Like most emergency physicians, I am much more comfortable taking care of adults than children. This is simply because of the generally low number of very sick children we see. This is doubly so for neonates.

One common chief complaint during the neonatal period is excessive spitting up (i.e. emesis). It is common during the neonatal period for a child to “spit up” and to sleep frequently. However, 8 episodes of vomiting associated with decreased urine output and sleeping through feedings are outside the range of normal neonatal behavior.

A differential of neonatal emesis includes:

Infection (highest prevalence)

• Sepsis (Escherichia coli, Listeria sp., group B streptococcus)
• Meningitis (E. coli, Listeria sp., group B streptococcus, herpes simplex virus, Candida albicans)
• Pneumonia (group B streptococcus)
• Urinary tract infections (E. coli)
• Necrotizing enterocolitis

Gastrointestinal

• Vomiting outside of the immediate neonatal period should prompt a work-up for gastrointestinal anatomic anomalies.
• Obstructive (malrotation, volvulus, intestinal atresia or stenosis, incarcerated hernia)
• Nonobstructive (gastric antral web, gastric duplication, hiatal hernia, hypertrophic pyloric stenosis, pylorospasm, and gastroesophageal reflux disease)

Other causes

• Increased intracranial pressure (2/2 hydrocephalus, hemorrhage, tumor, or trauma)
• Renal insufficiency secondary to infection or obstruction.
• Metabolic causes (eg, hypoglycemia, inborn errors of metabolism, congenital adrenal hyperplasia)