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Bilious aspirates and vomiting - assessment in the neonate

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Investigation of bilious aspirates or vomiting

Feed intolerance is common in preterm infants. However, it is less common in term infants. In term infants, especially those with bile-stained vomiting or bilious aspirates, gastrointestinal pathology needs to be investigated and early surgical consultation should be considered.

Indicative Colour Chart for assessing aspirate colour

    Milk     Lemon Mustard  Wasabi      Lime Avocado Spinach
  • Note that colostrum may appear yellow in colour.
  • Some infants will have bilious aspirates that are bright yellow in colour in the initial phases

Causes of bilious aspirates/vomiting include (but are not limited to)

  • Proximal bowel obstruction (yet distal to the duodenum).
    It is particularly important to consider intestinal malrotation2. Radiographs and abdominal examination may be normal in infants with malrotation, particularly in the early stage of the condition or if the obstruction is intermittent. If malrotation is considered a possible diagnosis, an upper GI contrast study should be considered. A recent report of infants presenting to a surgical NICU with bilious vomiting demonstrated that 22% had an intestinal malrotation3.
  • Other bowel obstruction
    Distal obstruction may result in bilious vomiting or aspirates. An abdominal radiograph may indicate intra-abdominal pathology, with air-fluid levels
  • Necrotising enterocolitis
  • Paralytic ileus associated with generalised sepsis
    This usually presents with a silent abdomen in an infant with signs of generalised sepsis.
  • In some infants, no cause will be found despite thorough investigation3.


  1. The baby should be examined for signs of generalised sepsis or instability. Close attention should be paid to the abdomen, paying particular attention to signs of tenderness, erythema, or guarding.
  2. The baby should be placed nil by mouth.
  3. An abdominal series (AP supine and lateral decubitus with the left side down) should be ordered. It may be appropriate to repeat the radiographs in 4-8 hours to evaluate any change in bowel gas pattern or any evolution in radiographic features
  4. Antibiotics after an appropriate sepsis screen should be considered. If intra-abdominal pathology is suspected, the antibiotics of first choice are amikacin, amoxycillin, and metronidazole. If sepsis is considered likely but an intra-abdominal source is not thought to be the primary source, then the antibiotics of first choice are amikacin and flucloxacillin.
  5. Surgical consultation should be considered early
  6. Reintroduction of feeding will depend on the underlying condition and the individual preferences of the supervising specialist.

Withholding feeds

  • Withholding feeds is a significant decision for infants in the NICU, particularly extremely low birth weight infants. An audit of practice in NICU identified that withholding feeds was a significant contributor to poor growth in infants.1
  • Calories and nutrients can be more safely and more easily delivered by enteral feeds than by intravenous nutrition, without increased cost and increased risks of complications.
  • However, some infants with feed intolerance may have significant intra-abdominal or other problems.

Absolute indications to withhold feeds

  1. Clear abdominal pathology
    1. Suspected or proven NEC
    2. Significant abdominal distension or discolouration
    3. Other suspected or proven bowel pathologies
    4. Blood in stool
  2. Heavily bile-stained or large gastric residuals or vomiting ("avocado" or "spinach" in the reference chart above)

Relative indications to withhold feeds

  1.  Feed intolerance
    1. If <25% of 6-hour total feed volume - return aspirate and give full feed
    2. 25 - 50% of 6-hour total feed volume - return aspirate and miss feed.
      Check aspirate next feed. If significant aspirate next feed, then withhold feed and notify registrar or NS-ANP
    3. >50% of 6-hour total feed volume - withhold feed and notify registrar or NS-ANP
  2. Unstable condition causing clinical concern. This may include infants with significant cardiorespiratory instability or presumed sepsis
  3. Infants about to undergo surgical or anaesthetic procedures. Refer to the pre-operative surgical guidelines


  1. Cormack BE, Bloomfield FH. An audit of feeding practices in babies <1200g or 30 weeks gestation during the first month of life. Perinatal Society of Australia and New Zealand 9th Annual Congress, Adelaide, 2005. A42.
  2. Strouse PJ. Disorders of intestinal rotation and fixation ("malrotation"). Pediatr Radiol 2004;34:837-51.
  3. Foster JK, Mills JF. Neonatal bilious emesis: when does it matter? Perinatal Society of Australia and New Zealand 9th Annual Congress, Adelaide, 2005. P61.

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Document Control

  • Date last published: 01 April 2015
  • Document type: Clinical Guideline
  • Services responsible: Neonatology
  • Owner: Newborn Services Clinical Practice Committee
  • Editor: Sarah Bellhouse
  • Review frequency: 2 years