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Bilious Vomiting in Newborns: Implications for a Neonatal Transfer Service

Presented as a poster at the Neonatal Society 2013 Summer Meeting.

Kawa B, Mohinuddin S, Ratnavel N, Sakhuja P, Bermundo B, Ward H, Sinha A

London Neonatal Transfer Service, Barts Health NHS Trust

Background: Bilious vomiting in a neonate could be a sign of critical intestinal obstruction. As it is difficult to differentiate between those with or without a true underlying surgical problem, neonates presenting with this clinical sign are often transferred to surgical centres for further assessment. Some of these cases may have a time critical pathology. The aim of this study was to evaluate the emergency response to requests for transfer and the clinical outcome of these infants.

Methods: A retrospective review of transfers of term babies less than or equal to seven days of age with bilious vomiting between January 2007 and December 2010 to six London neonatal surgical centres was undertaken by The London Neonatal Transfer Service. Cases were identified from the Neonatal Transfer Service database and data were extracted from notes. Follow-up outcome data was collected from all receiving unit hospitals. The study was approved by the local Clinical Effectiveness Unit.

Results: Of 2880 transfers carried out during the review, 163 met the study criteria. The median (range) gestation, birth weight and age at transfer were.39.9 (37-42) weeks, 3.3 (1.8-5.0) kg and 35.3 (2.3 – 166) hrs respectively. Of these, 74 (45%) had a surgical diagnosis confirmed. Table below shows the sensitivity, specificity, positive predictive value (PPV) and negative predictive value of abdominal distension, tenderness, feel of abdomen (soft vs firm or tense) and abdominal X-Ray for a diagnosis of surgical condition.

Median (IQR) for dispatch of transport team, arrival at referring hospital (response time) were 31 (16-106) minutes and 70 (50-131) minutes respectively. In 34% of transfers dispatch time was longer than 60 minutes. Overall 22/163 (14%) of patients transferred for bilious vomiting and 7 of those with dispatch time of greater than 60 minutes had an underlying surgical diagnosis that was time critical in nature.

Conclusion: Bilious vomiting is a clinical sign of underlying surgical pathology in 45% of cases. Abdominal distension and abnormal AXR findings has high sensitivity, whereas feel of abdomen and abdominal tenderness has high specificity for diagnosis of underlying surgical condition. A proportion of surgical diagnoses are time critical and an urgent response to requests for transfer need to be prioritised.

Corresponding author: nandiran.ratnavel@bartshealth.nhs.uk

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