Index of Suspicion in the Nursery
Vomiting and Bradycardia in a Newborn
AUTHOR DISCLOSURE Drs Cheang, Kaur,
Haleem, Borole, and Velazquez have disclosed
no financial relationships relevant to this
article. This commentary does not contain a
discussion of an unapproved/investigative
use of a commercial product/device.
e222 NeoReviews
Downloaded from http://neoreviews.aappublications.org/ by guest on April 1, 2019
1 Infant
Stefanie Cheang, MD,* Rupinder Kaur, MD,† Sadia Haleem, MD,*
Swapna Borole, MD,* Danitza Velazquez, MD*
*Robert Wood Johnson Medical School, New Brunswick, NJ
†
Orange Park Medical Center, Jacksonville, FL
PRESENTATION
A male infant is born at 39 weeks and 5 days’ gestational age via normal
spontaneous vaginal delivery to a 21-year-old gravida 1, para 0 woman with no
known medical problems. The pregnancy is uncomplicated and prenatal labo-
ratory results are all unremarkable. Apgar scores are 8 and 9 at 1 and 5 minutes,
respectively. Initial newborn examination findings are within normal limits. The
infant is born with a birthweight of 3.34 kg, head circumference of 32.3 cm, and
length of 52.1 cm, with all measurements plotted to be appropriate for gestational
age. The infant is noted to be tolerating breast and bottle feeds well and is voiding
and passing stools normally. He is discharged from the newborn nursery 2 days
after birth with normal physical examination findings and a weight of 3.3 kg,
which is 1.2% below birthweight.
Four days after birth, the infant is brought back to the birth hospital for feeding
intolerance and having increased nonbloody, nonbilious vomiting with phlegm
after each feeding. In the emergency department (ED), the infant is noted to have
lost 12% of his birthweight. He is also found to have self-limiting episodes of
bradycardia with heart rates in the 70 beats/min range. Electrocardiography is
performed, which shows sinus bradycardia. He receives two 10-mL/kg boluses
of normal saline, and the heart rate improves to around 100 beats/min with
intermittent dips to around 90 beats/min. The infant’s other vital signs are
otherwise within normal limits for age. A full sepsis evaluation is initiated in the ED
and the infant is started on ampicillin and gentamicin treatment for presumed
sepsis. The lumbar puncture is unsuccessful, but blood and urine culture spec-
imens are obtained. Rapid testing for respiratory syncytial virus and influenza A and
B has negative results and the chest radiograph is normal. Complete blood cell count
reveals a white blood cell count of 8,000/mL (8.8109/L), with a normal differ-
ential, hemoglobin of 17.6 g/dL (176 g/L), hematocrit of 53.2%, and platelet count of
409103/mL (4.09109/L). The basic metabolic panel is significant for hyper-
natremia, with a sodium level of 151 mEq/L (151 mmol/L). The sample is hemolyzed
and the potassium level is not reported. Other values are within normal limits with
chloride of 112 mEq/L (112 mmol/L), total bicarbonate of 22 mEq/L (22 mmol/L),
glucose of 73 mg/dL (4.05 mmol/L), blood urea nitrogen of 11 mg/dL (3.9 mmol/L),
creatinine of 0.55 mg/dL (48.6 mmol/L), and calcium of 10.1 mg/dL (2.5 mmol/L).
The infant is transferred to a level III NICU for further evaluation and
management. Abdominal radiography is performed on admission to the unit,
which shows an overall ‘gasless’ abdomen and a cystic lucency projecting over the
lower mediastinum (Fig 1). He is given nothing by mouth on admission and

Figure 1. Radiograph depicting a ‘gasless’ abdomen. The black arrow
points to a cystic lucency projecting over the lower mediastinum.
started on intravenous fluids. Pediatric surgery is consulted
and computed tomography (CT) of the chest, abdomen, and
pelvis is completed, which shows a complex gastric hernia
with the gastroesophageal junction above the diaphragm
(Fig 2). A subsequent barium esophagography confirms a
hiatal hernia or intrathoracic stomach with significant par-
tial obstruction (Fig 3). Echocardiography is also performed,
which shows a structurally normal heart with good function
but an external impingement on the posterior aspect of the
left atrium is noted.
A diagnosis of a hiatal hernia with compression of the
heart is made, which is likely the factor contributing to the
episodic bradycardia. The infant is taken to the operating
room 8 days after birth for open repair of the hiatal hernia
with gastrostomy tube placement. A gastrostomy is placed to
provide support or hold the stomach to the anterior abdom-
inal wall. Intraoperatively, the infant is found to have a small
diaphragmatic defect and a large portion of the proximal
stomach in the chest, with only the distal stomach and
pylorus in the thoracic cavity. The stomach is reduced
and the hiatal defect is repaired with crural approximation.
The infant has no postoperative complications and is able
to tolerate ad libitum feeds by mouth before discharge on
postoperative day 6. No further episodes of vomiting or
Downloaded from http://neoreviews.aappublications.org/ by guest on April 1, 2019
bradycardia are noted and he demonstrates appropriate
weight gain. The infant is discharged from the hospital
with instructions to the family to follow up with pediatric
surgery 2 months later. On outpatient follow-up, he con-
tinues to gain weight appropriately, and the gastrostomy was
reversed successfully without complications.
DISCUSSION
Congenital hiatal hernias are very rarely seen in the neonatal
period and are characterized by a herniation of the abdom-
inal organs, most commonly the stomach, into the thorax
from a physiologic opening caused by the laxity of the
attachment of the stomach and gastroesophageal junction.
Congenital hiatal hernia has to be distinguished from the
congenital diaphragmatic hernia, which is a separate entity
where there is a pathologic defect in the diaphragm. There
are 4 anatomic classifications of hiatal hernias, types I, II, III
and IV. Type I or a sliding-type hernia is the most common
type, accounting for more than 90% of cases. (1) Type II or a
paraesophageal-type hernia, although considered a rarer
type, has a higher risk of complications such as incarcera-
tion, strangulation, complete gastric herniation with organo-
axial volvulus, and a perforation of herniated viscera. (2)(3)
Type III is a combination of type I and II, and type IV is
characterized by the presence of a structure other than the
stomach, such as the omentum, colon, or small bowel
within the hernia sac. (1)
Congenital hiatal hernias may present with symptoms
such as respiratory distress, vomiting, poor feeding, failure
to thrive, poor feeding, or signs such as bradycardia as
observed in the current case when the hernia is massive
enough to cause cardiac compression. These signs and
symptoms have a broad list of differential diagnoses includ-
ing sepsis, gastroesophageal reflux disease, pneumonia,
pneumatocele, pneumothorax, pleural effusion, and congen-
ital diaphragmatic hernia. The diagnosis of hiatal hernias is
usually made with a barium swallow esophagography, upper
endoscopy, or CT scan showing the herniation of intra-
abdominal contents into the thorax. (1)
Although rare, there have been 9 reported cases of
congenital hiatal hernia diagnosed antenatally. (4)(5)(6)(7)
(8)(9) All of the reported cases were identified during the
third trimester of pregnancy. It is postulated that the late
onset of findings is because of the fact that the fetus may
only be able to develop sufficient pressure to dilate the
intrathoracic stomach by the third trimester. Hence, with
the development of adequate pressure during swallow-
ing and likely with the effect of reflux of gastric secretions
into the esophagus, the dilated esophagus/stomach may be
Vol. 20 No. 4 APRIL 2019 e223
 Figure 2. Computed tomography scan of the chest, abdomen, and pelvis with the white arrow pointing to a gastric hernia with the gastroesophageal
junction above the diaphragm.
visualized during third-trimester ultrasonography. (8) This
finding has been described as a presence of a cystic mass in
the posterior mediastinum, usually located behind the heart
juxtaposed to the vertebral body and connecting to the intra-
abdominal stomach. (7)
Figure 3. Barium esophagram confirming a hiatal hernia with the black
arrows pointing to an intrathoracic stomach with significant partial
obstruction.
e224 NeoReviews
Downloaded from http://neoreviews.aappublications.org/ by guest on April 1, 2019
Surgical correction is the treatment of choice, especially
in symptomatic paraesophageal hernias with obstructive
symptoms. Patients may also be asymptomatic; however,
because of the risk of subsequent complications, elective
surgical treatment is necessary shortly after diagnosis. (10)
Lessons for the Clinician
• Although rare, congenital hiatal hernia should be con-
sidered in a neonate with gastrointestinal symptoms,
such as vomiting, and respiratory distress.
• Early diagnosis and surgical treatment are important to
prevent complications and morbidity of hiatal hernia such
as aspiration pneumonitis, gastric ulcers, gastric dilation,
perforation, gangrene, and ultimately, cardiopulmonary
arrest.
American Board of Pediatrics
Neonatal-Perinatal Content
Specification
• Know the morphogenesis of the GI tract and factors that lead to
congenital malformations.

References
1. Kohn GP, Price RR, Demeester SR, et al. Guidelines for the
Management of Hiatal Hernia. Los Angeles, CA: SAGES;
2013
2. Maruyama T, Fukue M, Imamura F, Nozue M. Incarcerated
paraesophageal hernia associated with perforation of the
fundus of the stomach: report of a case. Surg Today. 2001;31
(5):454–457
3. Pearson FG, Cooper JD, Ilves R, Todd TR, Jamieson WR. Massive
hiatal hernia with incarceration: a report of 53 cases. Ann Thorac
Surg. 1983;35(1):45–51
4. Di Francesco S, Lanna MM, Napolitano M, et al. A case of ultrasound
diagnosis of fetal hiatal hernia in late third trimester of pregnancy.
Case Rep Obstet Gynecol. 2015;2015:194090
Downloaded from http://neoreviews.aappublications.org/ by guest on April 1, 2019
5. Ogunyemi D. Serial sonographic findings in a fetus with congenital
hiatal hernia. Ultrasound Obstet Gynecol. 2001;17(4):350–353
6. Chacko J, Ford WDA, Furness ME. Antenatal detection of hiatus
hernia. Pediatr Surg Int. 1998;13(2-3):163–164
7. Bahado-Singh RO, Romero R, Vecchio M, Hobbins JC. Prenatal
diagnosis of congenital hiatal hernia. J Ultrasound Med. 1992;11
(6):297–300
8. Ruano R, Benachi A, Aubry M-C, et al. Prenatal sonographic
diagnosis of congenital hiatal hernia. Prenat Diagn. 2004;24
(1):26–30
9. Yamamoto N, Hidaka N, Anami A, et al. Prenatal sonographic
diagnosis of a hiatal hernia in a fetus with asplenia syndrome.
J Ultrasound Med. 2007;26(9):1257–1261
10. Yazici M, Karaca I, Etensel B, et al. Paraesophageal hiatal hernias in
children. Dis Esophagus. 2003;16(3):210–213
Vol. 20 No. 4 APRIL 2019 e225
 Case 1: Vomiting and Bradycardia in a Newborn Infant
Stefanie Cheang, Rupinder Kaur, Sadia Haleem, Swapna Borole and Danitza
Velazquez
NeoReviews 2019;20;e222
DOI: 10.1542/neo.20-4-e222

Updated Information & including high resolution figures, can be found at:
Services http://neoreviews.aappublications.org/content/20/4/e222
References This article cites 9 articles, 1 of which you can access for free at:
http://neoreviews.aappublications.org/content/20/4/e222.full#ref-list-
1
Subspecialty Collections This article, along with others on similar topics, appears in the
following collection(s):
Pediatric Drug Labeling Update
http://classic.neoreviews.aappublications.org/cgi/collection/pediatric
_drug_labeling_update
Permissions & Licensing Information about reproducing this article in parts (figures, tables) or
in its entirety can be found online at:
https://shop.aap.org/licensing-permissions/
Reprints Information about ordering reprints can be found online:
http://classic.neoreviews.aappublications.org/content/reprints

Downloaded from http://neoreviews.aappublications.org/ by guest on April 1, 2019

 Case 1: Vomiting and Bradycardia in a Newborn Infant
Stefanie Cheang, Rupinder Kaur, Sadia Haleem, Swapna Borole and Danitza
Velazquez
NeoReviews 2019;20;e222
DOI: 10.1542/neo.20-4-e222

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://neoreviews.aappublications.org/content/20/4/e222

Neoreviews is the official journal of the American Academy of Pediatrics. A monthly publication,
it has been published continuously since 2000. Neoreviews is owned, published, and trademarked
by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village,
Illinois, 60007. Copyright © 2019 by the American Academy of Pediatrics. All rights reserved.
Online ISSN: 1526-9906.

Downloaded from http://neoreviews.aappublications.org/ by guest on April 1, 2019