach does not close properly. Spitting up decreases as the baby gets older, and it generally goes away before the baby reaches one year of age.

Ways to help your baby

You can reduce the amount that your baby spits up by trying the following:

  • Feed your baby before she becomes frantically hungry.
  • If you are bottle feeding, feed her smaller amounts, as overfeeding can make spitting up worse. Your baby does not have to finish a bottle.
  • If you are bottle feeding, make sure the nipple is neither too large nor too small. A nipple that is too large will cause the milk to flow too fast; a nipple that is too small will cause your baby to swallow a lot of air.
  • Keep feeding times quiet and calm, and try to minimize distractions.
  • Avoid tight diapers because they put pressure on the abdomen. Don’t put pressure on your baby’s tummy.
  • Burp your baby a couple of times during feedings, to get rid of some of the air in her tummy. Don’t interrupt her feeding, but instead burp her when she takes a break.
  • Hold your baby upright after each feeding.

When to visit the doctor

Usually spitting up is harmless; however, it can pose a problem if it leads to poor weight gain, choking, or acid damage to the esophagus. If your baby experiences any of the following symptoms when she spits up, bring her to the doctor:

  • streaks of blood in the spit-up
  • spit-up that causes your baby to choke or gag
  • spit-up that causes your baby to turn blue
  • problems gaining weight
  • vomiting or projectile vomiting

A note about sleeping position

Putting your newborn baby to sleep on her back is considered one of the best things you can do to help prevent sudden infant death syndrome (SIDS). This is recommended by the Canadian Paediatric Society, the American Academy of Pediatrics, and many other paediatric societies around the world. Although you may be concerned about putting your newborn baby to sleep on her back if she is prone to spitting up, there is no need to worry. There is no increase in choking in newborn babies who are put to sleep on their backs.

Vomiting and projectile vomiting

Vomiting is more forceful than spitting up, and it involves more than just a couple of tablespoons of stomach contents. Vomiting can be a sign of a viral infection in the stomach, a reaction to something the baby ate, or another gastrointestinal problem.

Treatment for vomiting

Initial treatment for vomiting involves feeding your baby in smaller amounts. If you are breastfeeding, reduce the amount of time that your baby spends at the breast at each feeding. You may need to feed your baby more frequently to make up for the smaller feedings.

You may need to temporarily replace breast milk or formula with an electrolyte solution such as Pedialyte. If this is the case, offer your baby the clear fluid for eight hours after the vomiting has stopped. Feed your baby small amounts at frequent intervals: about 5 mL (one teaspoon) every five minutes to start. After four hours without vomiting, double the amount each hour. If your baby vomits at this point, let her stomach rest for one hour and then start the feedings again with smaller amounts.

When vomiting becomes a concern

If there is a viral infection, vomiting is often accompanied by diarrhea. If there is green bile in the vomit, it could be a sign of a blockage in the intestine, which requires immediate attention and possibly emergency surgery. Contact your doctor immediately if the vomiting appears to be excessive, if there is green bile or blood in the vomit, or if the vomiting is accompanied by diarrhea. Also call the doctor if your newborn baby shows signs of dehydration such as dry mouth, less than six wet diapers per day, sunken eyes, a sunken fontanelle, or dry skin.

Projectile vomiting is when spit-up or vomit forcefully flies out of a baby’s mouth. If your baby begins projectile vomiting, contact your doctor immediately. It could be a sign of pyloric stenosis, which is a common condition in young infants. Pyloric stenosis occurs when there is a narrowing of the lower tubular portion of the stomach that prevents food from leaving the stomach. Surgery is used to correct this problem.

Digestive system abnormalities

Some babies are born with birth defects in their digestive system. They form as the result of something going wrong with the development of the baby’s digestive system during pregnancy. It is important to keep in mind that these abnormalities are rare. They may require treatment with surgery.

Abnormalities of the esophagus

Tracheoesophageal fistula/esophageal atresia is a condition where the esophagus is not properly connected to the stomach and there is a small connection between the windpipe, called the trachea, and the esophagus. This is caused by a problem with the partitioning of the esophagus from the trachea during development of the unborn baby. One complication of this condition is that milk refluxes from the esophageal pouch and may be inhaled into the lungs. Another complication is that the milk could flow across the fistula from the esophageal pouch into the lungs. Aspiration of milk into the lungs causes respiratory distress and inflammation within the lungs. Babies born with tracheoesophageal fistula/esophageal atresia must not be fed water, glucose solution, breast milk, or any other form of milk. Oral secretions are removed from the esophageal pouch with a suction tube called a replogyle tube. Tracheoesophageal fistula/esophageal atresia is repaired by surgery and most babies begin tube feeding a few days after their operation.

Congenital hiatal hernia occurs when the esophagus is not long enough, which causes the stomach to pull up through the diaphragm. Hiatal hernia may cause no symptoms, or it may result in a condition called gastroesophageal reflux, in which the stomach contents flow back into the esophagus. Surgery is sometimes required to correct congenital hiatal hernia.

Esophageal stenosis is an esophagus that is too narrow. Surgery may be needed to ease the narrowing.

Abnormalities of the stomach

Pyloric stenosis blocks the passage of food from the stomach to the intestine, which causes severe vomiting. This is one of the most common conditions in young infants. Pyloric stenosis occurs when the round end of the stomach enlarges and the lower, tubular portion of the stomach becomes extremely narrow. This narrowing is what blocks food from leaving the stomach. Surgery is used to correct this problem.

Abnormalities of the intestines

Malrotation with volvulus happens when parts of the gastrointestinal system end up in the wrong place as a result of a developmental problem. Normally in early pregnancy, the unborn baby’s gastrointestinal tract moves into the umbilical cord to develop and grow. Soon after, the gastrointestinal tract moves back into the abdomen and rotates into its final position. If this process does not occur properly, parts of the gastrointestinal tract can end up in the wrong place. This is called malrotation. Sometimes the gastrointestinal tract ends up twisting around itself to such an extent that the blood supply to part of the intestine is reduced. This twisting of the intestine is called volvulus. Nearly all newborn babies with malrotation with volvulus have bile-stained vomiting. They must be investigated very promptly because they require emergency surgery to prevent part of the small intestine from being strangled.

Intestinal atresia is a malformation where part of the intestine has become a thread and there is a complete blockage of the intestine. Sometimes the problem is stenosis, or a narrowing of the intestine, that causes a partial blockage of the intestine. Atresia and stenosis can occur​ anywhere in the gastrointestinal tract. Regions within the small intestine are affected more commonly than the large intestine. Intestinal atresia and stenosis are repaired with surgery.

Hirschsprung’s disease is a condition where nerve cells called ganglia are not properly formed on the inner walls of the intestine. This causes the bowel to contract and spasm, and block part of the lower intestine. Surgery is used to correct this condition. The surgeon removes the section of the intestine that is missing the ganglia and then reattaches the two ends of the healthy intestine. The outlook for babies who have gone through this surgery is very good.

Abnormalities of the liver and gall bladder

Biliary atresia is damage to the biliary tract and/or the bile ducts within the liver. In this condition, the biliary tract or the bile ducts within the liver have not developed properly within the womb, perhaps due to an infection in the baby during pregnancy. As a result, bile is trapped inside the liver, which causes liver damage and scarring. This is a rare condition. About 20% of newborn babies with this condition can have their biliary tract repaired with surgery. The remainder of patients will require a liver transplant.

Abnormalities of the abdominal wall

Omphalocele is a condition where the abdominal organs protrude through the umbilical region, surrounded by a sac called amnion. This condition occurs when the gastrointestinal organs do not completely move back from the umbilical cord to the abdomen in early pregnancy. This is a rare but very serious condition with a 25% rate of infant death. This condition is often associated with cardiac abnormalities, neural tube defects, and chromosomal abnormalities. Omphalocele is treated with surgery.

Gastroschisis is a condition where the abdominal organs protrude through the body wall. The organs hang outside the body beside the umbilical cord. The protruding organs are not covered with the protective membrane called amnion, and therefore they may be damaged by exposure to amniotic fluid. Unlike omphalocele, gastroschisis is not associated with chromosomal abnormalities or other severe defects. Surgery is usually quite successful in the treatment of this condition. The survival rate for gastroschisis is excellent.

Abnormalities of the anus and rectum

There are different types of malformations of the anus and rectum. The opening of the anus may be missing, which is a condition called imperforate anus, and there may be a small opening called a fistula running from the rectum to the urinary tract or to the vagina. Abnormalities of the anus and rectum can be corrected with surgery. If the opening of the anus is missing, the surgeon will create a new opening. If there is a fistula present, the surgeon will close it. Depending on the nature and severity of these malformations, children may have full, partial, or no control over their bowel movements. ​​

Andrew James, MBChB, MBI, FRACP, FRCPC

Andrew James, MBChB, MBI, FRACP, FRCPC