Peds
Pediatric Vomiting
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Pediatric Vomiting
, Vomiting in Children, Vomiting in the Newborn, Infant with Vomiting
See Also
Vomiting
Vomiting Causes in Children
Spitting Up
(
Pediatric Reflux
)
Pediatric Acute Cough
Pediatric Diarrhea
Pediatric Dehydration
Pathophysiology
See
Vomiting
(includes definitions)
Causes
See
Vomiting Causes in Children
History
See
Vomiting History
for clinical clues (geared toward adults)
Prenatal and Birth History
Prenatal conditions
Did infant pass meconium and how long after birth (
Hirschsprung's Disease
)?
Congenital disorders
Inborn Errors of Metabolism
(e.g. abnormal
Newborn Screening
)
Recent exposures
Travel history
Spoiled food intakes
Contagious contacts
Possible toxin exposures or
Unknown Ingestion
s
Systemic Symptoms and Signs
Fever
Malaise or
Fatigue
Weight loss (red flag)
Emesis
Characteristics
Onset of
Vomiting
Timing between food or milk and
Emesis
Projectile
Emesis
Evaluate for
Pyloric Stenosis
in the young infant
Emesis
appearance or color
Undigested food or milk or yellow color (
Stomach
contents)
Hematemesis
(
Upper GI Bleed
ing)
Bilious Emesis
Evaluate for obstruction (e.g.
Small Bowel Obstruction
from mid-gut
Volvulus
in infants)
Gastrointestinal Symptoms or Signs
Abdominal Pain
before
Vomiting
(red flag)
Gastrointestinal Bleeding
(
Hematemesis
, Melana)
Dysphagia
Constipation
Diarrhea
Diarrhea
that follows
Vomiting
is consistent with
Gastroenteritis
Vomiting
that follows
Diarrhea
is consistent with enteritis (or
Urinary Tract Infection
in girls, women)
Jaundice
Genitourinary Symptoms
Urine Output
At least three times daily in infants and twice daily in children and older
Dysuria
Urgency or frequency
Hematuria
Endocrine Symptoms
Polyuria
, Polydypsia, polyphagia
Associated Conditions
Pharyngitis
Otalgia
Neurologic Symptoms and Signs
Altered Level of Consciousness
(GCS, mental status)
Consider
Non-accidental Trauma
Focal neurologic changes
Ataxia
History
Red Flags
Weight loss or failure to gain weight
Dehydration
Urinating <3 times daily in age <1 year and <2 times daily in older children
Tachycardia
for age, lethargy, dry mucous membranes
Projectile
Emesis
in the young infant
Evaluate for
Pyloric Stenosis
Bilious Emesis
Evaluate for
Intestinal Obstruction
Newborn
Evaluate for malrotation and
Volvulus
(emergent management needed)
Bloody stools,
Abdominal Distention
and
Emesis
in a newborn
Evaluate for necrotizing entercolitis
Increased Intracranial Pressure
Refractory
Vomiting
in a benign
Abdomen
with
Altered Level of Consciousness
, neurologic changes
Evaluate for
Non-accidental Trauma
, brain mass,
Hydrocephalus
Examination
Gene
ral observation
Irritability or discomfort at rest (observed from doorway)
Consolability
Observe for
Dehydration
Weight loss since prior exam
Decreased skin turgur
Dry mucus membranes (or not making tears in children)
Sunken
Fontanelle
s (age <15 months)
Sinus Tachycardia
Orthostatic Hypotension
Decreased
Capillary Refill
Other systemic signs of serious illness
Tachypnea
(
Sepsis
,
Metabolic Acidosis
)
Abdominal examination
Abdominal Distention
Abdominal wall
Hernia
Peritoneal signs (abdominal guarding,
Rebound Tenderness
)
Abdominal Trauma
(e.g.
Bruising
)
Costovertebral Angle Tenderness
Abdominal tenderness to palpation
Right lower quadrant pain:
Appendicitis
(esp. with
Psoas Sign
, Rosving's sign)
Flank Pain
:
Pyelonephritis
or Uretolithiasis
Bowel
sounds
Hyperactive suggests
Gastroenteritis
High pitched suggests
Small Bowel Obstruction
Absent or decreased suggests ileus
Genitourinary exam
Inguinal Hernia
Testicular Torsion
(testicular tenderness, swelling, absent
Cremasteric Reflex
)
Ovarian Torsion
Neurologic Exam
ination
Altered Level of Consciousness
Neurologic Exam
appropriate for age
Bulging
Fontanelle
s (age <15 months)
Ataxia
on gait exam
Skin
Jaundice
Differential Diagnosis
See
Vomiting Causes
Ptyalism
(
Excessive Salivation
)
Gastroesophageal Reflux
Disease (
Acid Reflux
) or
Spitting Up
in an infant
Forceful
Cough
ing
Post-nasal drainage
Asthma
,
Bronchitis
or
Bronchiolitis
Pneumonia
Undigested Food Regurgitation
Esophageal Obstruction
Esophageal Diverticulum
Overfilled
Stomach
Delayed Gastric Emptying
or
Gastroparesis
Labs
Precautions
Most children will not need lab testing (esp. first 24 hours, without red flag findings)
Labs should be directed by history and exam
Fingerstick
Glucose
(for
Hypoglycemia
, DKA)
Complete Blood Count
Comprehensive metabolic panel (
Electrolyte
s,
Renal Function
tests,
Liver Function Test
s)
Urinalysis
and
Urine Culture
Urine Pregnancy Test
Obtain in all biological females of reproductive age
Review
Newborn Screen
results for
Inborn Errors of Metabolism
Typically drawn at 24 to 48 hours of life and results available within the first week of life
Additional labs to consider in
Sepsis
Blood Culture
Lactic Acid
Lumbar Puncture
Additional labs/measures to consider in newborns
Ammonia (
Inborn Errors of Metabolism
)
Attempt passage of oral
Gastric Tube
Serum
Lipase
Stool
testing for enteric organisms and
Clostridium difficile
(if indicated)
Evaluation
See
Triage of Children with Vomiting
Imaging
Abdominal Ultrasound
Pyloric Stenosis
Intussusception
Appendicitis
Cholecystitis
Hydronephrosis
Abdominal XRay (flat and upright, or in infants, a left lateral decubitus image)
Malrotation
Small Bowel Obstruction
Upper GI Series
Malrotation
Contrast enema
Distal
Bowel Obstruction
(e.g.
Hirschsprung Disease
)
Chest XRay
Abdominal free air
Pneumonia
CT Head
or rapid MRI Brain
Findings suggestive of CNA cause (
Increased Intracranial Pressure
)
Management
See
Vomiting Management in Children
Stabilization
See
ABC Management
See
Pediatric Dehydration Management
(includes oral and IV fluid
Resuscitation
)
See
Oral Rehydration Therapy Protocol in Pediatric Dehydration
See
Vomiting Management in Children
Antiemetic
followed by oral liquid trial
Ondansetron
(
Zofran
) 0.15 mg/kg up to 4-8 mg (FDA approved for age >6 months)
Give 2 mg orally for weight <15 kg
Give 4 mg orally for weight >15 kg
Avoid
Promethazine
(
Phenergan
) in children (FDA black box warning)
Always consider
Nonaccidental Trauma
See
Pediatric Nonaccidental Trauma Screening
(
SPUTOVAMO-R2 Checklist
)
See
Nonaccidental Trauma
and
TEN-4 Rule
Consider extra-abdominal causes
Neurologic causes
Unknown Ingestion
Diabetic Ketoacidosis
Inborn Errors of Metabolism
Urgent and emergent surgical
Consultation
indications (early surgical
Consultation
)
Bilious Emesis
Pyloric Stenosis
Intussusception
Appendicitis
Volvulus
(esp.
Intestinal Malrotation
)
Ectopic Pregnancy
Disposition
Discharge home indications
Tolerating oral fluids
Reassuring
Vital Sign
s without significant
Dehydration
No red flags for more serious Pediatric Vomiting causes
Home instructions
Ondansetron
(
Zofran
) prescription (see dosing above)
Review
Oral Rehydration Therapy Protocol in Pediatric Dehydration
Review
Vomiting Management in Children
Follow-up
Follow-up clinic visit at 24 to 48 hours
References
(2017) Crit Dec Emerg Med 31(4): 19-25
(2022) Crit Dec Emerg Med 36(1): 3-11
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