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Six Months old With Vomiting

A mother brought her six months old son to an Emergency room because of fever and vomiting. He had a cough and runny nose for one week.  But on the day of the ER visit, he has several non-bilious vomiting. There was no blood.

Upon further questioning at the ER, the mother said that in the past two days her baby was not drinking well and the urination was reduced. He is not making any tears when he cries. There was no diarrhea and in fact he has not passed any stools for three days. Before, the mother has not noticed any belly pain, but at the ER she commented “his belly is bothering him.”

He has a two year old sister at home with runny nose and cough for about two weeks.  Both of them goes to a day care.

This baby was born at term by Ceasarean section because of fetal distress. The birth weight was 8 pounds. He was bottled fed. He rolled at 4 months old, sat at 6 months old, and now babbling. There was no hospitalization before. His immunizations are complete. No known allergies.

His only ongoing problem was constipation. His bowel movement was about every three days. There are times that his bowel movement is once a week and when he goes, it is explosive. Mom commented that when he passes stool he seems to be in pain.

He was fussy on physical examination but consolable. He is grunting and looks “sick.” His temperature is 102.2 F, heart rate of 184/minute, respiratory rate of 30/min, blood pressure of 90/40, and his Oxygen saturation, 99%. The rest of the physical examination was normal except of mild tender belly but not distended. The fontanel was soft and not bulging. The skin did not have rashes or petechiae.

Blood tests were done and the only abnormal report showed a WBC of 2,400 in the CBC. The electrolytes were normal. The urinalysis showed trace blood, without WBC and nitrites. An intravenous fluid was started.

Discussion and Thinking Process about this six months old baby:

The first decision to make is to put the baby in the hospital. He is grunting and looks “sick.”

The next question is what is the baby suffering from (diagnosis). He has fever and looks “sick” should make the clinician think of bacterial or viral infection. The two common conditions that most pediatricians will consider are sepsis and pneumonia. This could explain the fever and vomiting. However, there is no cough to implicate pneumonia unless this process is early.

Because there was vomiting and slightly tender belly on physical examination, an abdominal process should be in the list of differential diagnosis. Intussuception could present with vomiting and tender belly. But there is no blood in the stool in this baby.

The attending physician did Chest X-ray, abdominal X ray (KUB) supine, prone, and left decubitus position, and spinal tap. All of the results turned out negative.

Ceftriaxone intravenously was started because of the possibility of serious bacterial infection.

Because the baby was getting worse and the concern of abdominal process, a barium enema was done.  The radiologist detected a “mass effect in the right lower quadrant.” Abdominal sonogram showed “a nondistensible loop of bowel and free fluid in the abdomen.”

The attending physician called a pediatric surgeon and started intravenous piperacillin and tazobactam. The surgeon did a laparoscopy and removed an “adult size appendix.” The diagnosis was in the bag: appendicitis.

This is extremely rare case. Appendicitis is rare under two years old. In a study of more than 3,000 cases of appendicitis, fewer than 3% of cases were found in children under 2 years old and less than 1% under one year old. Appendicitis is rara avis in newborns, but has happened especially in prematures.

Because appendicitis is rare in infants, most physicians, do not put it in the top of their list of differential diagnosis. The average time of diagnosis of appendicitis in infants is four days. Because of delay in diagnosis of appendicitis in infancy, 70% to 90% are perforated on time of surgery. In older children, the perforation rate is 10% to 20%.

A ruptured appendix has more complications such as peritonitis, abscess formation needing drainage, and partial bowel obstruction. And longer hospital stay.

There will be always ruptured appendix because of the difficulty in the diagnosis in young children. However, if most physicians think about it in “sickly looking” baby with vomiting, fever, and tender belly, we might bag more intact appendix through laparoscopy and send the baby home sooner.

[Reference: Contemporary Pediatrics, December 2002, page 21]

Comment: This baby was handled very well and the attending physcian should be commended. A Monday morning quarterback will probably say: a CT of the belly might help in a faster diagnosis.

Differential diagnosis of Acute Abdomen in an Infant:

Gastrointestinal:  Intussuception, Appendicitis, Hirschsprung disease, Trauma, Cholesystitis, Meckel diverticulitis, Inflammatory bowel disease, Cholesystitis, Hepatitis, Constipation, Gastroenteritis.

Respiratory: Pneumonia

Genitourinary: Testicular torsion, Urinary Tract Infection, Hernia, Stones

Neurologic: Meningitis

Hematologic: Sickle Cell Crisis

Musculoskeetal: Septic arthritis of the hip

Systemic: Bacterial Sepsis, Diabetic Ketoacidosis, Henoch-Schonlein Purpura, Ingestion or poisoning

Social: Child Abuse

Leo Leonidas, MD, FAAP, Assistant Clinical Professor in Pediatrics, Tufts University School of Medicine, Boston; Attending Pediatrician, Eastern Maine Medical Center, Bangor, Maine

Please send my your suggestions and comments to improve this site:

lleonidas@pcpediatrics.org

I wrote and desinged this website for parents of our practice. Before you use ideas from this website, please discuss it first with your clinician if you are not with our practice.

copyright Leo Leonidas 2002

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