2 month old baby vomit after feeding
Why This Happens and What to Do
It can be difficult to tell the difference between vomit and spit-up. Both might look the same since your baby is currently on a steady of diet of milk or formula. The main difference is in how they come out.
Spit-up usually happens before or after a burp and is most common in babies under the age of 1 year. Spit-up will easily flow from your baby’s mouth — almost like white, milky drool.
Vomit typically comes out forcefully (whether you’re a baby or an adult). This is because vomiting happens when the muscles around the stomach are triggered by the brain’s “vomiting center” to squeeze it. This forces whatever is in the stomach to be hurled out.
In a baby’s case, vomit may look like milky spit-up but have more clear stomach juices mixed into it. It may also look like milk that has been fermented for a little while — this is called “cheesing.” Yes, it sounds gross. But the texture probably won’t bother you when you see it — you’ll be more concerned with baby’s well-being.
Your baby may also cough or make little retching noises before they vomit. This is likely the only warning you’ll have to grab a towel, bucket, burp cloth, sweater, your shoe — hey, anything.
Additionally, spit-up is normal and can happen at any time. Your baby will only vomit if there’s a digestive issue or they have another illness.
Babies have to learn everything from scratch, including how to feed and keep the milk down. Along with spit-up, your baby may vomit occasionally after being fed. This is most common in the first month of life.
It happens because your baby’s tummy is still getting used to digesting food. They also have to learn to not gulp milk down too fast or overfeed.
Post-feeding vomiting typically stops after the first month. Give your baby more frequent, smaller feeds to help stop the vomit.
But let your pediatrician know if your baby vomits often or has very forceful vomits. In some cases, it might be a sign of something other than feeding difficulty.
Also known as the tummy bug or “stomach flu,” gastroenteritis is a common cause of vomiting in babies and children. Your baby may have cycles of vomiting that come and go for about 24 hours.
Other symptoms in babies may last for 4 days or longer:
- watery, runny poop or mild diarrhea
- irritability or crying
- poor appetite
- stomach cramps and pain
The tummy bug can also cause a fever, but this is actually less common in babies.
Gastroenteritis usually looks a lot worse than it is (thank goodness!). It’s typically caused by a virus that goes away by itself in about a week.
In babies, severe gastroenteritis can lead to dehydration. Call your pediatrician immediately if your baby has any signs of dehydration:
- dry skin, mouth, or eyes
- unusual sleepiness
- no wet diapers for 8 to 12 hours
- weak cry
- crying without tears
In some ways, babies really are like tiny adults. Just like adults of any age can have acid reflux or GERD, some babies have infant reflux. This can lead to baby vomiting in the first weeks or months of your baby’s life.
Vomiting from acid reflux happens when the muscles at the top of the stomach are too relaxed. This triggers baby vomiting shortly after feeding.
In most cases, the stomach muscles strengthen, and your baby’s vomiting goes away on its own. Meanwhile, you can help slow down the vomiting by:
- avoiding overfeeding
- giving smaller, more frequent feeds
- burping your baby often
- propping your baby up in an upright position for about 30 minutes after feeding
You can also thicken milk or formula with more formula or a bit of baby cereal. Caveat: Check with your pediatrician before you try this. It might not be suitable for all babies.
Cold and flu
Babies catch colds and flus easily because they have shiny new immune systems that are still developing. It doesn’t help if they’re in day care with other sniffling kiddos, or they’re around adults that can’t resist kissing their little faces. Your baby may have up to seven colds in their first year alone.
Cold and flu can cause different symptoms in babies. Along with a runny nose, your baby may also have vomiting without a fever.
Too much mucus in the nose (congestion) can lead to a nasal drip in the throat. This can trigger bouts of forceful coughing that sometimes cause vomiting in babies and children.
As in adults, colds and flu in babies are viral and go away after about a week. In some cases, sinus congestion may turn into an infection. Your baby will need antibiotics to treat any bacterial — not viral — infection.
Ear infections are another common illness in babies and children. This is because their ear tubes are horizontal rather than more vertical like in adults.
If your little one has an ear infection, they might have nausea and vomiting without a fever. This happens because an ear infection can cause dizziness and loss of balance. Other symptoms of ear infections in babies include:
- pain in one or both ears
- tugging or scratching at or near the ears
- muffled hearing
Most ear infections in babies and children go away without treatment. However, it’s important to see a pediatrician in case your baby needs antibiotics to clear up the infection. In rare cases, a serious ear infection can damage a baby’s tender ears.
Before you swaddle your baby or put them in that adorable fluffy bunny suit, check the temperature outside and in your home.
While it’s true that the womb was warm and cozy, babies can overheat quickly in hot weather or in a very warm house or car. This is because their tiny bodies are less able to sweat out heat. Overheating might cause vomiting and dehydration.
Overheating can lead to heat exhaustion or in much more serious cases, heatstroke. Look for other symptoms like:
- pale, clammy skin
- irritability and crying
- sleepiness or floppiness
Immediately remove clothing and keep your baby out of the sun and away from heat. Try to breastfeed (or give your baby water if they’re 6 months or older). Get urgent medical attention if your baby doesn’t seem their usual self.
Babies below the age of 2 years don’t commonly get motion or car sickness, but some babies may get sick after a car ride or being twirled around — especially if they’ve just eaten.
Motion sickness can make your baby dizzy and nauseous, leading to vomiting. It might be more likely to happen if your baby already has an upset tummy from bloating, gas, or constipation.
Strong smells and windy or bumpy roads can also make your baby dizzy. Nausea triggers more saliva, so you might notice more dribble before your baby vomits.
You can help prevent motion sickness by traveling when your baby is ready to sleep. (Great trick if your baby loves to sleep in the car!) A sleeping baby is less likely to feel queasy.
Keep their head well supported in the car seat so it doesn’t move around too much. Also, avoid going for a drive right after giving your baby a full feed — you want your baby to digest the milk, not wear it.
A rare kind of milk intolerance is called galactosemia. It happens when babies are born without a certain enzyme needed to break down sugars in milk. Some babies with this condition are even sensitive to breast milk.
It can cause nausea and vomiting after drinking milk or any kind of dairy products. Galactosemia can also cause a skin rash or itching in both babies and adults.
If your baby is formula fed, check the ingredients for any dairy, including milk proteins.
Most newborns are screened at birth for this rare condition and other illnesses. This is usually done with a heel prick blood test or a urine test.
In the rare event that your baby has this, you’ll know it very early on. Make sure your baby completely avoids milk to help stop vomiting and other symptoms.
Pyloric stenosis is a rare condition that happens when the opening between the stomach and intestines is blocked or too narrow. It can lead to forceful vomiting after feeding.
If your baby has pyloric stenosis, they may be hungry all the time. Other symptoms include:
- weight loss
- wave-like stomach contractions
- fewer bowel movements
- fewer wet diapers
This rare condition can be treated with surgery. Tell your pediatrician immediately if your baby has any of the symptoms of pyloric stenosis.
Intussusception is a rare intestinal condition. It affects 1 in every 1,200 babies and most commonly happens at the age of 3 months or older. Intussusception can cause vomiting without a fever.
This condition happens when the intestines are damaged by a virus or other health conditions. The damaged intestine slips — “telescopes” — into another part of the intestine.
Along with vomiting, a baby may have severe stomach cramps that last for about 15 minutes. The pain can cause some babies to curl their knees up to their chest.
Other symptoms of this intestinal condition include:
- fatigue and tiredness
- blood or mucus in bowel movements
If your baby has intussusception, treatment can push the intestine back into place. This gets rid of vomiting, pain, and other symptoms. Treatment includes using air in the intestines to gently move the intestines. If that doesn’t work, keyhole (laparoscopic) surgery heals this condition.
See your baby’s pediatrician if your baby has vomiting for longer than 12 hours. Babies can get dehydrated quickly if they’re vomiting.
Get immediate medical attention if your baby is vomiting and has other symptoms and signs like:
- pain or discomfort
- constant or forceful coughing
- hasn’t had a wet diaper for 3 to 6 hours
- refusing to feed
- dry lips or tongue
- few or no tears when crying
- extra tired or sleepy
- weakness or floppy
- won’t smile
- swollen or bloated stomach
- blood in diarrhea
Baby vomiting without a fever can happen because of several common illnesses. Your baby will likely have one or more of these several times in the first year. Most of these causes go away on their own, and your little one will stop vomiting without any treatment.
But too much vomiting can lead to dehydration. Check for signs of dehydration and call your pediatrician if you’re not sure.
Some causes of baby vomiting are more serious, but these are rare. Your baby will need medical care for these health conditions. Know the signs and remember to keep the doctor’s number saved in your phone — and take a deep breath. You and baby got this.
Vomiting (0-12 Months)
Is this your child's symptom?
- Vomiting (throwing up) stomach contents
- Other names for vomiting are puking, barfing and heaving
Causes of Vomiting
- Viral Gastritis. Stomach infection from a stomach virus is the most common cause. Also called stomach flu. A common cause is the Rotavirus. The illness starts with vomiting. Watery loose stools may follow within 12-24 hours.
- Food Allergy. Vomiting can be the only symptom of a food reaction. The vomiting comes on quickly after eating the food. Uncommon in infants, but main foods are eggs and peanut butter.
- Coughing. Hard coughing can also cause your child to throw up. This is more common in children with reflux.
- Serious Causes. Vomiting alone should stop within about 24 hours. If it lasts over 24 hours, you must think about more serious causes. An example is a kidney infection. A serious cause in young babies is pyloric stenosis. See below for more on this.
Pyloric Stenosis (Serious Cause)
- The most common cause of true vomiting in young babies.
- Onset of vomiting is age 2 weeks to 2 months
- Vomiting is forceful. It becomes projectile and shoots out.
- Right after vomiting, the baby is hungry and wants to feed. ("hungry vomiter")
- Cause: The pylorus is the channel between the stomach and the gut. In these babies, it becomes narrow and tight.
- Risk: Weight loss or dehydration
- Treatment: Cured by surgery.
- Mild: 1 - 2 times/day
- Moderate: 3 - 7 times/day
- Severe: Vomits everything, nearly everything or 8 or more times/day
- Severity relates even more to how long the vomiting goes on for. At the start of the illness, it's common for a child to vomit everything. This can last for 3 or 4 hours. Children then often become stable and change to mild vomiting.
- The main risk of vomiting is dehydration. Dehydration means the body has lost too much fluid.
- The younger the child, the greater the risk for dehydration.
Dehydration: How to Tell
- The main risk of vomiting is dehydration. Dehydration means the body has lost too much water.
- Vomiting with watery diarrhea is the most common cause of dehydration.
- Dehydration is a reason to see a doctor right away.
- Your child may have dehydration if not drinking much fluid and:
- The urine is dark yellow and has not passed any in over 8 hours.
- Inside of the mouth and tongue are very dry.
- No tears if your child cries.
- Slow blood refill test: Longer than 2 seconds. First, press on the thumbnail and make it pale. Then let go. Count the seconds it takes for the nail to turn pink again. Ask your doctor to teach you how to do this test.
When to Call for Vomiting (0-12 Months)
Call 911 Now
- Can't wake up
- Not moving
- You think your child has a life-threatening emergency
Call Doctor or Seek Care Now
- Dehydration suspected. No urine in over 8 hours, dark urine, very dry mouth and no tears.
- Stomach pain when not vomiting. Exception: stomach pain or crying just before vomiting is quite common.
- Age less than 12 weeks old with vomiting 2 or more times. Exception: normal spitting up.
- Vomited 3 or more times and also has diarrhea
- Severe vomiting (vomits everything) more than 8 hours while getting Pedialyte (or breastmilk)
- Head injury within the last 24 hours
- Weak immune system. Examples are sickle cell disease, HIV, cancer, organ transplant, taking oral steroids.
- Vomiting a prescription medicine
- Fever over 104° F (40° C)
- Fever in baby less than 12 weeks old. Caution: Do NOT give your baby any fever medicine before being seen.
- Your child looks or acts very sick
- You think your child needs to be seen, and the problem is urgent
Contact Doctor Within 24 Hours
- All other infants (age less than 1 year) with vomiting. See Care Advice while waiting to discuss with doctor.
Seattle Children's Urgent Care Locations
If your child’s illness or injury is life-threatening, call 911.
- Federal Way
Care Advice for Vomiting
- What You Should Know About Vomiting:
- Most vomiting is caused by a viral infection of the stomach.
- Vomiting is the body's way of protecting the lower gut.
- The good news is that stomach illnesses last only a short time.
- The main risk of vomiting is dehydration. Dehydration means the body has lost too much fluid.
- Here is some care advice that should help.
- Formula Fed Babies - May Give Oral Rehydration Solution (ORS) for 8 Hours:
- If vomits once, give half the regular amount of formula every 1 to 2 hours.
- If vomits formula more than once, offer ORS for 8 hours. If you don't have ORS, use formula until you can get some.
- ORS is a special fluid that can help your child stay hydrated. You can use Pedialyte or the store brand of ORS. It can be bought in food stores or drug stores.
- Spoon or syringe feed small amounts. Give 1-2 teaspoons (5-10 mL) every 5 minutes.
- After 4 hours without throwing up, double the amount.
- Return to Formula. After 8 hours without throwing up, go back to regular formula.
- Breastfed Babies - Reduce the Amount Per Feeding:
- If vomits once, nurse half the regular time every 1 to 2 hours.
- If vomits more than once, nurse for 5 minutes every 30 to 60 minutes. After 4 hours without throwing up, return to regular nursing.
- If continues to vomit, switch to pumped breastmilk. (ORS is rarely needed in breastfed babies. It can be used if vomiting becomes worse).
- Spoon or syringe feed small amounts of pumped milk. Give 1-2 teaspoons (5-10 mL) every 5 minutes.
- After 4 hours without throwing up, return to regular feeding at the breast. Start with small feedings of 5 minutes every 30 minutes. As your baby keeps down the smaller amounts, slowly give more.
- Pumped Breastmilk Bottle-Fed Infants - Reduce the Amount per Feeding:
- If vomits once and bottle-feeding breastmilk, give half the regular amount every 1-2 hours.
- If vomits more than once within last 2 hours, give 1 ounce (30 mL) every 30 to 60 minutes.
- If continues to vomit, give 1-2 teaspoons (5-10 mL) every 5 minutes. Only if not tolerating breastmilk, switch to ORS (e.g., Pedialyte) for every 5 minutes for a few hours.
- After 4 hours without vomiting, return to regular feedings. Start with 1 ounce (30 mL) every 30 minutes and slowly increase as tolerated.
- Stop All Solid Foods:
- Avoid all solid foods and baby foods in kids who are vomiting.
- After 8 hours without throwing up, gradually add them back.
- If on solid foods, start with starchy foods that are easy to digest. Examples are cereals, crackers and bread.
- Do Not Give Medicines:
- Stop using any drug that is over-the-counter for 8 hours. Reason: Some of these can make vomiting worse.
- Fever. Mild fevers don't need to be treated with any drugs. For higher fevers, you can use an acetaminophen suppository (such as FeverAll). This is a form of the drug you put in the rectum (bottom). Ask a pharmacist for help finding this product. Do not use ibuprofen. It can upset the stomach.
- Call your doctor if: Your child vomits a drug ordered by your doctor.
- Try to Sleep:
- Help your child go to sleep for a few hours.
- Reason: Sleep often empties the stomach and removes the need to vomit.
- Your child doesn't have to drink anything if his stomach feels upset and he doesn't have any diarrhea.
- Return to Child Care:
- Your child can return to child care after the vomiting and fever are gone.
- What to Expect:
- For the first 3 or 4 hours, your child may vomit everything. Then the stomach settles down.
- Vomiting from a viral illness often stops in 12 to 24 hours.
- Mild vomiting and nausea may last up to 3 days.
- Call Your Doctor If:
- Vomits clear fluids for more than 8 hours
- Vomiting lasts more than 24 hours
- Blood or bile (green color) in the vomit
- Stomach ache present when not vomiting
- Dehydration suspected (no urine in over 8 hours, dark urine, very dry mouth, and no tears)
- You think your child needs to be seen
- Your child becomes worse
And remember, contact your doctor if your child develops any of the 'Call Your Doctor' symptoms.
Disclaimer: this health information is for educational purposes only. You, the reader, assume full responsibility for how you choose to use it.
Last Reviewed: 12/10/2022
Last Revised: 09/21/2022
Copyright 2000-2022 Schmitt Pediatric Guidelines LLC.
Spitting up and vomiting in infants
Spitting up and vomiting in babies is a common reason for visiting a doctor.
Regurgitation and vomiting is a reflex action that occurs when receptors located in various anatomical zones are irritated, incl. in the stomach, esophagus, pharynx, oral cavity. The signal is transmitted to the vomiting center, which is located in the medulla oblongata and a gag reflex occurs.
What is the difference between regurgitation and vomiting?
The difference lies in the volume and kinetics (movement) of the gastric contents expelled to the outside. When regurgitation occurs, leakage occurs without the participation of the diaphragm and abdominal muscles, i. e. passively. There is little content, up to about 10-15 ml. If the child does not swallow it, it quietly expires from the oral cavity. When vomiting, a wave-like bending of the upper half of the body occurs as a result of contraction of the muscles of the diaphragm and the anterior wall of the abdomen, the volume of vomit is greater, and they are erupted with pressure from the oral cavity with an ejection trajectory of up to 50 cm. In children of the first year of life, this is defined by the term "fountain vomiting" .
Regurgitation is observed only in children of the first year of life and, mainly, up to 6 months. Contribute to this anatomical and physiological features of the esophagus and stomach of the baby. Their esophagus is short and wide, the angle of connection of the esophagus with the stomach is less pronounced, and its obturator function is weak. These regurgitations are physiological. They can be after each feeding, up to 15 ml, do not affect the well-being and weight gain of the baby. They can also be caused by excessive feeding, aerophagia (swallowing air while sucking), straining during intestinal colic. The frequency and volume of such regurgitation decreases with the growth of the child. With the introduction of complementary foods, and this is a thicker food, regurgitation stops or becomes much less frequent.
If regurgitation persists in a child older than 1 year, then this is a sign of a pathological process.
Vomiting, unlike regurgitation, is accompanied by vegetative symptoms - increased salivation, pallor of the skin, palpitations. This is due to the fact that next to the vomiting center there are additional centers of autonomic regulation, which are reflexively excited, and active biological substances such as serotonin, dopamine, histamine and others are released into the blood.
Regurgitation and vomiting, from the moment of eating, may occur during feeding, after feeding for the first 20-30 minutes or delayed, sometimes after several hours.
Regurgitation and vomiting that occurs immediately after feeding unchanged breast milk or formula may be due to narrowing of the esophagus. If they persist until the next feeding, and the milk / mixture is curdled, has a sour or musty smell, then this is the result of a long standing food in the stomach. The reason for this may be the low tone of the muscle layer of the stomach and, as a result, its peristalsis or narrowing of the output section due to an anomaly in the development or high tone of the sphincter of the lower stomach. With narrowing of the duodenum, bile is present in the regurgitated masses.
Gastroesophageal reflux is a common cause of regurgitation in infants. It is likely that there is a complex problem here, starting with the immaturity of the gastrointestinal tract and disorders of the central nervous system. Perinatal injuries of the central nervous system accompany every second child. Their manifestations are varied. Regurgitation and vomiting can be facilitated by an increase in intracranial pressure, disorders in the segment of the cervical spine, and so on. Therefore, quite often, when carrying out rehabilitation measures for neurological dysfunctions, a positive effect is manifested in the form of a decrease or cessation of regurgitation. A hernia of the esophageal opening of the diaphragm will also manifest itself in a similar way.
We should not forget about allergic gastrointestinal reactions in the form of regurgitation and vomiting. The most common cause of this is cow's milk protein. With intolerance to cow's milk protein, inflammation of the mucous membrane of the esophagus, stomach and intestines occurs. And, as a result of this, regurgitation and vomiting, pain and increased gas formation, diarrhea or constipation.
Rare endocrine disorders (adrenogenital syndrome) are manifested by vomiting in children from the first weeks of life. In such cases, vomiting is frequent, there may be an admixture of bile, the child loses weight due to loss of fluid and nutrients, and severe metabolic disorders develop.
Vomiting can also be caused by an intestinal infection. Viral gastroenteritis is now common. It must be remembered that the younger the child, the more severe the disease. Within a few hours, the child's condition can go from satisfactory to extremely serious.
As you can see, the causes of regurgitation and vomiting in children of the first year of life are quite diverse, but most often these are transient conditions that disappear with the growth of the child.
Prevention of regurgitation in children of the first months of life is quite simple. Don't overfeed your baby. If he cries, it does not always mean that he is hungry. Excess feeding leads to increased gas formation and colic, during which the child is worried, straining, thereby increasing the likelihood of spitting up. After feeding, hold the baby more upright so that he can burp the swallowed air. This will take 15-20 minutes. If the child is bottle-fed, do not change his formula milk without the recommendation of a pediatrician.
If the child has frequent regurgitation and vomiting, it is necessary to consult a pediatrician or gastroenterologist to diagnose the cause. To make a diagnosis, it is sometimes enough to carry out simple and affordable diagnostic methods in a polyclinic. These include an ultrasound of the stomach and, if necessary, stool tests. However, the approach in each case is individual. Examination and treatment will be assigned to your baby, depending on the diagnosis. Perhaps it will be preventive measures or a certain milk formula, perhaps drug therapy. Rarely, but it happens that it is necessary to examine the child in a hospital and surgical treatment.
Regurgitation and vomiting in children
Regurgitation syndrome is one of the most common reasons parents of young children visit a pediatrician and a surgeon. The causes of regurgitation in children under 1 year old are different: anatomical and functional features, neurological disorders, infectious processes, malformations or other problems. The mechanism that prevents regurgitation and vomiting in children is very complex and depends on the anatomical structure and physiological processes of the child. The formation of this mechanism occurs in the last trimester of pregnancy and continues in the first months of a child's life. Although regurgitation and vomiting can be a symptom of various diseases, in themselves these processes are physiological, i.e. normal. The pathological reflux of stomach contents into the esophagus is called gastroesophageal reflux, and the mechanism that prevents vomiting is called the antireflux mechanism.
Anti-reflux mechanism in children
In children, the nervous regulation of the antireflux mechanism is very complex and easily disturbed under the influence of external and internal factors. Regurgitation and vomiting easily occur in children with an immature antireflux mechanism, if the mode or volume of feeding is incorrectly selected, as a reaction to artificial mixtures, at the slightest sign of infectious processes. This is especially often observed in children with intrauterine growth retardation and premature babies, as well as in severe pregnancy and toxicosis, caesarean section, complicated childbirth, etc.
When to see a doctor
Despite the fact that moderate spitting up in a child under 6 months is considered a variant of the norm, parents should definitely tell the pediatrician about this during a routine examination. The reason for serious concern and immediate examination of the child is an increase in the frequency or increase in the volume of regurgitation, the appearance of streaks of blood or bile impurities, a lag in recruitment or weight loss, and high temperature. In this case, it is urgent to consult a surgeon to rule out surgical causes.
In most cases, an ultrasound examination (ultrasound) is necessary to establish an accurate diagnosis and select the correct treatment. An experienced doctor of ultrasound diagnostics helps to establish the correct diagnosis in more than half of the cases. Sometimes, for a more accurate diagnosis, a flexible gastroscopy, X-ray examination, or computed tomography of the abdominal organs is performed.
When surgery is required
Pyloric stenosis, or impaired patency of the gastric outlet, is the cause of the most severe regurgitation syndrome (vomiting "fountain") in children under 2 months, accompanied by severe weight loss and progressive deterioration of the child's condition. This disease requires urgent surgical care. In leading clinics, such operations are performed using a minimally invasive laparoscopic method. The current level of development of surgery and pediatric anesthesiology allows the use of endoscopic surgery techniques even in children in the first weeks of life.
There are also other causes of regurgitation that require surgical intervention, such as hiatal hernia, chalazia (gaping) of the esophagus, and others. These malformations are characterized by a violation of the formation of the antireflux mechanism and lead to constant regurgitation in a child, impaired weight gain, decreased appetite, chronic cough, bronchial asthma, and anemia. If drug therapy is ineffective, then a gastrofundoplication operation is indicated, in which an artificial antireflux valve is surgically formed. Like many other interventions, in modern children's clinics this operation is performed laparoscopically - with less trauma, minimal blood loss, minimal cosmetic defect and a quick recovery of the child after the operation.
Of course, vomiting and regurgitation can be symptoms of many other diseases and occur at any age of the child. Thus, vomiting is often observed in acute appendicitis and intestinal obstruction, it can be a symptom of an intestinal infection, intoxication, etc. In addition to the disease itself, vomiting and profuse regurgitation are dangerous because the child loses a large amount of water and salts necessary for life, which can lead to dehydration - exsicosis. The younger the child, the faster the disruption of compensatory mechanisms and the worsening of his condition. Therefore, the appearance in a child of symptoms of vomiting or severe regurgitation in young children requires immediate medical attention to identify the causes, establish the correct diagnosis and select the optimal treatment, and, if necessary, surgical.