Recurrent Vomiting in an Otherwise Healthy Infant

Presentation

A 27-day-old previously healthy term boy presents for new-onset frequent nonbilious vomiting. At the time of presentation, he is 30 g below his birthweight despite regularly receiving approximately 3.5 oz of formula or pumped human milk every 2 to 3 hours. Findings from laboratory evaluation, including a complete blood cell count and chemistry, are normal. An abdominal radiograph reveals an apparent filling defect in the region of the stomach (Fig 1), and this filling defect is demonstrated again on an upper gastrointestinal series. The patient is admitted to the general pediatric service, designated to receive nothing by mouth, and started on intravenous fluids. He is given normal saline lavages every 4 hours via nasogastric tube. Lavage output is initially white, semisolid, and curdled, but it clears within 48 hours. A repeated upper gastrointestinal series shows normal anatomy and no residual filling defect in the gastric region. The infant resumes feeds without emesis or other issues, is noted to gain 40 g daily while hospitalized, and is then discharged.

The patient presents again 20 days later for return of forceful vomiting. He has been asymptomatic, with weight gain of 56 g per day since discharge. Vomitus is “white and curdled” (Fig 2). He is receiving 5 oz of premixed formula 7 times a day (approximately 224 mL/kg per day and 150 calories/kg per day) plus ad lib breastfeeding. An abdominal radiograph shows mottled lucencies in the stomach, (Fig 3) and abdominal ultrasonography shows echogenic material in the gastric region. The patient is admitted to …