'Spitting up' isn't always harmless in infants

It was off to the pediatric emergency department for the concerned woman and her little son. The mother had to find out why, for the past 48 hours, her 1-month-old was experiencing frightening waves of forceful vomiting.

The astute emergency physician performed a careful exam on the little boy, and while checking the abdomen, felt a suspicious olive-shaped lump. The boy's recent history along with the right-on physical exam helped the pediatric specialist to arrive at a prompt diagnosis. Mom's recollection that she herself had been diagnosed with a similar gastrointestinal condition when she was an infant was the icing on the cake.

Priority ultrasound of the suspicious abdominal area confirmed the diagnosis of pyloric stenosis. A surgeon with pediatric experience was called in to evaluate the child, quickly agreed with the assessment of the ER physician and the radiologist, and prepared for surgery.

While much of the spitting and vomiting of early infancy is linked to varying degrees of gastroesophageal reflux, or baby GERD, vomiting caused by underlying anatomic obstruction is seen in a small subset of the pediatric population. In babies with pyloric stenosis, the muscles of the pylorus, the outlet or last portion of the stomach leading to the lower GI tract, are thickened to such a degree that they obstruct the normal passage of foods and fluids.

Substances that can't pass through to the lower gut are subsequently vomited up in a classic projectile manner. That's why, during routine history-taking, parents of spitty babies are asked if the vomit just "comes out" of the little one's mouth, or if it shoots out with enough force to hit a wall several feet away.

Specialists from the International Pediatric Endosurgery Group report that infantile hypertrophic pyloric stenosis occurs in up to three out of every 1,000 live births and is usually diagnosed among infants age 3 to 10 weeks. Boys are affected more than girls at an overwhelming 4 to 1 ratio. The condition is most common in Caucasians, and interestingly, children of parents with a history of pyloric stenosis are also considered to be at higher risk for this gastric outlet obstruction.

Fortunately, the baby in question looked very good during his emergency evaluation, with near-normal electrolytes and a healthy blood count. After a brief period of IV rehydration, he was considered stable enough to undergo surgery. The little guy was then whisked to the operating room for a pyloromyotomy, a corrective surgical procedure that involves clearing the gastric obstruction by splitting the thickened pyloric muscles.

Surgical repair of pyloric stenosis can be performed through the traditional open pyloromyotomy, or the more recently introduced laparoscopic approach. In uncomplicated cases, babies can be fed relatively soon after surgery, often within hours, and are generally sent home one to three days following surgical repair.

• Dr. Helen Minciotti is a mother of five and a pediatrician with a practice in Schaumburg. She formerly chaired the Department of Pediatrics at Northwest Community Hospital in Arlington Heights.