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Category: Article Critique

Critique the article provided. This analytical assessment should include comment (appropriateness, issues, etc) on the following:

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The student is encouraged to use the supplemental reading on assessing published papers (BMJ, 1997; 315: 305-308).
NOTE: The current article on color of bile is from the UK. In the UK, babies see general practitioners unless they are referred to a pediatrician for advanced care.

2006;332;1363-; originally published online 31 May 2006; BMJ

Gregor M Walker, Andrew Neilson, David Young and Peter A M Raine

in the newborn: questionnaire study
Colour of bile vomiting in intestinal obstruction

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(1248 articles) Neonates •
(394 articles) Pancreas and biliary tract •
(466 articles) Small intestine •

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on 13 June 2006 Downloaded from
Colour of bile vomiting in intestinal obstruction in the newborn:
questionnaire study
Gregor M Walker, Andrew Neilson, David Young, Peter A M Raine
Objectives To identify the colour that different groups of
observers thought represented bile in a newborn’s vomit.
DesignQuestionnaires displaying eight colours (pale yellow to
dark green).
SettingGeneral practices in Glasgow, postnatal ward and level
III special care baby unit in a university teaching hospital, and
mother and toddler groups in Glasgow.
Participants 47 general practitioners, 29 nurses on the baby
unit, 48 midwives, and 41 mothers of babies and infants.
Outcome measures Participants indicated which colour would
represent bile in a baby’s vomit. More than one colour could be
chosen. Respondents were also asked to indicate one colour
that was the best match for bile.
ResultsWhen any colour could be chosen, 12 (25%) general
practitioners, 1 (3%) nurse on the baby unit, 5 (10%) postnatal
midwives, and 23 (56%) parents did not consider green an
appropriate colour for a baby’s vomit containing bile. Twenty
three (49%) general practitioners, 7 (24%) neonatal nurses, 15
(31%) postnatal midwives, and 29 (71%) parents thought yellow
was the best colour match.
Conclusions There is little agreement about the colour of bile
vomit in a newborn. It is more pertinent to ask parents about
the colour of vomit rather than whether it contained bile. Many
general practitioners and parents do not recognise green as an
appropriate colour for bile in the vomit of newborns, which
may delay surgical referral. Though yellow vomit does not
exclude intestinal obstruction, the presence of green vomiting
in a baby is a surgical emergency and requires expeditious
Classic teaching in paediatric surgery is that vomiting of bile in
the newborn should be attributed to intestinal obstruction until
proved otherwise. Reported series have confirmed the
requirement for further investigation in this group, with a need
for surgical intervention in 30-40%.
To “avoid errors in
judgment” these studies included only babies with green vomit
and excluded babies with yellow vomit. Together with other neo-natal surgeons we advocate prompt and thorough investigation
of any infant with green vomit to specifically exclude mechanical
obstruction. In several infants referred to our unit with reported
bile vomiting, however, a detailed history reveals only yellow
vomiting, though we are aware that a proportion of such babies
are found to have intestinal obstruction. We determined what
colour was perceived by different observer groups to represent
bile in a baby’s vomit.
We developed a questionnaire with eight numbered colours
varying from pale yellow through to dark green (fig 1). Respond-ents were asked to indicate which colour would represent bile in
a baby’s vomit. More than one colour could be chosen, but
respondents were also asked to indicate one colour that was the
best match for bile. We used four groups of observers. Question-naires were delivered by hand to general practitioner clinics with
stamped addressed envelopes. One questionnaire was left for
each general practitioner in every practice visited. Question-naires were distributed by hand to specialist nurses in a special
care baby unit and in a postnatal ward, and a large envelope for
collection was left on each site to ensure anonymity. Local
mother and toddler groups were visited and questionnaires were
handed to the parents of infants. Again, a large envelope for col-lection was left. The respondents in each group were asked not to
We divided responses in returned questionnaires into yellow
and green. We then analysed the proportions of yellow and
green responses from each group using 
tests, comparing each
group with the responses from general practitioners.
The response rate differed between the groups and reflects the
methods used to ensure return of the questionnaires. All
questionnaires handed to parents (41), special care baby unit
nurses (29), and postnatal ward midwives (48) were returned. Of
the 80 questionnaires delivered to general practitioners, 47
(58%) were returned using the stamped addressed envelopes.
When asked to indicate any colour that could represent bile
in a baby’s vomit, 23 (56%) parents did not choose any of the four
green colours. Of the healthcare professionals, 12 (25%) general
practitioners, 5 (10%) midwives from the postnatal wards, and 1
(3%) special care nurse did not chose any of the four green col-ours.
When we asked participants to indicate the one colour that
was the best match for bile in a vomit, the distribution of results
was similar to those above (table 1). There were significant differ-ences in the proportions of green or yellow responses for each
group (P = 0.002). We compared responses for each group with
those from general practitioners (table 2). General practitioners
identified a green colour in a significantly greater proportion of
responses than parents but a significantly lower proportion of
responses than special care nurses. Though the postnatal ward
midwives identified a green colour more often than general
practitioners, the difference was not significant.
Cite this article as: BMJ, doi:10.1136/bmj.38859.614352.55 (published 31 May 2006)
BMJOnline First page 1 of 3
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Because bile enters the intestine in the second part of the
duodenum, intestinal obstruction below this level can result in
bile in the vomit or gastric aspirate (fig 2). In the newborn this
can be associated with surgical conditions including intestinal
atresia, intestinal malrotation, and Hirschsprung’s disease.
These conditions are associated with considerable morbidity,
particularly intestinal malrotation, in which rapid diagnosis is
essential to prevent catastrophic ischaemia resulting from small
bowel volvulus.
In cases of small bowel volvulus, bile vomiting
may be the only early sign
and failure to act at this stage will
result in avoidable delay. The presence of bile in the vomit is an
independent sign of severity of disease and is rarely seen in well
Our study shows that, though there may be general
awareness that bile in a baby’s vomit is worrying, there is clearly
no consensus as to its appearance. Parents often refer to their
children’s vomit as bilious when a small amount of non-food
gastric residue is produced, so the responses were not surprising.
When a history is taken from parents of a vomiting baby it is
more informative to ask about the colour of the vomit rather
than whether it contained “bile.” The parents participating in this
study were not asked if their children had any medical history of
note. We used local mother and toddler groups rather than ask-ing parents of inpatients to obtain a representative sample of the
The specialist nurses on the baby unit would be expected to
have the highest exposure to bile vomiting in the newborn, and
nearly all respondents indicated a green colour when any box
could be ticked. It was surprising that nearly a quarter thought
the best colour match was yellow. Postnatal midwives, both in
hospital and in the community, have considerable experience in
the assessment of newborns, yet a third indicated yellow as the
best match.
The fact that half the general practitioners thought the best
colour match for bile was yellow may be worrying, but the more
relevant finding was that when given the opportunity to tick any
colour, a quarter did not tick any green boxes at all. These data
suggest that, in the community, a considerable number of
parents and healthcare professionals would fail to recognise the
importance of green vomiting. In cases of malrotation and
volvulus, if intestinal ischaemia had developed at the time of the
first green vomit, delay in surgical referral could result in critical
intestinal loss.
We emphasise that yellow vomiting in babies should not be
disregarded and that the clinical state of the patient should be
paramount in assessing the need for referral. Further study
should identify the proportion of newborns found to have intes-tinal obstruction whose vomit is predominantly yellow. Green
vomiting in a newborn, however, is of major importance and
78 Fig 1 Choices of colours representing bile in a baby’s vomit. Respondents were
asked to tick all options that could represent bile, and then select the one best
Table 1 Colour chosen as best match for bile in a baby’s vomit
Group Green (%) Yellow (%)
Parents 12 (29) 29 (71)
General practitioners 24 (51) 23 (49)
SCBU nurses 22 (76) 7 (24)
Postnatal midwives 33 (69) 15 (31)
SCBU=special care baby unit.
Table 2 Comparison of responses between observer groups
Comparison  green/yellow (95% CI) P value
GPv parents 0.218 (0.018 to 0.417) 0.038
GPv SCBU nurses −0.248 (−0.459 to −0.037) 0.032
GPv ward midwives −0.177 (−0.0371 to 0.017) 0.079
GP=general practitioner; SBCU=special care baby unit.
Fig 2 Gastric aspirate from a newborn with upper intestinal obstruction
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requires expeditious referral for surgical assessment, and failure
to recognise this may have grave consequences.
Contributors: GMW was responsible for the original idea, identified the
observer groups, visited the groups of parents, and drafted the manuscript.
AN designed and distributed the questionnaire to healthcare professionals.
DY advised on statistical analysis and modified the manuscript. PAMR
(guarantor) provided advice throughout the study and modified the manu-script.
Funding: None.
Competing interests: None declared.
Ethical approval: Not required as responses were anonymous.
1 Godbole P, Stringer MD. Bilious vomiting in the newborn: how often is it pathologic?J
Pediatr Surg2002;37:909-11.
2 Lilien LD, Srinivasan G, Pyati SP, Yeh TF, Pildes RS. Green vomiting in the first 72
hours in normal infants. Am J Dis Child1986;140:662-4.
3 Kimura K, Loening-Baucke V. Bilious vomiting in the newborn: rapid diagnosis of
intestinal obstruction. Am Fam Physician 2000;61:2791-8.
4 Bonadio WA, Clarkson T, Naus J. The clinical features of children with malrotation of
the intestine. Pediatr Emerg Care1991;7:348-9.
5 Morley CJ, Thorton AJ, Cole TJ, Fowler MA, Hewson PH. Symptoms and signs in
infants younger than 6 months of age correlated with the severity of their illness. Pedi-atrics1991;88:1119-24.
(Accepted 28 March 2006)
doi 10.1136/bmj.38859.614352.55
Department of Paediatric Surgery, Royal Hospital for Sick Children, Glasgow G3
Gregor Walkerspecialist registrar in paediatric surgery
Andrew Neilsonfinal year medical student
Peter Raineconsultant paediatric surgeon
Department of Statistics and Modelling Science, University of Strathclyde, Glasgow
G1 1XH
David Young senior statistician
Correspondence to: G Walker [email protected]
What is already known on this topic
Bile vomiting in the newborn indicates intestinal
obstruction and should result in immediate referral
Observational studies of bile vomiting in newborns have
included only those with green vomit
What this study adds
There is no clear consensus on the colour of bile vomiting
Many parents and general practitioners do not think green
vomiting represents bile, which may result in avoidable
delay in surgical referral
It is more informative to ask about the colour of vomit
rather than whether it contained bile
BMJOnline First page 3 of 3
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