Vomiting and Weight Loss

Dear Lisa,

My eight week old daughter has had GERD since birth, which seemed to be controlled by Prilosec, but for the last two weeks she has been projectile vomiting breast milk, regular formula, and hypoallergenic formula, only keeping down Pedialyte, she has been exhibiting irritability, slight eczema, increased muscle tone, increased muscle reflex activity, and diarrhea. She has been losing weight. The fecal test ruled out a parasite and it seems too long for a stomach flu bug. She was tested for PKU 12 hours after birth and it was negative. What could be causing this?

"Concerned About 8 week old Daughter"

Dear "Concerned About 8 week old Daughter",

Persistent vomiting in infancy can be due to a variety of conditions. Sometimes it is caused by a gastrointestinal problem and sometimes it may be due to a problem outside of the gastrointestinal tract. Gastroesophageal Reflux is a very common cause and has already been identified in your daughter. Since her symptoms have been under control with Prilosec, the first question to be answered is, has there been something that is worsening her GERD? In some cases a food allergy triggers or exacerbates GERD. Since babies who are allergic to milk exhibit an increase in GERD symptoms, it would be important to investigate the relationship between your baby’s vomiting and milk intake.(1)

Both GERD and Cow's milk allergy exhibit the same symptoms which include; crying, irritability, colic, feeding refusal, failure to thrive (doesn’t gain weight), vomiting, regurgitation, wheezing , apnea and sleep disturbances.(2) When an infant is diagnosed with cow milk’s allergy the treatment is to remove all cow’s milk from the diet by changing to a hypoallergenic formula such as Nutramigen. It is also necessary to remove all milk from a mother’s diet if she is breastfeeding. Switching to a Hypoallergenic formula is the treatment for a cow’s milk allergy because the milk proteins in the formula are chopped into small pieces which are not identified as milk. Since the baby doesn’t identify the formula as milk, allergy symptoms should subside. Once a dietary change takes place it typically takes a few days, up until a couple of weeks to see the resolution of symptoms.

Many times I found that an infant’s milk allergy symptoms did not subside because milk was not totally eliminated from the breastfeeding mother’s diet. I had plenty of mothers who continued to ingest small amounts of milk because they thought it wouldn’t bother the baby. Unfortunately, this was not the case and mother’s who had only a few splashes of milk in their coffee or grated cheese on their pasta ended up with babies suffering from increased GERD and Milk Allergy symptoms. In a few isolated cases, infants with a severe allergy to milk protein needed to be changed to a formula called Neocate which is similar to Nutramigen, but the proteins are chopped up even tinier so the body doesn’t identify or react to them.

Eczema can be triggered by many things including stress, weather changes, irritation and food allergies. Eczema has been associated with food allergies particularly in young children.(3) The types of food that usually trigger eczema in children include milk, soy, egg and wheat.(3) Further investigation into this area would be appropriate since your daughter has eczema and GERD, which are both associated with food allergies.

If all measures to control an Infant’s GER and Milk allergy are exhausted and an infant continues to vomit and lose weight, a further work up is indicated. Infant vomiting can be due to other gastrointestinal conditions, central nervous system problems, urinary tract infections or inborn errors of metabolism. Pyloric stenosis is one of the more likely causes of persistent vomiting in an infant that should be considered. The incidence varies from 1 in 200 to 1 in 750 live births.(4) Pyloric stenosis is a condition that is caused by an overgrowth of the circular muscle of the pylorus which is located between the stomach and the intestines. The symptoms include a gradual onset of non-bilous vomiting which tends to occur within the first two months of life.(4) The vomiting can be projectile and usually is progressive, occurring during or shortly after feeding. Shortly after vomiting the infant usually appears hungry and has an appetite.(4) Pyloric stenosis is diagnosed by physical examination and abdominal ultrasound.

After the more common causes of infant vomiting are ruled out, other causes may need to be investigated. Some infants vomit due to a central nervous system disorder such as infection, hydrocephalus or premature closure of a baby's fontanel (soft spot) or cranial sutures. Infants with a urinary tract infection demonstrate non-specific signs such as vomiting and weight loss. The signs of a urinary tract infection in infants include; vomiting, diarrhea, irritability, poor feeding, slow weight gain, and unexplained jaundice.(5) Other rare causes of vomiting and weight loss in infants include inborn errors of metabolism such as Phenylketonuria or PKU, which you reported was normal in your child. Signs of PKU include irritability, recurrent vomiting, delayed motor skills, seizures, increased muscle tone, tremors, hyperreflexia, microcephaly (a small head), a lingering musty odor to the urine which is mousy or barn-like in character and eczema. (6) Approximately 25% of children with untreated PKU have eczema.(6) Although it is reassuring that your daughter’s PKU screen at birth was normal, persistence of symptoms in an infant consistent with PKU should always be re-investigated.

It can be very frustrating and worrisome watching your baby vomit and lose weight. A lot of patience is needed in order to deal with the situation. You should continue the careful follow up that you have received so far with your baby’s current doctor. Through repeat evaluations and possibly further testing the root of your daughter’s problem will soon be discovered and treated.

I wish you and your daughter well.

References:
(1)Salvatore S.Vanderplas Y. Gastroesophageal reflux and cow milk allergy: is there a link Pediatrics. 2002;110:972-984.
(2)Edmunds A. Gastroesophageal Reflux Disease in the Pediatric Patient. Therapeutic Spotlight. 2005. August:4-13.
(3)Ledford DK. Recognizing and managing atopic dermatitis. Presented at: 2006 American Academy of Asthma, Allergy and Immunology Annual Meeting; March 3-7, 2006; Miami Beach, Fla.
(4)Joshi S, Mahajan P, Kamat D. Infantile Hypertrophic Pyloric Stenosis. Consultant for Pediatricians. 2006. Feb:106-110.
(5)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed.Philadelphia, PA:W.B.Saunders Company. 1994:1525.
(6)Jackson P, Vessey J. Primary Care of the Child with a Chronic Condition. St. Louis Missouri: Mosby –Yearbook, Inc. 1992:429.


Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice Updated Daily