pediatric housecalls Robert R. Jarrett M.D. M.B.A. FAAP

Recurring Vomiting – Tonsillitis in Former Premature Infant

[A 3-year-old with recurrent bouts of vomiting and coughing phlegm in the mornings is thought to have a “form of tonsillitis” and her mother wonders about a tonsillectomy.]

My daughter was 6 weeks premature. She has some complications and had to have open heart surgery when she was 4 weeks old. She has just turned 3 and is doing very well. She is pretty small for age, has a few scares but other than that is like a normal child. Ever since she has come home from the hospital she has this thing where she will wake up some morning with a fever coughing and throwing up phlegm. She could throw up 100 + times in one day. To the point were I think she is throwing up vile (bile) or stomach acid because it because a green/yellow thin liquid. When she first came home this happened to her 2 or more times a week. Now that she is 3 it happens maybe 1 or 2 times a month. Every time I have taken her to the doctors and asked them about it they just keep telling me its because she is a preemie and her bridge of her nose hasn’t developed so her nasal passages are small as everything else in there is too. So its cause her mucous to back up rather than drain. Ok I go with that for awhile. But it is still happening. She is 3 and everything seems to be developed. When she gets like it is like BOOM she wakes up crying, gagging and throwing up. It only lasts about a day usually gone by 2:00 pm. Sometimes a little sooner sometimes a little longer. She just lays around all day throwing up. She just had this happen on Wednesday. My father took her to the doctors because he was afraid she was going to be sick for Christmas. I knew what the problem was but he wanted to take her anyhow. The same doctor we always had said now that she is getting older they can see things a little better and said it looks like a form of tonsillitis. He said that she is having puss lay on her lungs which is causing her to gag and then throw up the phlegm. He put her on penicillin for 5 days to try and clear it up for her. Of course by the time they got home from the doctors she was feeling better. I’m still going to give her the prescription. I feel in my heart something is going on with her and I’m not sure if I should take her to a specialist to be checked. Or Maybe its just Mommy worrying to much. I would like to know how to prevent this from happening. There are no signs the night before that she is going to be like this. She just wakes up with it. I hate to see her in pain like that and I cant imagine throw up that much is good for her esophagus either. Any suggestions or comments? … Bridget C.
Wow. It sounds like quite a story and, frankly, it probably “looses something in the translation to Email”; but there is probably more than one issue going on. It would be nice if everything was related and one answer would solve it all, but probably there is an infectious illness, a stomach problem and her “heart” problem all happening at once within the setting of what WAS “prematurity.”

Prematurity itself is a significant problem, while it is happening; but, as the child gets older it means less and less. By three years of age the child usually is developed enough to have “outgrown” most issues of being born too soon (EXCEPTing those inflicted upon them during their prematurity care – like respirators, surgeries etc. etc.)

The heart of a premature infant is also not usually any different than full term infants EXCEPT that, on occasion, the Ductus Arteriosus (bypass shunt used before birth – which normally squeezes shut with their first breath of oxygen) might stay open and therefore sometimes need to be closed off artificially. But you don’t need to “open the heart” in order to do it. It is usually closed by placing a “band” around the duct on the “outside” of the heart.

Actual “open heart” surgery (like for a mis-formed valve etc) would truly be a different matter and could occur whether the baby was premature or not. So they wouldn’t normally “grow out” of the issue with age. Which of these your daughter had I cannot tell from your letter.

The term “throwing up” is usually reserved to mean the “forceful expulsion” of stomach contents by the contraction of it’s musculature and diaphragm. If it is severe (like out into the room) that could mean Pyloric stenosis which would require surgery (which you didn’t mention, so is probably not the case). True vomiting more than a few times a day would most likely result in dehydration and hospitalization. More likely, what your child had was regurgitation/reflux (often seen in premature’s) from the “valve” at the opening of the stomach not closing well and formula/food etc “bubbling,” or refluxing, back up into the mouth.

Reflux sometimes requires surgery to relieve (you didn’t mention that either); but, most often is treated by keeping the baby upright, especially after feedings. Sometimes a “reflux” board is used to strap them upright during sleep etc. Preme’s usually “grow out” of the problem; but, other things can precipitate it as well – like being overweight, eating before lying down, hiatal hernia, gassy foods etc. By 3 years old, “reflux” is not related to being premature. It could be any of the things I’ve mentioned – or some others that your pediatrician could discuss with you. At any rate she should be completely off the bottle by now; not be fed within 1-2 hours of bedtime or drink within 30 minutes of bed; especially not take “gassy” foods; and watching growth so as not to cross body stature growth lines (i.e. get overweight for height); etc. Reflux has nothing to do with “nasal passages.”

Recurrent ear infections are somewhat related to “nasal passages”; but, more likely related to anyone smoking in the same enclosure as the baby and being put to bed with a bottle.

The NORMAL child has 100 “illnesses” (cold’s, flu etc) by the time they are ten! Smokers kids have even more than that. Premature’s also are “more prone” to respiratory and gastric “illnesses” but that resolves as their lungs and other organs grow. Some, if not most, of those illnesses produce cough and congestion; and, if she has a “weak stomach valve,” would be more prone to gagging and vomiting with coughing spells.

Some of those illnesses are sore throats which usually resolve by themselves without antibiotics. And some of those sore throats are STREP throats which do require antibiotics; but NOT before a test for strep has been shown to be positive. In that case you must use the antibiotics as directed for the full course in order to prevent complications.

The doctor would not be able to see “puss sitting on the lungs” as the lungs are not visible from an oral exam. If there is exudate (puss) on the tonsils he/she should have done a strep test. IF that was positive he should use antibiotics. Although, arbitrarily putting a child on antibiotics by “looking and guessing” is an old fashioned practice which has led to the development of dangerous and deadly bacteria strains and is no longer considered proper for pediatricians.

A doctor does not need a child to “get bigger” in order to diagnose tonsillitis as they are easily visible at the back of the throat on an oral exam. Diagnosis can even be done in preme’s merely by “looking” and swabbing for any necessary cultures.

The steps to resolve any problem such as this would include:

  1. Realize that the regurgitating, vomiting, colds, tonsillitis are probably separate problems. A child is “supposed” to be ill many times in childhood in order to develop resistance to viruses etc.
  2. Make sure that any of the problems are not being “caused/inflicted” by anything that can be stopped. (like the bottle, smoking, overfeeding, etc); and stop any practice that you are suspicious might be precipitating or aggravating the problem.
  3. Seek advice from a medical professional who is not only trained (for example a board certified Pediatrician) but who has “people skills” such that he/she can explain and communicate. A Pediatrician is trained in solely children’s diseases. There are other generalists and family doctors whose training in children’s diseases is no where near as extensive.
  4. If you ARE seeing a board certified Pediatrician who is answering questions and communicating well then the next referral source would probably be a pediatric gastroenterologist who will, in addition to the things I’ve mentioned above, possibly do other testing (like x-rays or endoscopy). Controlling “stomach” reflux can be done by: diet, sleeping position, medications and surgery- preferably in that order.

This may help you formulate your plan for identifying and resolving the problem with your physician.

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