Nausea in Children: Clinical Evaluation Learning Tool
Clinical History Assessment
Systematic approach to history taking for a child presenting with nausea without vomiting
Physical Examination Guide
Systematic approach to examining a child with nausea without vomiting
Diagnostic Approach
Initial Assessment
For a child presenting with nausea without vomiting, the initial assessment should include:
- Detailed history focusing on onset, duration, pattern, and associated symptoms
- Complete physical examination to identify potential organic causes
- Assessment of hydration status and nutritional intake
- Screening for psychological factors and stressors
Diagnostic Criteria for Functional Nausea
When no organic cause is identified, consider functional nausea syndromes:
| Criteria | Definition | Key Features |
|---|---|---|
| Rome IV Criteria for Functional Nausea | Bothersome nausea occurring at least twice per week, not consistently associated with meals, for at least 2 months | Normal physical examination, growth, and development |
| Cyclic Vomiting Syndrome (Prodromal Phase) | Stereotypical episodes of intense nausea with or without vomiting, returning to baseline health between episodes | Intense prodromal nausea, predictable pattern, complete resolution between episodes |
| Functional Dyspepsia | Postprandial fullness, early satiety, epigastric pain or burning not explained by structural disease | Meal-related symptoms, upper abdominal discomfort, normal endoscopic findings |
Differential Diagnosis
| System | Conditions | Red Flags |
|---|---|---|
| Gastrointestinal |
- Gastroesophageal reflux disease - Peptic ulcer disease - Gastritis - Gastroparesis - Pancreatitis - Biliary disorders - Appendicitis (early) |
- Localized abdominal pain - Weight loss - Blood in stool - Nocturnal symptoms - Persistent right upper quadrant pain - Progressive symptoms |
| Neurological |
- Migraine (abdominal/classic) - Increased intracranial pressure - Vestibular disorders - Motion sickness - Post-concussion syndrome |
- Headache with focal neurological signs - Visual changes - Early morning headache/nausea - Positional worsening - Altered mental status - Recent head injury |
| Infectious |
- Viral gastroenteritis (early) - Streptococcal pharyngitis - Otitis media - Sinusitis - Urinary tract infection - Viral hepatitis |
- Fever - Exposure to illness - Concurrent respiratory symptoms - Dysuria - Jaundice - Seasonal patterns |
| Metabolic/Endocrine |
- Diabetic ketoacidosis - Adrenal insufficiency - Hypercalcemia - Hyperthyroidism - Inborn errors of metabolism |
- Polydipsia/polyuria - Weight loss - Growth deceleration - Fatigue - Hyperpigmentation - Family history of metabolic disorders |
| Psychological |
- Anxiety disorders - Depression - School avoidance - Somatization disorder - Post-traumatic stress |
- Pattern related to school/events - Concurrent psychological symptoms - Improvement during weekends/holidays - Recent life stressors - Family history of anxiety/functional disorders |
| Other |
- Medication side effects - Food intolerances - Vertigo/inner ear disorders - Pregnancy (adolescents) - Toxin exposure |
- Temporal relationship to medications - Relation to specific foods - Dizziness/vertigo - Menstrual history in adolescent females - Environmental exposures |
Laboratory Studies
Consider these studies when red flags are present:
| Investigation | Clinical Utility | When to Consider |
|---|---|---|
| Complete Blood Count | Assess for infection, inflammation, or anemia | Persistent symptoms, fever, weight loss, fatigue |
| Comprehensive Metabolic Panel | Evaluate liver, kidney function, electrolytes | Persistent symptoms, abdominal pain, altered mental status |
| Amylase/Lipase | Screen for pancreatitis | Upper abdominal pain, radiation to back |
| Urinalysis | Identify UTI, ketones (DKA), pregnancy | Dysuria, polyuria, flank pain, adolescent females |
| ESR/CRP | Non-specific inflammatory markers | Suspected inflammatory conditions, persistent symptoms |
Advanced Studies
Reserve for concerning presentations or persistent symptoms:
| Investigation | Clinical Utility | When to Consider |
|---|---|---|
| Upper GI Endoscopy | Evaluate for mucosal disease, H. pylori | Persistent symptoms, weight loss, dysphagia, pain |
| Abdominal Ultrasound | Assess gallbladder, liver, pancreas, appendix | Right upper quadrant pain, suspected biliary disease |
| Brain MRI | Evaluate for intracranial pathology | Headache, neurological signs, early morning symptoms |
| Gastric Emptying Study | Diagnose gastroparesis | Early satiety, postprandial fullness, weight loss |
| 24-hour pH/Impedance Study | Diagnose GERD | Suspected reflux unresponsive to empiric therapy |
Diagnostic Algorithm
A stepwise approach to diagnosing nausea without vomiting:
- Assess for red flags suggesting organic pathology
- Complete history and physical examination
- Consider timing pattern:
- Consistent morning nausea: Evaluate for increased ICP, pregnancy, anxiety
- Postprandial nausea: Consider GERD, gastroparesis, functional dyspepsia
- Episodic with complete resolution: Consider cyclic vomiting syndrome, migraine
- Situational: Evaluate for psychological triggers, motion sensitivity
- Basic labs if red flags present or symptoms persist >2 weeks
- Trial of lifestyle modifications for suspected functional nausea
- Consider empiric therapy based on presumptive diagnosis
- Advanced testing only if guided by specific concerns or failure to improve
- Screen for psychological factors as primary cause or contributing factors
Management Strategies
General Approach to Management
Key principles in managing nausea without vomiting in children:
- Establish diagnosis: Differentiate between organic and functional causes
- Validate symptoms: Acknowledge the discomfort and impact on quality of life
- Set realistic expectations: Discuss management versus cure for functional disorders
- Address underlying causes: Treat identified organic pathology
- Biopsychosocial approach: Address physical, psychological, and social factors
- Regular follow-up: Monitor response to interventions and symptom patterns
Non-Pharmacological Interventions
| Intervention | Description | Evidence Level |
|---|---|---|
| Dietary Modifications |
- Small, frequent meals - Low-fat diet - Avoid trigger foods - Adequate hydration - Ginger-containing foods |
Moderate; clinical experience supports, some controlled studies |
| Behavioral Techniques |
- Deep breathing exercises - Progressive muscle relaxation - Guided imagery - Distraction techniques - Regular sleep schedule |
Moderate; several studies show benefit for functional symptoms |
| Cognitive Behavioral Therapy |
- Identify thought patterns - Develop coping strategies - Gradual exposure therapy - Relaxation training |
High; strong evidence for functional gastrointestinal disorders |
| Acupressure/Acupuncture |
- P6 (Neiguan) point stimulation - Sea-Bands or similar devices - Professional acupuncture |
Low to moderate; mixed results in pediatric studies |
| Physical Activity |
- Regular, moderate exercise - Yoga or tai chi - Outdoor activities |
Low; limited pediatric studies but generally beneficial for GI function |
Nutritional Interventions
| Intervention | Approach | Evidence and Considerations |
|---|---|---|
| Elimination Diets |
- FODMAP reduction - Gluten-free trial - Dairy elimination - Food chemical reduction |
- Time-limited trials (2-4 weeks) - Supervised by healthcare provider - Moderate evidence for specific conditions - Nutritional adequacy must be maintained |
| Anti-Nausea Foods |
- Ginger products - Peppermint tea - Bland, starchy foods - Cold foods when nauseated |
- Strongest evidence for ginger - Low risk intervention - Limited formal studies in children - May help with mild symptoms |
| Probiotic Supplements |
- Specific strains (L. rhamnosus GG, B. infantis) - Age-appropriate formulations - Regular administration |
- Limited evidence specifically for nausea - Better evidence for IBS-related symptoms - Generally safe intervention - Consider in functional disorders |
| Meal Pattern Adjustments |
- Regular eating schedule - Avoid prolonged fasting - Small, frequent meals - Adequate protein with meals |
- Clinical experience supports benefit - Particularly helpful for morning nausea - Important for blood glucose regulation - Low-risk intervention |
Pharmacological Management
Reserve for moderate to severe symptoms or specific diagnoses:
| Medication | Considerations | Evidence and Recommendations |
|---|---|---|
| Proton Pump Inhibitors |
- Reduces gastric acid production - For GERD-related nausea - Time-limited courses recommended |
- Moderate evidence for GERD-related nausea - Limited benefit in functional nausea without GERD - Consider 4-8 week trial if reflux symptoms present - Monitor for side effects with prolonged use |
| H1 Antihistamines |
- Dimenhydrinate, diphenhydramine - Sedating properties - Short-term use preferred |
- Effective for motion sickness, vestibular causes - Limited evidence for chronic nausea - Side effects include drowsiness, dry mouth - Not recommended for long-term management |
| 5-HT3 Antagonists |
- Ondansetron - Generally for acute rather than chronic nausea |
- Strong evidence for chemotherapy-induced nausea - Limited evidence for chronic functional nausea - Consider for severe, intermittent episodes - Monitor for cardiac and GI side effects |
| Cyproheptadine |
- Antihistamine with antiserotonergic effects - Appetite stimulant properties |
- Moderate evidence for cyclic vomiting syndrome - Some benefit in abdominal migraine - Side effects include increased appetite, sedation - Consider for episodic functional nausea |
| Neuromodulators |
- Low-dose tricyclic antidepressants - SSRIs for concurrent anxiety - Specialist initiation recommended |
- Moderate evidence in functional GI disorders - Not first-line therapy in children - Start with low doses - Best for chronic, severe functional nausea - Monitor closely for side effects |
| Prokinetic Agents |
- Erythromycin (low-dose) - Metoclopramide (limited use) - Domperidone (availability varies by country) |
- Benefit in gastroparesis or delayed gastric emptying - Limited evidence for functional nausea - Significant side effect profile - Not recommended for long-term use without specialist oversight |
Management of Specific Conditions
| Condition | Management Approach | Follow-up Recommendations |
|---|---|---|
| Functional Nausea/Dyspepsia |
- Reassurance about benign nature - Dietary modifications (small meals, low fat) - Stress reduction techniques - Consider acid suppression if upper GI symptoms - Psychological support if anxiety present |
- Follow-up every 4-6 weeks initially - Focus on function rather than symptoms - Set realistic improvement goals - Consider GI referral if symptoms persist >3 months |
| Abdominal Migraine |
- Migraine prevention strategies - Trigger avoidance (sleep, stress, dietary) - Consider cyproheptadine or propranolol - Acute treatment for breakthrough episodes - Maintain headache/symptom diary |
- Follow-up every 4-8 weeks during initial management - Neurology referral if poor response - Monitor for development of classic migraine - Adjust preventive strategies as needed |
| Anxiety-Related Nausea |
- Cognitive behavioral therapy - Relaxation techniques - Gradual exposure to anxiety triggers - Regular school attendance - Family-based interventions |
- Regular follow-up with mental health provider - Monitor school attendance - Assess family functioning - Consider medication for severe anxiety - Focus on function over symptoms |
| GERD-Associated Nausea |
- Dietary modifications - Positional therapy (no lying down after meals) - PPI trial (4-8 weeks) - Weight management if applicable - Consider endoscopy for persistent symptoms |
- Re-evaluate after 4-8 weeks of therapy - Attempt weaning from medication if symptoms resolve - Consider pH study if diagnosis uncertain - Long-term follow-up for chronic GERD |
| Motion-Related Nausea |
- Preventive measures (seating position, visual focus) - Scheduled antihistamines before travel - Acupressure bands - Ginger products - Gradual exposure therapy |
- As-needed follow-up - Focus on prevention strategies - Assess for improvement with age - Consider neurological evaluation if severe/progressive |
Psychological Support and Education
- Explanation of brain-gut connection: Age-appropriate education about how emotions affect physical symptoms
- Validation of symptoms: Acknowledge real discomfort while avoiding reinforcement of sick role
- Coping strategies: Develop toolbox of techniques for managing nausea episodes
- School accommodations: Work with school for appropriate support while maintaining attendance
- Family dynamics: Address family responses that may inadvertently reinforce symptoms
- Resources: Books, apps, and online resources for managing chronic symptoms
When to Refer
- Gastroenterology: Persistent symptoms >3 months, weight loss, abnormal labs, dysphagia
- Neurology: Associated headaches, neurological symptoms, suspected cyclic vomiting/abdominal migraine
- Psychology/Psychiatry: Significant anxiety/depression, school avoidance, family dysfunction
- Otolaryngology: Prominent vestibular symptoms, suspected inner ear disorders
- Endocrinology: Suspected metabolic or endocrine disorders, abnormal growth patterns
Prognosis and Long-Term Outcomes
Understanding expected course and potential complications:
- Functional nausea: Often improves with time, but may wax and wane; focus on coping strategies
- Abdominal migraine: May evolve into typical migraine in adolescence/adulthood; good response to preventive strategies
- Anxiety-related: Excellent response to psychological interventions; risk of recurrence during stress
- GERD-related: Good response to lifestyle and medication; may require long-term management
- Impact on development: Address potential effects on school performance, social development, and family function
- Complications to monitor: School avoidance, nutritional deficiencies, medication side effects, development of dysfunctional coping
