Approach to Vomiting in Children
Introduction to Vomiting in Children
Vomiting is a common symptom in pediatric patients, ranging from benign, self-limiting conditions to severe, life-threatening disorders. It is defined as the forceful expulsion of gastric contents through the mouth, which is different from regurgitation or reflux. Understanding the underlying causes, proper assessment, and management of vomiting in children is crucial for healthcare providers to ensure optimal patient care and prevent complications.
This comprehensive guide aims to provide doctors and medical students with a structured approach to evaluating and managing vomiting in pediatric patients, covering etiology, clinical assessment, diagnostic evaluation, management strategies, and potential complications.
Etiology of Vomiting in Children
The causes of vomiting in children can be broadly categorized as follows:
- Gastrointestinal Causes:
- Gastroenteritis (viral, bacterial, parasitic)
- Gastroesophageal reflux disease (GERD)
- Food allergies or intolerances
- Inflammatory bowel disease
- Appendicitis
- Intestinal obstruction
- Pyloric stenosis (in infants)
- Central Nervous System Causes:
- Increased intracranial pressure
- Migraine headaches
- Vestibular disorders
- Brain tumors
- Metabolic/Endocrine Causes:
- Diabetic ketoacidosis
- Adrenal insufficiency
- Inborn errors of metabolism
- Toxin-Induced:
- Food poisoning
- Medication side effects
- Accidental ingestion of toxins
- Other Systemic Causes:
- Urinary tract infections
- Sepsis
- Pneumonia
- Hepatitis
- Psychogenic Causes:
- Anxiety disorders
- Depression
- Eating disorders
Clinical Assessment of Vomiting in Children
- History Taking:
- Onset and duration of vomiting
- Frequency and timing of episodes
- Character of vomitus (bilious, bloody, projectile)
- Associated symptoms (fever, diarrhea, abdominal pain)
- Recent dietary history and potential exposures
- Medication history
- Travel history
- Family history of similar symptoms
- Physical Examination:
- Vital signs (including weight)
- General appearance and level of consciousness
- Hydration status assessment
- Abdominal examination (tenderness, distension, masses)
- Neurological examination (including fundoscopy)
- ENT examination
- Red Flag Symptoms:
- Bilious vomiting
- Hematemesis
- Projectile vomiting in infants
- Signs of shock or severe dehydration
- Altered mental status
- Severe abdominal pain or distension
- Signs of increased intracranial pressure
Diagnostic Evaluation of Vomiting in Children
- Laboratory Tests:
- Complete blood count
- Electrolytes, BUN, creatinine
- Liver function tests
- Urinalysis
- Blood glucose
- Stool studies (if diarrhea present)
- Imaging Studies:
- Abdominal X-ray (to assess for obstruction or perforation)
- Abdominal ultrasound (for appendicitis, pyloric stenosis)
- CT scan of abdomen (if serious intra-abdominal pathology suspected)
- CT or MRI of brain (if increased intracranial pressure suspected)
- Specialized Tests (as indicated):
- Upper GI series
- Gastric emptying study
- Endoscopy
- Metabolic and endocrine studies
Management of Vomiting in Children
- General Measures:
- Assess and manage dehydration
- Oral rehydration therapy (ORT) for mild-moderate dehydration
- Intravenous fluids for severe dehydration or ORT failure
- Gradual reintroduction of diet
- Pharmacological Management:
- Antiemetics (use with caution in children):
- Ondansetron
- Metoclopramide (not recommended in young children due to side effects)
- Acid suppressants (for GERD):
- H2 blockers (e.g., ranitidine)
- Proton pump inhibitors (e.g., omeprazole)
- Antibiotics (if bacterial infection confirmed)
- Antiemetics (use with caution in children):
- Condition-Specific Management:
- Surgical intervention (e.g., for pyloric stenosis, malrotation)
- Dietary modifications (for food allergies or intolerances)
- Migraine prophylaxis
- Management of underlying metabolic or endocrine disorders
- Supportive Care:
- Electrolyte replacement
- Nutritional support
- Monitoring of vital signs and clinical status
Complications of Vomiting in Children
- Dehydration: Most common and potentially serious complication
- Electrolyte Imbalances: Particularly hyponatremia and hypokalemia
- Metabolic Alkalosis: Due to loss of hydrochloric acid in vomitus
- Mallory-Weiss Tears: Esophageal mucosal tears from forceful vomiting
- Aspiration Pneumonia: Due to inhalation of gastric contents
- Malnutrition: In cases of prolonged vomiting
- Dental Erosion: From repeated exposure to gastric acid
- Esophagitis: Inflammation of the esophagus due to acid reflux
Vomiting in Children
- What is the most common cause of acute vomiting in children?
Answer: Viral gastroenteritis - Which of the following is NOT a typical symptom associated with vomiting in children?
Answer: Weight gain - What is the term for forceful vomiting in infants that may be projectile in nature?
Answer: Pyloric stenosis - Which of the following is considered a red flag symptom in a child with vomiting?
Answer: Bilious vomiting - What is the most appropriate initial management for a child with acute vomiting due to gastroenteritis?
Answer: Oral rehydration therapy - Which medication is commonly used as an antiemetic in children with persistent vomiting?
Answer: Ondansetron - What is the term for vomiting blood?
Answer: Hematemesis - Which of the following is NOT a typical complication of persistent vomiting in children?
Answer: Hypertension - What is the most common cause of cyclic vomiting syndrome in children?
Answer: Unknown (idiopathic) - Which diagnostic test is most useful in evaluating for intracranial causes of vomiting in children?
Answer: Brain MRI - What is the term for the regurgitation of stomach contents into the esophagus?
Answer: Gastroesophageal reflux - Which of the following dietary changes is most effective in managing gastroesophageal reflux in infants?
Answer: Thickening feeds - What is the most appropriate initial imaging study for a child with suspected pyloric stenosis?
Answer: Abdominal ultrasound - Which medication class should be used with caution in children with vomiting due to its potential to mask serious underlying conditions?
Answer: Antiemetics - What is the term for vomiting that occurs immediately after eating?
Answer: Early satiety - Which of the following is NOT a typical cause of chronic vomiting in children?
Answer: Acute appendicitis - What is the most common cause of bilious vomiting in newborns?
Answer: Intestinal obstruction - Which metabolic disorder can present with recurrent vomiting as a symptom in children?
Answer: Inborn errors of metabolism - What is the term for the involuntary contraction of abdominal muscles during vomiting?
Answer: Retching - Which of the following is NOT a typical physical examination finding in a child with severe dehydration due to vomiting?
Answer: Bounding pulses - What is the most appropriate long-term management strategy for children with gastroesophageal reflux disease (GERD)?
Answer: Combination of lifestyle modifications and acid suppression therapy - Which medication is commonly used as a prokinetic agent in children with gastroparesis?
Answer: Metoclopramide - What is the term for the backflow of intestinal contents into the stomach during vomiting?
Answer: Retrograde peristalsis - Which of the following is NOT a typical risk factor for developing cyclic vomiting syndrome in children?
Answer: Obesity - What is the most appropriate initial management for a child with suspected intussusception presenting with vomiting?
Answer: Rapid referral for diagnostic imaging and possible reduction - Which neurological condition is associated with an increased risk of vomiting in children?
Answer: Increased intracranial pressure - What is the term for the gradual onset of vomiting over several days to weeks?
Answer: Subacute vomiting - Which of the following is NOT a typical complication of chronic vomiting in children?
Answer: Respiratory alkalosis - What is the most appropriate follow-up interval for children with resolved acute gastroenteritis?
Answer: As needed, based on symptom recurrence - Which medication is used as a histamine-2 receptor antagonist in children with gastroesophageal reflux disease?
Answer: Ranitidine
