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Thursday 20 June 2019

Dear Dr Nina: My two-year-old son vomits after every meal

Ask the doctor...

Reflux after feeding is one possible explanation
Reflux after feeding is one possible explanation

Nina Byrnes

Question: I am at the end of my tether trying to get the proper care for my two-year-old son. He hasn't been right since he was born - he vomits after almost every bottle and meal, and has done so since birth. Sometimes it gets particularly acute and I bring him to A&E in the children's hospital. I have been referred to the paediatrician with the HSE. Coeliac disease has been ruled out and his x-rays, they tell me, are normal. Are there questions I am not asking? Can you help me to maybe communicate better? I know that he is not ok but I am finding it hard to get any help.

Dr Nina replies: Vomiting can be a symptom of many conditions. You mention your son has had the problem since birth so it is worth looking back to the start of his feeding habits.

Reflux is one possible explanation. It is thought to occur in up to 30pc of infants. Symptoms in babies and children include vomiting or regurgitating regularly after feeds, crying and irritability after feeding or when put lying flat, irritability or difficulty sleeping. Simple home remedies include placing the cot mattress at a slight angle, burping during and after feeds, giving smaller more frequent feeds, and keeping upright for 30 minutes after each feed. There are thickened formulas also available but these don't always make a difference. In more severe cases of reflux antacids such as sodium alginate (baby Gaviscon) can be added to breast milk or formula. In more recent times the same medication used in adults is being used in infants and children with great success. If a baby is vomiting profusely or with force, isn't gaining weight, has blood in vomit or stool, or has difficulty breathing it is important to see your doctor as further tests may be required. If your child hasn't tried reflux medicine it may still be worth trying.

Chronic constipation can be another cause of abdominal pain, food refusal and fussy eating. It can cause nausea in some children.

Food allergy is often over diagnosed but may be another cause of food refusal, fussiness or vomiting after meals. Given the symptoms started in infancy milk allergy should be ruled out. It can occur in breast and bottled-fed infants but is more common in formula-fed infants. Weaning can be a time when this becomes apparent. Why this only occurs in some people is unclear but we do know that a family history of allergy does increase the risk. Having a history of eczema or asthma also increases the risk. Symptoms of cow's milk allergy vary greatly and may occur within a few minutes to hours after ingesting the food. They include obvious allergic symptoms such as itching, a rash, hives, tingling of the lips or mouth, runny nose, watering eyes, wheezing or shortness of breath. More subtle symptoms include irritability, abdominal pain and cramping, vomiting, loose stool, which may contain blood or food refusal. In severe allergy there may be a risk of anaphylaxis.

If you feel there is a close link between dairy intake and your toddler's problems it may be worth eliminating cow's milk for a period of eight weeks. If symptoms resolve then there may be a link.

It sounds like your son needs a general medical review with your GP. Some of the possibilities above could be considered and further tests can be arranged if required.

Bleeding from the back passage: Do I need to see the doctor for haemorrhoids?

Haemorrhoids are thought to affect more than 50pc of adults at some time in their lives

Q I have what, I suspect, are bleeding piles. Do I need to go to the doctor?

Dr Nina replies: It is never normal to pass blood from the back passage so this should always be checked out. If you are passing bright red blood, most notable on wiping yourself, then haemorrhoids are a likely cause. Haemorrhoids are thought to affect more than 50pc of adults at some time in their lives. They mainly occur in those over 30.

Haemorrhoids can be internal or external. External ones are more painful. They become inflamed and protrude out as lumps of skin from the back passage. If a clot forms in one of these we refer to it as a thrombosed haemorrhoid, which can cause severe pain. Internal haemorrhoids are less likely to be painful but they can bleed causing bright red blood to be passed from the back passage. Haemorrhoids can also cause itching, burning or discomfort.

Anything that causes increased pressure into the back passage can cause haemorrhoids. Pregnancy and childbirth are a very common cause because, as the baby grows, the pressure increases and forceful pushing during labour further exacerbates this issue. Other common causes are constipation, straining during bowel motions, and obesity.

Haemorrhoids can be diagnosed easily by examining the anal area or during a rectal exam where the doctor examines just inside the back passage with a finger. They may also be noticed during a routine bowel exam or colonoscopy. If you have noticed swelling in the anal area or are having pain or passing blood, especially if you are over 50, it is important to see a doctor. Although haemorrhoids are the most common cause of these symptoms other conditions including bowel cancer can also cause swelling pain and blood from the back passage.

Thankfully, in most cases, haemorrhoids settle without the need for too much medical intervention. If you suffer with a flare up using over the counter haemorrhoid treatment may provide relief. Other simple remedies include warm baths several times daily, gently cleansing with witch hazel solution, taking over the counter painkillers such as paracetamol or ibuprofen and applying ice to the anal area.

If the haemorrhoid is particularly painful there are some prescription remedies available as suppository and cream or ointment that can add to the relief. If a clot has formed in an external pile and the pain is severe, a doctor may recommend attending to have the clot released. This is usually only done within the first two days of the pile flaring. Otherwise inflammation or clots will resolve themselves over seven to 10 days. Once the inflammation has settled a small skin tag may remain outside the anal area. If haemorrhoids are becoming a chronic problem or are reoccurring there are a number of surgical procedures that can be tried.

Start treatment early and if things don't settle within a week, see your doctor.

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