Newborn infants with bilious vomiting: a national audit of neonatal transport services

Abstract

Objective: The precautionary approach to urgently investigate infants with bilious vomiting has increased the numbers referred to transport teams and tertiary surgical centres. The aim of this national UK audit was to quantify referrals, determine the frequency of surgical diagnoses, with the purpose to inform the consequent inclusion of these referals in the national 'time critical' dataset. Method:A prospective, multi-centre UK-wide audit was conducted (01 August 2015 to 31 October 2015). Term infants, ≤ 7 days of age, referred for transfer due to bilious vomiting were included. Data at the time of transport and outcomes at seven days after transfer were collected by the local teams and tranferred anonymously for analysis.Results: Sixteen teams contributed data on 165 cases. Teams that consider such transfers as "time-critical" responded significantly faster than those that do not classify bilious vomiting as time-critical. There was a surgical diagnosis in 22% cases and 7% had a condition where delayed treatment may have caused bowel loss. Most surgical problems could be predicted by clinical and/or X-ray findings but two infants with normal X-ray features were found to have a surgical problem.

How should the neonatal retrieval team respond to the neonate referred with bilious vomiting?

“…Birthweight was not investigated as a factor in other studies; this study found a time‐critical diagnosis did decrease significantly with every increase in kilogram of weight (OR 0.48; 95% CI 0.29–0.77; P = 0.0024). The median weight of our cohort was similar to the other studies 4–6,10,11 . The clinical significance of this finding is unclear.…”

“…The median weight of our cohort was similar to the other studies. [4][5][6]10,11 The clinical significance of this finding is unclear.…”

“…For this reason, several studies have highlighted the need for urgent transfer of the neonate with BV to a surgical centre. [4][5][6] The current gold standard for diagnosing malrotation is an upper gastrointestinal contrast study with definitive diagnosis on laparotomy. It has been reported that the sensitivity of an upper gastrointestinal study to diagnose malrotation is between 93% and 100%.…”

Low incidence of surgical pathology in infants with bilious vomiting

“…This may explain the higher incidence of surgical pathology demonstrated in these studies. [3][4][5][6]8]. Our study was population-based from a single centre from a cohort of 'well / normal' term infants, therefore unlikely to have a high incidence of underlying pathology.…”

“…One study reported that 15% of term infants less than 7 days old transferred by the London Neonatal Transport Service were for BV. [8]. An upper gastrointestinal contrast study (UGI) remains the best available radiological investigation for diagnosing malrotation with a positive predictive value of 90% [2], although ultrasonography has also been shown to be safe and reliable.…”